Every finding on record at Culpeper Health & Rehabilitation Center

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure three of five residents were free from verbal abuse, Residents #3, #4 and #5.The findings include:1. For Resident #3 (R3), the facility staff failed to protect the resident from verbal abuse from a staff member. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/6/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of events dated 6/13/25, documented the incident occurred on 6/3/25, documented in part, On 6/13/25 the Administrator was notified by patient (#3) of an allegation of verbal abuse that occurred on 6/3/25 by dietary cook, (other staff member) (OSM) #4. During dinner. Patient BIMS is 14. NP (nurse practitioner), RP (responsible party) and (name of local) police department notified. (OSM #4) suspended. Facility investigation initiated. The resident statement dated 6/13/25 documented in part, I was asking for a sandwich and (OSM #4) started yelling and arguing with me. She slammed the door on me and got very mad and was rude and told me to (explicative) off. I want her to apologize. She did not need to do all that. An interview was conducted with R3 on 7/28/25 at 4:00 p.m. R3's statement was reviewed with him. He stated he had never had that happen to him before. It affected him for quite a while. When asked how the incident made him feel, R3 stated he felt disrespected. R3 stated no one had asked him before how it made him feel. The email dated 6/13/25 at 10:17 a.m. documented an interview between OSM #2, the kitchen manager and OSM #4, the dietary staff member. It documented in part, she (OSM #4) was able to tell that she did yell at the resident because he yelled at her and she did shut the door on him. OSM #2 documented she informed that her behavior was not acceptable, and it was being investigated and OSM #4 kept pointing out things that the resident did and said. OSM #4 really didn't see that she did anything wrong. An interview was conducted with LPN (licensed practical nurse) #5, the unit manager on 7/28/25 at 4:56 p.m. LPN #5 stated if a resident tells her or it is reported to her that someone has been verbally abused, she first separates the resident from the abuser for safety. She then notifies her director of nursing and the administrator. LPN #5 was not aware of the incident between R3 and OSM #4. An interview was conducted with OSM #2, the kitchen manager, on 7/29/25 at 8:08 a.m. OSM #2 stated upon interview, OSM #4 stated she had yelled at the resident. OSM #4 told OSM #2 that she felt she was defending herself and yelled back. OSM #4 stated she did not do anything wrong. OSM #2 informed OSM #4 the facility was the resident's home and OSM #2 tried to stress the resident needed to be treated with kindness and respect. OSM #2 stated that OSM #4 never accepted responsibility for her actions. The facility policy, Abuse/Neglect/Misappropriation/Crime, documented in part, There is zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician. ASM (administrative staff member) #1, ASM #2, the director of nursing, and ASM #4, regional director of clinical services, were made aware of the above concern on 7/29/25 at 1:04 p.m. No further information was provided prior to exit. 2. For Resident #4 (R4) and Resident #5 (R5), the facility staff failed to ensure the residents were free from verbal abuse on 6/12/25. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/21/25, R4 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On the most recent MDS, a quarterly assessment with an ARD of 5/30/25, R5 scored 14 out of 15 on the BIMS, indicating the resident was cognitively intact for making daily decisions. An initial facility synopsis of events dated 6/12/25 documented, The Administrator was notified by patient (R4), of an allegation of verbal abuse today by (LPN [licensed practical nurse] #1). Patient BIMs of 15. NP (Nurse Practitioner), RP (Responsible Party) notified and [NAME] Police Department notified. (LPN #1) sent home and suspended. Facility investigation initiated. A written statement obtained from R4 on 6/18/25 documented, Sitting in the smoking courtyard with (R5). Nurse (LPN #1) came outside and started yelling at (R5). I told her that she could not speak to (R5) that way. (LPN #1) then yelled at me and told me to shut up. I then asked for her name and she gave it to me. A written statement obtained from R5 on 6/18/25 documented, I was outside in the smoking courtyard sitting beside (R4). Nurse (LPN #1) came out there and started yelling at me to come give her a urine sample. I told her I already did it then (R4) said to (LPN #1) to not speak to me that way then (LPN #1) yelled at him and told him to shut up then (R4) asked for her name and she said (name). A final facility synopsis of events dated 6/20/25 documented, On 6/12/2025 the Administrator was notified by staff that patient (R4) reported an allegation of verbal abuse by (LPN #1). Patient BIMs of 15. NP, RP notified, and [NAME] Police Department notified. (LPN #1) was sent home and suspended. Facility investigation initiated. During our comprehensive investigation, the other resident present [sic] with a BIMs of 14 who witnessed said alleged interaction was interviewed. The interview revealed that (LPN #1) yelled at (R4) and told him to shut up. We are therefore substantiating the allegation of verbal abuse. (LPN #1) has been terminated and reported to the Virginia Board of Nursing . On 7/28/25 at 2:53 p.m., an interview was conducted with R4. R4 stated that on the date of the incident, LPN #1 came out to the smoking courtyard screaming at R4, and yelling, We have been over this, you have to get inside right now. R4 stated he told LPN #1, Excuse me, you can't talk to her like that and LPN #1 began yelling at him, This is none of your business. Why don't you get away. R4 stated he felt LPN #1 was verbally abusive and really rude. On 7/28/25 at 3:53 p.m., an interview was conducted with R5. R5 stated one day a staff member (whose name she could not recall) came out to the courtyard hollering and yelling at her that she needed to come inside for a urine sample. R5 stated she told the staff member that she had already provided a urine sample, but the staff member continued to yell at her and said she needed to come inside right away. R5 stated a gentleman told the staff member, You don't need to talk to her like that but could not remember the staff member's response. R5 stated she felt the staff member was verbally abusive and the incident made R5 feel angry. On 7/29/25 at 10:40 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated there have been instances when residents begin yelling at a staff member and the staff member raises his or her voice so the residents can hear what the staff member is saying. ASM #1 stated at times, there is a difference in a staff member actually yelling and in what a resident perceives as yelling but this is also dependent on the staff member's verbalizations such as saying shut up and cursing. In regard to the verbal abuse incident involving R4 and R5 on 6/12/25, ASM #1 stated LPN #1 denied the allegations but both residents' BIMS were 13 or greater, both residents were interviewed separately and their statements aligned so he substantiated the allegation of verbal abuse because he did not want to jeopardize anyone else. On 7/29/25 at 1:07 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for three of five residents in the survey sample, Residents #3, #4, and #5. The findings include: 1. For Resident #3 (R3), the facility staff failed to review and revise the comprehensive care plan after a staff member verbally abused the resident. The comprehensive care plan dated 2/5/25 was reviewed. It failed to evidence any documentation related to the resident being verbally abused by a staff member. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/6/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of events dated 6/13/25, documented the incident occurred on 6/3/25, documented in part, On 6/13/25 the Administrator was notified by patient (#3) of an allegation of verbal abuse that occurred on 6/3/25 by dietary cook, (other staff member) (OSM) #4. During dinner. Patient BIMS is 14. NP (nurse practitioner), RP (responsible party) and (name of local) police department notified. (OSM #4) suspended. Facility investigation initiated. The resident statement dated 6/13/25 documented in part, I was asking for a sandwich and (OSM #4) started yelling and arguing with me. She slammed the door on me and got very mad and was rude and told me to (explicative) off. I want her to apologize. She did not need to do all that. An interview was conducted with OSM (other staff member) #2, the director of discharge planning/social services, on 7/28/25 at 4:39 p.m. OSM #2 stated she did not review and revise the care plan after a resident has been verbally abused. An interview was conducted with LPN (licensed practical nurse) #5, the unit manager on 7/28/25 at 4:56 p.m. When asked if the care plan should be reviewed and revised if a resident was verbally abused, LPN #5 stated, yes, so that everyone is aware of the incident and what interventions were put in place, such as care needs and need for counseling. The facility policy titled, Care Planning documented, 5. Care plans will be updated on an ongoing basis as changes in the patient occur . ASM (Administrative staff member) #1, ASM #2, the director of nursing, and ASM #4, regional director of clinical services, were made aware of the above concern on 7/29/25 at 1:04 p.m. No further information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to review and revise the resident's comprehensive care plan regarding verbal abuse. A review of written statements obtained from R4 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents and told R4 to shut up (on 6/12/25). A review of R4's comprehensive care plan (dated 5/16/25) failed to reveal the care plan was reviewed and revised after the verbal abuse incident on 6/12/25. On 7/28/25 at 4:40 p.m., an interview was conducted with OSM (other staff member) #2 (the director of discharge planning/social services). OSM #2 stated she does not review and revise residents' care plans after residents have been verbally abused. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated residents' care plans should be reviewed and revised after an incident of verbal abuse, so everyone is aware of the situation and aware of the interventions that have been put into place. On 7/29/25 at 1:07 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #5 (R5), the facility staff failed to review and revise the resident's comprehensive care plan regarding verbal abuse. A review of written statements obtained from R5 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents (on 6/12/25). A review of R5's comprehensive care plan (dated 11/17/22) failed to reveal the care plan was reviewed and revised after the verbal abuse incident on 6/12/25. On 7/28/25 at 4:40 p.m., an interview was conducted with OSM (other staff member) #2 (the director of discharge planning/social services). OSM #2 stated she does not review and revise residents' care plans after residents have been verbally abused. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated residents' care plans should be reviewed and revised after an incident of verbal abuse, so everyone is aware of the situation and aware of the interventions that have been put into place. On 7/29/25 at 1:07 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, facility document review and clinical record review, it was determined the facility staff failed to provided medical related social services for three of five residents in the survey sample, Residents #3, #4 and #5. The findings include: 1. For Resident #3 (R3), the facility staff failed to provide medically related social services after an incident of verbal abuse by a staff member. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/6/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of events dated 6/13/25, documented the incident occurred on 6/3/25, documented in part, On 6/13/25 the Administrator was notified by patient (#3) of an allegation of verbal abuse that occurred on 6/3/25 by dietary cook, (other staff member) (OSM) #4. During dinner. Patient BIMS is 14. NP (nurse practitioner), RP (responsible party) and (name of local) police department notified. (OSM #4) suspended. Facility investigation initiated. The resident statement dated 6/13/25 documented in part, I was asking for a sandwich and (OSM #4) started yelling and arguing with me. She slammed the door on me and got very mad and was rude and told me to (explicative) off. I want her to apologize. She did not need to do all that. An interview was conducted with R3 on 7/28/25 at 4:00 p.m. R3's statement was reviewed with him. He stated he had never had that happen to him before. It affected him for quite a while. When asked how the incident made him feel, R3 stated he felt disrespected. R3 stated no one had asked him before how it made him feel. An interview was conducted with OSM (other staff member) 2, the director of discharge planning/social services, on 7/28/25 at 4:49 p.m. OSM #2 stated if a resident comes to her and alleges abuse by a staff member, she files a complaint and informs the administrator. She further stated if a resident doesn't come to her and goes straight to the administrator, she does not get involved. When asked if she does any psychosocial assessment to determine if the resident needs anything, OSM #2 stated she will go talk to the resident to see if they need to see the psychiatric nurse practitioner or the clinical psychologist. She speaks to the residents about the incident, if the resident feels safe in the building and what the resident wants to do about the concern/incident. Most of the time, she stated, the residents are already seeing psych (psychological) services. OSM #2 further explained that she does a trauma informed screen on the resident. When asked where she documents the conversation or informed trauma screen completed on the resident, OSM #2 stated, she honestly doesn't. OSM #2 stated she was not aware of the incident between the kitchen staff member and R3 and did not complete an assessment at that time. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 7/29/25 at 9:15 a.m. When asked if a psychosocial assessment be completed on a resident who was verbally abused by a staff member, ASM #2 stated she could not recall which assessment it is, but social services go around for anyone who has had an allegation of abuse to determine the severity of where the resident is at. They should complete the assessment to see how the resident is doing mentally and emotionally. The facility policy titled, Medically Related Social Services documented, In conjunction with medical and clinical staff, Social Work and Discharge Planning Staff will identify and provide assistance in meeting patients' psychosocial and medically related social service needs . ASM #1, ASM #2, the director of nursing, and ASM #4, regional director of clinical services, were made aware of the above concern on 7/29/25 at 1:04 p.m.No further information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to assess the resident's psychosocial status and implement psychosocial interventions to address verbal abuse on 6/12/25. A review of written statements obtained from R4 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents and told R4 to shut up (on 6/12/25). Further review of R4's clinical record failed to reveal the resident's psychosocial status related to the verbal abuse was assessed or psychosocial interventions were implemented. On 7/28/25 at 4:40 p.m., an interview was conducted with OSM (other staff member) #2 (the director of discharge planning/social services). OSM #2 stated she does not complete a formal assessment after a resident reports an allegation of abuse, but she talks to the resident, asks about a visit with the psychiatric nurse practitioner or psychologist, and would complete a trauma informed screening if the resident felt something more was needed. OSM #2 stated she did not complete an assessment or follow-up regarding R4's verbal abuse incident on 6/12/25. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that after a resident has reported an allegation of abuse, staff should frequently check on the resident, and a follow-up with the psychiatric nurse practitioner and/or the psychologist should occur. On 7/29/25 at 1:07 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #5 (R5), the facility staff failed to assess the resident's psychosocial status and implement psychosocial interventions to address verbal abuse on 6/12/25. A review of written statements obtained from R5 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents (on 6/12/25). Further review of R5's clinical record failed to reveal the resident's psychosocial status related to the verbal abuse was assessed or psychosocial interventions were implemented. On 7/28/25 at 4:40 p.m., an interview was conducted with OSM (other staff member) #2 (the director of discharge planning/social services). OSM #2 stated she does not complete a formal assessment after a resident reports an allegation of abuse, but she talks to the resident, asks about a visit with the psychiatric nurse practitioner or psychologist, and would complete a trauma informed screening if the resident felt something more was needed. OSM #2 stated she did not complete an assessment or follow-up regarding R5's verbal abuse incident on 6/12/25. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that after a resident has reported an allegation of abuse, staff should frequently check on the resident, and a follow-up with the psychiatric nurse practitioner and/or the psychologist should occur. On 7/29/25 at 1:07 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for three of five residents, Resident #3, #4, and #5. The findings include: 1. For Resident #3 (R3), the facility staff failed to document in the clinical record, an incident between the resident and a staff member. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/6/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of events dated 6/13/25, documented the incident occurred on 6/3/25, documented in part, On 6/13/25 the Administrator was notified by patient (#3) of an allegation of verbal abuse that occurred on 6/3/25 by dietary cook, (other staff member) (OSM) #4. During dinner. Patient BIMS is 14. NP (nurse practitioner), RP (responsible party) and (name of local) police department notified. (OSM #4) suspended. Facility investigation initiated. The resident statement dated 6/13/25 documented in part, I was asking for a sandwich and (OSM #4) started yelling and arguing with me. She slammed the door on me and got very mad and was rude and told me to (explicative) off. I want her to apologize. She did not need to do all that. Review of the clinical record failed to evidence any documentation related to the incident above. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 7/29/25 at 9:15 a.m. When asked if a note should be entered into the resident's clinical record when there is a substantiated allegation of abuse, ASM #2 stated, yes, it is dependent upon whose patient it is, she didn't recall but felt the IDT (interdisciplinary team) would put a note regarding the incident happening. An interview was conducted with ASM #1, the administrator, on 7/29/25 at 10:40 a.m. ASM #1 stated, when there is an allegation of verbal abuse, he typically does the (facility synopsis of event) and obtains statements, he does not document in the clinical record. The facility policy, Medical Records – Duties, documented in part, 1. An accurate and complete clinical record is to be maintained for each patient. ASM (Administrative staff member) #1, ASM #2, the director of nursing, and ASM #4, regional director of clinical services were made aware of the above concern on 7/29/25 at 1:04 p.m. No further information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to document an incident regarding verbal abuse on 6/12/25 in the resident's clinical record. A review of written statements obtained from R4 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents and told R4 to shut up (on 6/12/25). A review of R4's clinical record failed to reveal documentation regarding the incident on 6/12/25. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN #5. LPN #5 stated the staff do not document allegations of abuse in residents' clinical records and she did not know why. On 7/29/25 at 9:23 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated allegations of abuse should be documented in residents' clinical records. On 7/29/25 at 1:07 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #5 (R5), the facility staff failed to document an incident regarding verbal abuse on 6/12/25 in the resident's clinical record. A review of written statements obtained from R5 and another resident by facility staff on 6/18/25 revealed documentation that LPN (licensed practical nurse) #1 yelled at the residents (on 6/12/25). A review of R5's clinical record failed to reveal documentation regarding the incident on 6/12/25. On 7/28/25 at 4:56 p.m., an interview was conducted with LPN #5. LPN #5 stated the staff do not document allegations of abuse in residents' clinical records and she did not know why. On 7/29/25 at 9:23 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated allegations of abuse should be documented in residents' clinical records. On 7/29/25 at 1:07 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, staff interview, and facility document review, it was determined that the facility staff failed to treat one of five residents in the survey sample, in a dignified manner, Resident #3.The findings include:For Resident #3 (R3) the facility staff failed to treat a resident in a dignified manner.On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/6/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions.The facility synopsis of events dated 6/13/25, documented the incident occurred on 6/3/25, documented in part, On 6/13/25 the Administrator was notified by patient (R3) of an allegation of verbal abuse that occurred on 6/3/25 by dietary cook, (other staff member) (OSM) #4. During dinner. Patient BIMS is 14. NP (nurse practitioner), RP (responsible party) and (name of local) police department notified. (OSM #4) suspended. Facility investigation initiated.The resident statement dated 6/13/25 documented in part, I was asking for a sandwich and (OSM #4) started yelling and arguing with me. She slammed the door on me and got very mad and was rude and told me to (explicative) off. I want her to apologize. She did not need to do all that.An interview was conducted with R3 on 7/28/25 at 4:00 p.m. R3's statement was reviewed with him. He stated he had never had that happen to him before. It affected him for quite a while. When asked how the incident made him feel, R3 stated he felt disrespected. R3 stated no one had asked him before how it made him feel.An interview was conducted with OSM (other staff member) #2, the director of discharge planning/social services, on 7/28/25 at 4:39 p.m. When asked her role when there is an allegation of abuse by a staff member, OSM #2, stated if a patient comes to her and alleges abuse, she files a complaint and informs the administrator. OSM #2 further stated that if the resident goes directly to the administrator, she doesn't get involved. When asked if she does a psychosocial assessment to determine if the resident needs any services, OSM #2 stated she goes and talks to the resident to see if they need to see their psychiatric nurse practitioner or clinical psychologist. Most of the time the resident is already seeing psych (psychological) services. Every time there is an allegation - she stated she would do a trauma informed screening. When asked what she talks to the residents about the incident, OSM #2 stated she speaks with them about the incident, if they want to talk about the incident, do they feel safe in the facility, and what they want done related to the allegation. When asked where she documents that she's spoken to the residents, OSM #2 stated, Honestly, I don't. OSM #2 stated she did was not aware of the incident with R3 and OSM #4.An interview was conducted with ASM (administrative staff member) #1, the administrator, on 7/29/25 at 10:40 a.m. When asked if a staff member is yelling at a resident, is that resident being treated in a dignified manner, ASM #1 stated no.The facility policy, Your Rights and Protections as a Nursing Home Resident documented in part, You have the right to be treated with respect: You have the right to be treated with dignity and respect.ASM (Administrative staff member) #1, ASM #2, the director of nursing, and ASM #4, regional director of clinical services, were made aware of the above concern on 7/29/25 at 1:04 p.m.No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to completely document grievances and failed to document the resolution of the grievances. The findings include: Review of the Grievance/Concern Logs revealed the following: 1. 12/20 (no year) - no room number, no Unit, no relationship to Resident documented 2. 12/27 (no year) - no first name of person filing the concern, no room number, no relationship to Resident documented. 3. 12/30 (no year) - No first name of person filing the concern, no time received, no received by, no staff title, no room number, no relationship to resident, Outcome: Concern Resolved - 12/30 (no year) documented. 4. 12/30 (no year) - no first name of person filing the concern, Concern resolved - 12/30 (no year), documented. 5. 1/9 (no year) - no room number or unit documented. No documentation of resolution. 6. 1/10 (no year) - no first name of resident, no room number or unit documented. 7. 1/10/ (no year) - no room number, no unit, no name of concerned party, no resolution documented. 8. No date, no time, no first name or resident, no dated documented next to Concern resolved. 9. 1/14 (no year) - no resident first name, no room number, no unit, no documentation that the concern was resolved, just a date with no year documented. 10. No date, no time, no received by, no staff title or resolution date documented. 11. No resolution documented. 12. 1/20 (no year) documented. No disposition by administrator. 13. 1/21 (no yea), no room number or Unit. Resolution date 1/23 (no year). 14. 1/27 (no year), no resolution date documented. 15. No date, no time, no received by, no resident name, no room number. Missing cigar silver holder, pt said he didn't know where it went was on the smoker's table. No resolution date documented. 16. 2/3 (no year) .Resolution ongoing - no date or signature from administrator. 17. 2/5/ (no year) no time, no received by documented. No resolution or date resolved or administrator signature. 18. 2/5 (no year) - Getting up on time - CNA (certified nursing assistant) concern. Nothing else documented on form. No resolution documented. 19. 2/5 (no year) - CNA on phone during meal pass, food is cold. No other documentation. The rest of the form is blank. 20. 2/7 (no year) - No first name of resident, no room number documented, Pt states she is missing all her clothes, pants and underwear. All of them. Nothing else is documented on the form regarding investigation or resolution. 21. 2/10 (no year) - No resolution documented and no review by the administrator. 22. 2/11 (no year) - No review by the administrator. 23. 2/18 - (no year) - No resolution documented. 24. 2/20 (no year) - no patient name, room number or unit. Resolved on 2/20/25. 25. 2/21 (no year) - no patient name, room number or unit. Resolved on 2/21 (no year) documented. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 3/12/25 at 3:35 p.m. ASM #1 stated the process for a resident, family or any concerned party, a concern form if filled in. I give it to the department that it involves. Once it is completed it is to be returned to him. The above forms were reviewed with ASM #1. He stated there is no excuse, it should be filled out and the grievances should have documentation as to when it was resolved. The facility policy, Service Concerns/Grievances documented in part, Policy: The Administrator is responsible for ensuring that the management staff are trained in appropriately resolving in-house. patient/family service concerns and grievances at the point of service as promptly as possible. The management staff of the Health and Rehabilitation Center is charged with listening and responding to questions, needs problems or concerns brought to their attention by patients and/or families within the Health and Rehabilitation Center .Procedure: 1. Center Nursing Staff, Social Work, and Discharge Planners or any other team member receiving questions or issues of concern regarding care and/or services are to immediately respond at the point of service in an effort to satisfactorily resolve issues of concern. 2. If an issue of concern cannot be immediately and satisfactorily resolved at the point of service, the management staff member will notify the patient/family member that the concern is being submitted to the appropriate department manager and that follow up for resolution will be provided as quickly as possible. The company Grievance form is to be promptly submitted by the staff member through the electronic system. 3. The department manager receiving the concern actively and promptly initiates action (no later than 48 hours of receiving the concern). The department manager will follow up with the patient/family to determine satisfaction and record their actions in the electronic system. This follow up will be sent electronically to the Administrator. 4. The Administrator will follow up as needed with the patient/family regarding satisfactory resolution and will verify the final outcome in the electronic system under the resolution section of the grievance form .6. Grievance logs should be downloaded from the electronic system each month and maintained in a separate administrative file and is to be used for summarizing, referencing and tracking Center concerns for the month. Thses forms are to be maintained on file for three years. ASM #1, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were made aware of the above concern on 3/12/25 at 11:00 a.m. No further information was provided prior to exit.

Based on family interview, staff interview, and clinical record review, it was determined the facility staff failed to release the medical records for one of three residents in the survey sample, in a timely manner, Resident #1. The findings include: An interview was conducted with the family member of Resident #1, (This person was not on the face sheet) on [DATE] at 11:15 a.m. The family member stated that the family requested the copy of the medical record on [DATE] and did not receive them until the second or third week of February. The emails sent between the resident's family, the facility medical records staff member (OSM [other staff member] #1), the administrator and the legal department of the facility were reviewed. This is the timeline of events related to the family obtaining the copies of the medical record. [DATE] - family reached out to administrator for records. Administrator notified OSM #1. [DATE] - OSM #1 contacted the other family member, listed on the face sheet and the responsible party, to let them know the needed to send to legal department for release of records. OSM #1 emailed the authorization to the family member. [DATE] - family member emailed the signed authorization and a copy of the death certificate. [DATE] - OSM #1 emailed the documents to legal department. [DATE] - legal emailed with confirmation stating received request, assigned a case number and asked for additional documents. [DATE] - OSM #1 responded to legal to let them know that she had attached the copy of the death certificate, and the requester is the next of kin (wife). [DATE] - family called and requested an update. OSM #1 let them know they were waiting on legal. [DATE] - OSM #1 reached out to the family and informed them that she had sent legal another email asking for an update and OSM #1 made ASM (administrative staff member) #1, the administrator, aware of the situation. [DATE] - family emailed for a follow up. Family email ASM #1 about being displeased with the request for how records being handled. (ASM #1) emails them back letting them know, yes, everything does go through legal and typically is quick, that medical records did send on [DATE] and he has reached out to legal that there is no POA (power of attorney) in this situation when they asked for that document, and why are they holding this request. [DATE] - Family provided POA to ASM #1. ASM #1 provided POA to OSM #1, POA sent to legal. [DATE] - OSM #1 emailed legal, resent all documents. [DATE] - OSM #1 emailed legal for update. [DATE] - ASM #1 responded to family, letting them know he just heard from legal that they need representative of the estate of deceased affidavit. [DATE] - Family provided Affidavit, Affidavit sent to legal. [DATE] - ASM #1 let family know documents have been sent. [DATE] - OSM #1 emailed legal to request status of request. [DATE] - OSM #1 emailed legal, legal stated they didn't have all of the documents. [DATE] - ASM #1 emailed family, letting them know they have sent all of the documents to legal. [DATE] - ASM #1 emailed legal and asked for update. Legal stated they don't have all of the documents. OSM #1 resent all documents. Legal stated they could release the records. The family asked for any update. ASM #1 informed them the facility had just got clearance to release the record. [DATE] - OSM #1 spoke with the son and made arrangement for the wife of Resident #1 to pick the records up. The son stated the wife would pick them up on [DATE]. Thirty-two days after the initial request for the records. An interview was conducted with OSM #1 on [DATE] at 10:25 a.m. OSM #1 stated the process for obtaining a copy of a resident's medical records is as followed. The person comes into the building and asks for a copy of the records. She gives them the form to fill out. OSM #1 then sends it to the legal department. Legal will email back with a case number. OSM #1 stated that if legal needs any other documents they will let her know. When asked how soon should records be release to the resident and/or family, OSM #1 stated it should be within 30 days. OSM #1 stated, in this case, the family informed me that the resident had passed away. From her training for this job, she was instructed that she needed the authorization form and the copy of the death certificate for deceased residents. She had never heard or been trained in needing some sort of Affidavit. An interview was conducted with ASM #1 on [DATE] at 10:41 a.m. ASM #1 stated the normal process if for him to give the request to OSM #1. OSM #1 normally handles the request, and he doesn't usually get involved. He stated the family was concerned and wanted updates as to why they were not getting the records in a timely manner. He reached out to legal, and it finally got the authorization to release the records. When asked how long the facility has to get the records to the requesting resident and/or family, ASM #1 stated they have 30 days. ASM #1, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were made aware of the above concern on [DATE] at 11:00 a.m. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide adequate supervision for residents smoking and leaving the building, for five of 50 residents in the survey sample; Residents #148, #90, #97, #120, and #136. 1. For Resident #148, the facility staff failed to provide resident supervision and safety for smoking. Resident #148 was assessed on the Smoking Safety Screen dated 3/8/24 and 6/8/24 as requiring supervision for smoking. On 7/8/24 at 3:00 PM, Resident #148 was observed smoking in an outdoor garden area with raised plant beds. There was no staff supervision present, no safe cigarette disposal receptacle, no fire blanket and no fire extinguisher in the immediate area. 2. For Resident #90 (R90), the facility staff failed to provide supervision for safety. 3. For Resident #97 (R97), the facility staff failed to provide supervision for safe leave of absence. On 7/9/24 at 5:50 PM, R97 was observed walking over to Walgreens without a cane. This resulted in Immediate Jeopardy (IJ) and SQC (substandard quality of care), which was identified in the area of Quality of Care on 7/8/24 at 4:17 PM for concerns related to smoking and on 7/9/24 at 5:30 PM for concerns related to unsupervised leave of absences. The plan of removal for the immediacy related to smoking concerns was accepted on 7/8/24 at 9:49 PM and as related to leave of absence concerns on 7/9/24 at 6:09 PM. The IJ was removed on 7/9/24 at 1:46 PM related to smoking concerns and on 7/11/24 at 10:32 AM related to the leave of absence issues, with the Scope and Severity lowered to a Level 2, Pattern. 4. For Resident #120, the facility staff failed to evidence staff were aware of the resident leaving the facility to ambulate unsupervised across the street to the local drug store. On 7/9/24 at 9:20 AM, Resident #120 stated that he leaves the facility two to three times a week to go across the street to the local drug store and does not sign out and does not notify staff that he is leaving. 5. The facility failed to provide a safe environment for Resident #136 On 7/9/24 at 7:53 AM, Resident #136 was observed ambulating independently with a rollator walker off facility property. Resident #136 was observed crossing the street at two points of a major intersection using the pedestrian walkways. Resident #136's gait was shuffling and show. He turned into the facility driveway and walked down the center of the driveway where cars were entering and exiting, rather than using the facility sidewalk. He was wearing a red and yellow safety vest. The findings include: 1. For Resident #148, the facility staff failed to prevent the resident from smoking unsupervised, in an unapproved area devoid of any safety requirements (staff supervision, safe disposal of cigarette butts, smoking blanket and fire extinguisher) on 7/8/24 at 3:00 PM. Resident #148 was admitted to the facility on [DATE] and was coded on the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/8/24 at 3:00 PM, Resident #148 was observed self-propelling his wheelchair down the main front sidewalk of the facility towards the wooded area. He then turned right onto another sidewalk and entered through a gate into a facility garden area with raised plant beds. He then was observed obtaining a cigarette and lighter from his person and lighting it. At this time he was interviewed and stated that he goes to this area to smoke and he keeps his smoking materials on his person. He was observed to throw his cigarette butt on the ground. On 7/8/24 at 3:24 PM, Resident #148 was still observed to be smoking in garden area. There was no staff present for supervision, no devices for the safe disposal of cigarette butts, no fire blanket and no fire extinguisher was observed in the immediate area. On 7/8/24 at 3:42 PM, in an interview with Resident #148 in his room, he stated that he keeps his lighter and cigarettes on himself at all times. He states that he smokes whenever he wants to and wherever he wants to when outside. A review of the clinical record revealed that Resident #148 was assessed on Smoking Safety Screen dated 3/8/24 and 6/8/24 as requiring supervision for smoking. A review of Resident #148's comprehensive care plan revealed one dated 3/8/24 for (Resident #148) prefers to smoke . This care plan included an intervention dated 3/8/24 for May smoke independently. This intervention did not accurately reflect the resident's Smoking Safety Screen that deemed the resident required supervision to smoke. Additional review of Resident #148's clinical record revealed a Patient Smoking Acknowledgement form, undated, but was scanned into the electronic health record on 3/12/24, and was signed by the resident. This form documented, in part, 4. Patients who wish to smoke will be evaluated using the Smoking Safety Screen upon admission and as needed to determine need for supervision. The patient must also agree to the policy and sign the Patient Smoking Acknowledgement form, which is to be maintained in the patient's medical record. 5. Based on the Smoking Safety Screen, a patient may smoke in designated smoking area(s) either independently or with supervision. 6. If supervision is deemed necessary the patient will be supervised by staff or other appropriate person (i.e., family member). 7. The facility will maintain all smoking paraphernalia for residents who require supervision with smoking. Residents who do not require supervision may maintain possession of their own smoking paraphernalia. 8. If there is reason to indicate failure to comply with the conditions stated in this policy, patient consents for staff to search patient's person and/or property for any smoking paraphernalia. 9. Failure to comply with the conditions of this policy may result in the initiation of the discharge process. A review of the facility policy, Patient Smoking dated 1/29/24 documented, identically to the above Patient Smoking Acknowledgement form, 4. Patients who wish to smoke will be evaluated using the Smoking Safety Screen upon admission and as needed to determine need for supervision. The patient must also agree to the policy and sign the Patient Smoking Acknowledgement form, which is to be maintained in the patient's medical record. 5. Based on the Smoking Safety Screen, a patient may smoke in designated smoking area(s) either independently or with supervision. 6. If supervision is deemed necessary the patient will be supervised by staff or other appropriate person (i.e., family member). 7. The facility will maintain all smoking paraphernalia for residents who require supervision with smoking. Residents who do not require supervision may maintain possession of their own smoking paraphernalia. 8. If there is reason to indicate failure to comply with the conditions stated in this policy, patient consents for staff to search patient's person and/or property for any smoking paraphernalia. 9. Failure to comply with the conditions of this policy may result in the initiation of the discharge process. On 7/8/24 at 4:26 PM an interview was conducted with RN#6 (Registered Nurse). She stated that there is a courtyard for smoking. She stated that some residents keep their supplies and some are kept at the nurse's station. She stated that it depends on if the resident requires supervision or not. She stated that the smoking area is accessible from 8:00 AM to 8:00 PM. She stated that the area contains a device for disposal of used cigarettes. She stated that there is no smoking anywhere else on the property. She stated that she is unaware of residents smoking anywhere else on the property. She stated that residents who smoke are care planned for smoking. On observation of this courtyard, a sign on the door documented the courtyard is not available from 8:20 PM to 8:00 AM, indicating that the courtyard area is available from 8:00 AM to 8:20 PM. There was a packet of a smoking blanket on the wall just inside the courtyard door. Smoking extinguishing receptacles were noted in the courtyard area. The nearest identified fire extinguisher was inside the building, several yards away from the courtyard door. There was not a fire extinguisher in the immediate vicinity of the courtyard, either inside or outside the door. On 7/8/24 at 4:42 PM an interview was conducted with RN #4. She stated that the facility does a quarterly safety smoking assessment, to determine if a resident is safe to smoke or if they need an apron or supervision. She stated that the nurses or unit manager does the assessment quarterly and with a significant changes in the resident's status. She stated that the times are posted by the courtyard, and that it is just this area where they are allowed to smoke. She stated that the facility prefers to keep the residents smoking materials, but that some residents refuse to let them. She stated that the facility prefers to keep them locked up, and give them to the residents and then have them bring them back. She stated, we prefer to store them for their safety. The potential of them having them is they might smoke in non-designated areas. She stated that the residents should smoke in the designated courtyard only for safety, as it is monitored, and has cigarette disposal receptacles and a fire blanket. 2. For Resident #90 (R90), the facility staff failed to provide supervision for safety while smoking R90 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (1) and hemiparesis (2) following cerebral infarction (3) and seizures. Observation was made of R90 on 7/8/24 at 3:21 p.m., self-propelling themselves in a manual wheelchair with their left arm down the sidewalk directly in front of the facility to the end of the building. The resident proceeded to the end of the sidewalk at the wooded edge of the facility property and stopped under the shade of a tree. R90 was observed to have two packs of cigarettes and a lighter on the side of their wheelchair cushion, they continued to take a cigarette out of the package, place it in their mouth and light it with the lighter using their left hand. When finished with the cigarette R90 was observed to throw the cigarette butt onto the ground. No fire extinguisher, smoking receptacles or safety equipment was observed in the area where R90 was observed smoking. A small round hole was observed on R90's t-shirt near the center of the upper abdomen that was smaller than the size of a dime. No ashes were observed on R90. At that time an interview was conducted with R90. R90 stated that their right side was paralyzed due to a stoke and they were wheelchair bound. They stated that kept their cigarettes and lighter with them all the time and liked to come out front to smoke in the shade. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 6/22/24, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. The most recent Smoking- Safety Screen, dated 6/22/24 documented R90 being assessed as being able to smoke independently. It further documented .Patient understands that smoking may only take place as designated times and in designated smoking areas. Yes . The Patient Smoking Acknowledgement dated 2/20/23 signed by R90 documented in part, .Smoking is only allowed in designated outside smoking areas and where oxygen is not being used or stored . The comprehensive care plan dated 3/3/23, documented in part, Smoking: [Name of R90] is a smoker. Created on: 11/25/2019. Revision on: 10/27/2023. It further documented, Behaviors: [Name of R90] has the potential to display the following behaviors; itching, picking at skin, restlessness (agitation), increase in complaints, cussing, aggression, refusing care, smoking in nonsmoking center, refusing medications, smoking in resident room/bathroom, removing assist bars, refusing KT tape, refusing to change clothes, refusing showers, refusing skin assessments. Created on: 10/19/2019. Revision on: 04/16/2024. On 7/8/24 at 3:44 p.m., an interview was conducted with OSM (other staff member) #12, service ambassador. OSM #12 stated that they worked at the front desk at the facility and saw the residents going in and out of the facility during the day when they were there. She stated that the residents were supposed to let the nurses know where they were going and they did not stop at the desk to let them know what they were doing or where they were going. On 7/8/24 at approximately 4:30 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the nurses completed quarterly smoking assessments were completed on residents that wanted to smoke while at the facility. She stated that these were done to determine if it was safe for the resident to smoke independently or if they needed supervision and any equipment they may need. She stated that there was a courtyard between the units with posted smoking times that they had for the residents to smoke in. She stated that the courtyard was the only area that residents were supposed to smoke because it was monitored, it had the ashtrays and fire blanket and it was for safety. She stated that R90 was alert and oriented but had difficulty getting out what they wanted to say due to the stroke. She stated that R90 preferred to keep their own smoking materials on themselves rather than having the nursing staff store them and the potential risk was them smoking in non-designated areas. RN #4 was asked to assess the hole observed in R90's t-shirt and stated that she could not say exactly what it was. She stated that she would expect to see charring if it were a burn and could not say if washing the shirt would have changed the appearance of the hole. RN #4 asked R90 if they had ever burned their clothing while smoking and R90 stated yes. RN #4 asked R90 if the hole was from a cigarette and they stated yes. No further information was provided prior to exit. Reference: (1) hemiplegia. Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) hemiparesis. Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (3) cerebrovascular disease, infarction or accident. A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm On 7/8/24 at 4:17 PM, the findings of Immediate Jeopardy and substandard quality of care were confirmed during a phone call with the State Agency, related to concerns identified for resident smoking. On 7/8/24 at 5:38 PM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were informed of the Immediate Jeopardy and subsequent SQC (substandard of care) finding and the need to complete a plan of removal. The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 7/8/24 at 6:18 PM. 49369 3. For Resident #97 (R97), the facility staff failed to provide supervision for safe LOA (leave of absence). On 7/9/24 at 10:08 a.m., R97 was interviewed. He stated that he leaves the premises and walks across the street to the store about once a week by himself. He also stated that he lets the front desk, and the nurses know before leaving, but staff do not supervise his trips. He stated that he should be using his cane to walk, but he does not. On 7/9/24 at 5:50 PM, R97 was observed walking over to Walgreens without a cane. He looked both ways on his way to Walgreens while crossing Sunset Lane. He was observed crossing 4 lanes of traffic across the street with no staff supervision. He walked with a shuffling gait. Upon his return to the facility, he was observed crossing the same 4 lanes of traffic with no staff supervision and did not look for oncoming traffic. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/17/24, R97 was admitted to the facility 4/11/24. R97 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). The resident was coded as having a walker and wheelchair and not attempting to walk 150 feet due to medical condition or safety concern. A review of R97's clinical record revealed the resident signed out once to leave the facility on 3/10/24. A review of physical therapy recommendations for 5/29/24- 6/25/24 revealed, in part: Pt (Patient) was re-educated as to the potential benefits of using an amb. (ambulation) device (vs. no device) - as well as to wear shoes with all standing/amb. Activity to minimize fall risk (in light of recent fall). A review of R97's physical therapy discharge summary for 5/29/24- 6/25/ revealed, in part: Ambulation .Walking 10 feet on uneven surfaces= supervision or touching assistance. 1 step (curb) = Supervision or touching assistance. A review of R67's care plan revealed, wheeled walker for ambulation and transfers. On 7/9/24 at 3:42 p.m., LPN (licensed practical nurse) #3 was interviewed. She stated that, to know if a resident is safe to leave, they look at their BIMS score, and it has to be above a 10. She also stated, with the BIMS score anything below 8 staff the resident is cognitively impaired. She stated that MDS does the BIMS coding on the residents, so if nursing staff disagree with a BIMS of someone trying to leave, nursing staff will look at safety. LPN #3 stated that in the past, staff had to assess people who wanted to leave and that somebody would go with them and see if they knew how to cross the street. She stated that as a floor nurse if someone wants to leave, she has to check if the resident is their own responsible party and if they are not, have them sign out in the sign out book. LPN#3 stated if the resident cannot sign out, a X is documented in the sign out book and a staff sign beside the X. She stated that nurses try to write a note for documentation. She also stated that sign out sheets tell staff where the person is, but they will call the resident if they want to check up. On 07/09/24 at 4:03 p.m., OSM (other staff member) #20, the Rehab Manager, was interviewed. She stated that if residents wish to independently leave the facility, therapy assesses them on community outings if that was something desired at admission. She also stated that it is something that is documented in therapy's evaluations and discharge summary. OSM #20 stated that therapy makes the determination that it is safe for residents to leave after they ambulate with residents or simulate those type of environments. She stated that therapy assess for safety so things like assistance device management and awareness of surroundings would be included in that. She also stated that R97's need for a cane or walker can increase the chances of injury if not used properly. OSM #20 further stated that the therapy staff did not specifically evaluate R97 for community outings, but the resident was assessed as requiring supervision or touching assistance when walking 10 feet on uneven surfaces. OSM #20 stated supervision meant someone should have eyes on the resident. OSM #20 stated that if R97 independently ambulated in the community without a complete assessment, and without supervision, he could have a fall with an injury. The facility policy, Leave of Absence (LOA), revealed, in part: When patients leave the center for reasons other than a medical transfer initiated by the center, the patient and/or responsible party will provide signature, accepting complete responsibility of the patient and absolving the management, personnel, and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away. On 7/9/24 at 5:42 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, and ASM #4, the regional vice president of clinical services, were notified of Immediate Jeopardy (IJ). The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 7/9/24 at 7:32pm. No further information was provided prior to exit. 42106 4. For Resident #120, the facility staff failed to implement a LOA (leave of absence) process for resident safety to ensure the facility had knowledge of Resident #120's whereabouts at all times. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #120 was coded as moderately impaired in ability to make daily life decisions, scoring a 12 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). A review of the physical therapy notes revealed the following: On 3/21/23 was documented, Gait training over indoor/outdoor surfaces for distance of 1033 (feet) without AD (assistive device) over concrete/carpet/grass/tile .focusing on directional changes and obstacle negotiation. On 3/27/23 was documented, Pt (patient) ambulated around building on uneven and even surfaces. Patient performed gait training showing ability to maneuver through environment and crouch when needed without LOB (loss of balance) over lvl (level) and unlevl (unleveled) surfaces (grass/concrete) . On 3/30/23 was documented, Pt performed gait training on level and unlevel surfaces both inside and outside for over 1000ft (feet). Also demonstrated ability to ascend and descend stairs to test balance and coordination . On 4/1/23 was documented, Gait training throughout facility over 1000 (feet) .focusing on directional changes and obstacle negotiation . On 4/3/23 was documented, Gait training over indoor/outdoor surfaces (I) (independently) without AD (assistive device) focusing on directional changes and obstacle negotiation with no LOB (loss of balance) noted. The above reflected the resident's ability to safely ambulate over various level and unlevel surfaces for an extensive distance in 2023. Further review of the clinical record revealed that Resident #120 has not had any falls in the calendar year of 2024 from 1/1/24 through this survey of 7/11/24. A nurse's note dated 4/9/24 documented, He went to (name of drugstore across the street) . A review of the sign out sheet for Resident #120 revealed the last time he actually signed out to go anywhere was on 10/18/23. There was no sign out for a leave of absence since 10/18/23 up through this survey of 7/11/24. On 7/9/24 at 9:20 AM, Resident #120 states he goes out about three times a week across the street to the local drug store. He stated that he does not tell anyone and does not sign out. He stated that he has no issues with walking, has had no falls, and does not need the assistance of a walker or wheelchair. He stated that he looks out for traffic and is careful about crossing the street. On 7/9/24 at 3:44 PM, an interview was conducted with LPN #3 (Licensed Practical Nurse). She stated that Resident #120 signs himself out frequently, goes to (local drug store across the street). She stated that she has not actually seen him cross the road, but that he is aware of his surroundings, is steady on feet, requires no assistive devices, has no disability with ambulation, but is hard of hearing. She stated that if a resident wants to leave the facility independently, that staff should check to see if the resident is their own RP (responsible party), check their BIMS, make sure they have their cell phone available, and have them sign out in the sign out book. She stated that everyone has to sign out when they leave. She stated that if possible, find out what they want and see if someone can go get it for them, so they do not have to go out if it is a really hot or cold day. She stated that risks would include heat stroke, passing out, getting hit by a car. When asked about the likelihood of these things happening, she stated that it could happen to anyone. She stated that a resident with a physical impairment or need for assistive devices increases the likelihood of something happening. She stated that therapy can help assess a resident to see if they are safe to leave independently. On 7/10/24 at 2:22 PM an interview was conducted with LPN #8. She stated that she always see him in the building, never seen him go out. He has never notified me he was going out. A review of the comprehensive care plan failed to reveal any interventions for the resident to go on leave of absence independently. The facility policy, Leave of Absence documented, When patients leave the center for reasons other than a medical transfer initiated by the center, the patient and/or responsible party will provide signature, accepting complete responsibility of the patient and absolving the management, personnel, and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away. 1. Before a patient leaves the premises for any reason other than a medical transfer initiated by the center, the patient and/or responsible party must notify a licensed nurse on the unit. 2. A licensed nurse ensures that medical approval of the leave has been provided by the patient's provider. This can be in the form of a provider's order. 3. The Release of Responsibility for Leave of Absence (LOA) Form is filled out prior to leaving the center, the date, time, and signature of the person accepting responsibility is filled in. 4. The estimated time of return is provided to a licensed nurse. 5. A licensed nurse will make arrangements with the pharmacy for any necessary medications to be sent with the patient, if applicable. 6. If the patient will not be returning to the center on the same day as the beginning of the leave, the patient and/or responsible party must also notify nursing, Admissions Director, Business Office Manager, or the Administrator prior to or at the time of departure to initiate a Voluntary Bed Retention Agreement, if applicable. 7. A licensed nurse will note the LOA in the medical record. 8. Upon return to the center, the patient or responsible party will sign back in with date and time on the LOA form and a center staff will sign the form accepting responsibility of the patient at that time. 9. A licensed nurse will note return in the medical record, including the condition of the patient or any issues experienced during the LOA expressed by the patient or responsible party (fall, bruise, skin tear, change in condition, etc.). 10. Notify the provider, if necessary, and document in the medical record. No further information was provided prior to exit. 42183 5. The facility failed to provide a safe environment for Resident #136 while on LOA (leave of absence) On 7/9/24 at 7:53 AM, Resident #136 was observed ambulating independently with a rollator walker off facility property. Resident #136 was observed crossing the street at two points of a major intersection using the pedestrian walkways. Resident #136's gait was shuffling and show. He turned into the facility driveway and walked down the center of the driveway where cars were entering and exiting, rather than using the facility sidewalk. He was wearing a red and yellow safety vest. Resident #136 stated he goes to the local gas station each morning, then returns to the facility to eat breakfast. He stated after breakfast each day, he leaves the facility to go off the property to a local wellness center. Resident #136 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ASCVD (atherosclerotic cardiovascular disease), atrial fibrillation and Poly osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/21/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for bed mobility, transfer, dressing and eating; supervision for hygiene and bathing. A review of the comprehensive care plan dated 9/13/23 revealed, FOCUS: The resident requires assistance with ADLS (activities of daily living). INTERVENTIONS: Resident frequently signs self out LOA, have provided safety vest to wear as tolerated. Remind resident to use walker for ambulation and transfers. A review of Resident #136's Elopement Risk assessment dated [DATE], scored the resident as a '3'= low risk. There was no evidence of an assessment to determine the resident's safety to leave the facility independently on leave of absence. A review of Resident #136's sign-out sheet, revealed the last time he signed out was 12/23. On 7/9/24, the facility receptionist was interviewed. She stated the resident leaves the facility each morning, and that he is supposed to sign out on his unit. An interview was conducted on 7/9/24 at 3:45 PM with LPN (licensed practical nurse) #3. When asked what is your role when a resident wants to leave the facility, LPN #3 stated, we check if they are their own RP (responsible party), their BIMS, sign them out in the sign out book and write a note in the sheet, what time they went out. If they are gone a long time, we call the resident's cell phone, 'just checking on you, when are you coming back'. If they are their own RP they must sign out, if they are not their own RP, we call the RP and get permission and then 2 nurses' sign. If the resident cannot sign their name, we have them do an X and then 2 nurses' witness. I am assuming Resident #136 has been assessed because he has a safety vest as on my days off, I have seen him at the pharmacy and the grocery store. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. The facility's LOA (Leave of Absence) policy revealed the following, When patients leave the center for reasons other than a medical transfer, the patient will provide signature accepting complete responsibility of the patient for any deterioration in condition or accident that may happen while the patient is away. Upon return to the facility, the patient will sign back in with date and time. No further information was provided prior to exit. Immediate Jeopardy: A. On 7/8/24 at 4:17 PM, the findings of Immediate Jeopardy and substandard quality of care were confirmed during a phone call with the State Agency, related to concerns identified for resident smoking. On 7/8/24 at 5:38 PM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were informed of the Immediate Jeopardy and subs [TRUNCATED]

Based on staff interview and facility document review, the facility staff failed to respond to resident council concerns for two of three resident council meetings reviewed, the May 2024 and June 2024 meetings. The findings include: The facility staff failed to respond to the May and June 2024 resident council's concern regarding missing clothing. A review of the 5/8/24 resident council meeting notes revealed the following documentation, .clothes still missing . A review of the 6/5/24 resident council meeting notes revealed the following documentation, .clothes still being missing . A review of the facility grievances/concerns for 5/1/24 to the present failed to evidence any grievances regarding the resident council's missing clothing concerns. On 7/9/2024 at 2:45 p.m., a request was made to ASM (administrative staff member) #4, the regional vice president of operations, for evidence of resolution of concerns voiced by residents regarding missing clothing during the May and June 2024 meetings. On 7/10/24 at 2:28 p.m., an interview was conducted with OSM (other staff member) #14, environmental service director. OSM #14 stated that activities was responsible for resident council meetings and they were not aware of any concerns voiced during meetings about ongoing missing clothing. OSM #14 stated that they handled individual resident concerns as they came in. On 7/10/24 at 3:22 p.m., an interview was conducted with OSM #16, the director of recreation. OSM #16 stated that they followed up with resident council concerns differently depending on what the concerns were. She stated that for the concerns with missing clothing she reported them to the director of environmental services and the administrator. She stated that this was a verbal conversation directly with the managers and she had not been documenting any grievances or resolutions of the concerns since she had been in the positron and moving forward she planned to start documenting them. On 7/11/24 at approximately 9:00 a.m., ASM #4, the regional vice president of operations stated that they did not have any evidence of resolution for the concerns regarding missing clothing voiced at the May and June 2024 resident council meetings. The facility policy titled, Resident Council dated 11/1/23, documented in part, .10. Document Council concerns/problems in Resident Council Minutes. Individual concerns should be addressed on the company's Service Concern report form. Immediately inform the Administrator of any urgent issues, council concerns, or problems . The facility policy Grievance dated 1/23/20, documented in part, The patient has a right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking their conclusion. On 7/11/2024 at approximately 9:12 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition and possible need to alter treatment for one of 50 residents in the survey sample, Resident #106. The findings include: For Resident #106 (R106), the facility staff failed to notify the physician of the resident's blood sugars over 400, per a physician's order. A review of R106's clinical record revealed a physician's order dated 4/15/24 that documented to administer Lispro insulin (used to treat diabetes) based on a sliding scale dependent on the resident's blood sugar before meals and at bedtime. The order further documented to contact the physician if R106's blood sugar was greater than 400 or less than 60. A review of R106's June 2024 and July 2024 MARs (medication administration records) revealed the following blood sugars on the following dates: 6/2/24 11:00 a.m.- 450 6/9/24 11:00 a.m.- 441 6/10/24 7:30 a.m.- 401 6/10/24 4:00 p.m.- 432 6/11/24 4:00 p.m.- 448 6/12/24 4:00 p.m.- 410 6/17/24 9:00 p.m.- 425 6/19/24 4:00 p.m.- 448 6/23/24 9:00 p.m.- 404 6/25/24 11:00 a.m.- 449 7/3/24 9:00 p.m.- 450 7/6/24 9:00 p.m.- 419 Further review of R106's clinical record (including the June 2024 and July 2024 MARs, nurses' progress notes, and change in condition notes) failed to reveal the facility staff contacted the physician regarding any of R106's above blood sugars that were greater than 400. On 7/10/24 at 1:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that if a resident has a physician's order to contact the physician for a blood sugar greater than a specified parameter, then when the nurse takes the blood sugar and the blood sugar is over the parameter, the nurse needs to call the physician to get new orders or maintain current orders, depending on what the physician wants to do. RN #3 stated nurses should evidence the physician notification by documenting a progress note or change in condition note. On 7/11/24 at 8:52 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Significant Change in Condition documented, 1. A licensed nurse will assess the patient for signs and symptoms of change in condition. 2. Notify provider and document in Progress Notes. No further information was presented prior to exit.

4. For Resident #32 (R32), Resident #34 (R34), and Resident #104 (R104), the facility staff failed to serve lunch in a homelike manner on 7/8/24. Staff left meal trays and plate lids sitting on the tables during the meal. On R32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/27/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On R34's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/29/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On R104's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/20/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On 7/8/24 at 12:46 p.m., staff were observed serving meal trays to residents in the dining room. Staff removed meal trays from carts in the dining room and placed the meal trays on tables. After placing the meal trays on the tables, staff left the plate of food, beverage, and utensils on the meal trays, removed the plate lids and left the lids on the table for the duration of the meal. On 7/8/24 at 12:58 p.m., an interview was conducted with R32, R34, and R104. All three residents stated they did not like the meal trays and plate lids being left on the table during meals because there was not enough room on the table. On 7/10/24 at 1:41 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated the staff leaves meal trays and plate lids on the tables during resident meals. CNA #1 stated this was not homelike and would not be done in a restaurant or at home. CNA #1 stated the meal trays and plate lids could be placed back on the meal carts while residents eat their meals. On 7/11/24 at 8:52 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding dining. No further information was presented prior to exit. 42106 Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for six of 50 residents in the survey sample, Residents #10, #131, #121, #32, #34 and #104. The findings include: 1. For Resident #10 (R10), the facility staff failed to maintain the resident's room in good repair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/5/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 7/8/24 at approximately 3:30 p.m., an observation of R10's room was conducted. Blue tape approximately one inch wide was observed along a portion of the baseboard approximately 12 inches long on the window side of the room. The electrical outlet above the area was observed to have blue tape surrounding the plastic outlet cover on each side. The un-taped portions of the baseboard on the wall located along the window side of the room were observed to be separated from the wall exposing dried adhesive on the wall beneath. At this time an interview was conducted with R10 who stated that they did not know why the tape was there and it had been that way for a long time. R10 stated that someone had worked on that area a long time ago and never came back and they felt that it was ugly. On 7/10/24 at 12:40 p.m., an interview was conducted with OSM (other staff member) #17, maintenance technician. OSM #17 stated that they had a program on their phone which showed them any open work orders for repairs needed in the facility. OSM #17 reviewed the program and stated that there were no open work orders for R10's room. OSM #17 observed the blue tape approximately one inch wide along the baseboard approximately 12 inches long on the window side of the room, the electrical outlet above the area with blue tape surrounding the plastic outlet cover on each side and the un-taped portions of the baseboard on the wall that were separated from the wall exposing dried adhesive on the wall beneath. He stated that it appeared that someone may have attempted to glue the baseboard back to the wall and then taped it to dry and it had not been removed. He stated that he was not sure why the electrical outlet cover was taped. OSM #17 stated that he did not think that the room was homelike with the baseboard coming off the wall and the blue tape on parts of the baseboard and electrical outlet. On 7/11/24 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. On 7/11/24 at approximately 11:51 a.m., ASM #4, the regional vice president of operations stated that the facility did not have a policy regarding maintaining a homelike environment. No further information was presented prior to exit. 2. For Resident #131 (R131), the facility staff failed to maintain the resident's room in good repair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/16/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 7/8/24 at approximately 3:27 p.m., an observation of R131's room was conducted. Blue tape approximately one inch wide was observed along a portion of the baseboard approximately 12 inches long on the window side of the room. The electrical outlet above the area was observed to have blue tape surrounding the plastic outlet cover on each side. The un-taped portions of the baseboard on the wall located along the window side of the room were observed to be separated from the wall exposing dried adhesive on the wall beneath. At this time an interview was conducted with R131 who stated that the wall on the window side of the room had looked like that for months. R131 stated that a staff member had taped it up and said they would be back to fix it and never came back. R131 stated that they would like to have it fixed. On 7/10/24 at 12:40 p.m., an interview was conducted with OSM (other staff member) #17, maintenance technician. OSM #17 stated that they had a program on their phone which showed them any open work orders for repairs needed in the facility. OSM #17 reviewed the program and stated that there were no open work orders for R131's room. OSM #17 observed the blue tape approximately one inch wide along the baseboard approximately 12 inches long on the window side of the room, the electrical outlet above the area with blue tape surrounding the plastic outlet cover on each side and the un-taped portions of the baseboard on the wall that were separated from the wall exposing dried adhesive on the wall beneath. He stated that it appeared that someone may have attempted to glue the baseboard back to the wall and then taped it to dry and it had not been removed. He stated that he was not sure why the electrical outlet cover was taped. OSM #17 stated that he did not think that the room was homelike with the baseboard coming off the wall and the blue tape on parts of the baseboard and electrical outlet. On 7/11/24 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit. 3. For Resident #121 (R121), the facility staff failed to exercise reasonable care for the protection of the resident's property from loss. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/23/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 7/8/24 at 12:22 p.m., an interview was conducted with R121 in their room. R121 stated that they had multiple missing clothing items over the course of about a year. R121 stated that they had reported the missing items multiple times to the nursing staff, the social worker and the laundry and they all told them that they would look into it. R121 stated that they were missing all of their underwear, multiple pairs of shorts, multiple shirts, and most recently a shirt and pants set that their family member had brought in to them. R121 stated that all items were labeled with their name prior to going to the laundry. R121 stated that the laundry staff had told them that they were unable to find anything and had given them some of the lost and found clothing and someone had cut off some leggings to make shorts for them. R121 stated that they took the lost and found clothing because that was the only option they were given and was told that they needed to have pictures of the clothing for the staff to be able to locate it. The resident property list for R121 documented two pages listing multiple clothing items including pants, shirts, sweaters and shorts dated 1/6/23. Review of the facility grievance logs from 1/1/23 to the present failed to evidence any documented grievances for R121. On 7/9/24 at 11:32 a.m., an interview was conducted with OSM (other staff member) #13, housekeeping assistant/laundry. OSM #13 stated that when a resident reported missing clothing they found out the residents name, room number and got a description of the clothing that was missing. She stated that they searched for the clothing in the laundry and if not found they reported to their manager. She stated that she remembered looking for missing clothing that R121 reported and remembered a CNA (certified nursing assistant) bringing in the name and color of the clothing. She stated that she thought they found something. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA #2. CNA #2 stated that if a resident reported missing clothing they went to the laundry to search for the items. She stated if they were unable to find the item they reported it to the nurse. She stated that she was not aware of R121 missing any clothing. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a resident was missing clothing they searched the room for the clothing and if not found they notified the laundry and unit manager. She stated that if the clothing was still not found the social worker became involved and normally they replaced the items. She stated that she was not aware of R121 missing any clothing but did not work with them every day. She stated that all residents had a personal belongings inventory list kept at the nurses station which they were encouraged to keep up to date to track any belongings that may go missing. On 7/10/24 at 2:28 p.m., an interview was conducted with OSM #14, EVS (environmental services)director. OSM #14 stated that when his staff had searched for a resident's missing clothing and were not able to find anything he reported it to the administrator and they normally replaced it. He stated that currently they were not completing grievances for missing clothing but they were starting the process. He stated that they asked families to send them pictures to help them identify missing clothing if possible. He stated that they had given R121 some of the lost and found clothing that would fit them. He stated that he had quarterly sessions for the residents to come look through unlabeled/unclaimed clothing in the dining room to see if anything was theirs and had put that in place when he came about 10 months ago but had told residents that there was not much that he could do for things that happened prior to him being in the position. He stated that after the quarterly sessions with lost and found the rest of the clothing was donated because they could only hold things for so long. On 7/10/24 at 2:42 p.m., an interview was conducted with OSM #15, the director of discharge planning. OSM #15 stated that if a resident reported missing clothing they went to the laundry to look for the items and talked with the EVS director. She stated that if the items were not found they typically would get approval from administrator to replace them. She stated that all resident belongings were supposed to be documented on the property list and they encouraged the resident and the family to keep the list up to date. She stated that on admission the nurse completed the list and it was updated as new items came in. She stated that R121 had reported missing clothing to them and she knew that the laundry had worked to find the items. She stated that the laundry had informed them that they had given R121 some donated clothes and she had not personally replaced any of the missing clothing. She stated that she was not aware that all of R121's underwear was missing and that she did the shopping for R121 and would be able to get them some if they wanted her to. The facility policy Personal Belongings dated 1/29/24, documented in part, .1. At the time of admission, a nursing staff member will assist the patient and their family in putting away and storing their personal belongings. All clothing should be marked with the patient's name (garment is to be marked on the inside of the garment with permanent ink) .4. If a patient is missing a personal item, the center will make every attempt to locate the item. Although the center is not responsible for personal possessions or valuables of the patients, a patient or their family is encouraged to meet with the administrator or other center administrative personnel regarding missing items or other concerns involving their personal belongings . On 7/11/24 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 50 residents in the survey sample, Residents #89, #13, #106, #86 and #56. The findings include: 1. For Resident #89 (R89), the facility staff failed to implement the comprehensive care plan to assist with personal hygiene. R89 was observed having a brown substance underneath their fingernails on 7/8/24 at 12:47 p.m., 7/9/24 at 9:05 a.m. and 7/10/24 at 9:19 a.m. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/18/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R89 requiring substantial/maximal assistance for personal hygiene and dependent on staff for bathing. The comprehensive care plan for R89 documented in part, ADLs (activities of daily living): [Name of R89] has an ADL self-care performance deficit r/t (related to) activity intolerance, muscle weakness, AMS (altered mental status) . Created on: 06/01/2020. Under Interventions it documented in part, . Bathing/Showering: The resident is a staff assist. Date Initiated: 10/26/2021 . Personal Hygiene/Oral Care: The resident is a staff assist. Resident is edentulous. Date Initiated: 10/26/2021 . On 7/8/24 at 12:47 p.m., an observation was made of R89 in their room. R89 was observed lying in bed. Observation of R89's fingernails revealed that they were approximately one-quarter inch long with a brown substance underneath them. Additional observations of R89's fingernails were made on 7/9/24 at 9:05 a.m. and 7/10/24 at 9:19 a.m. Observations revealed the brown substance remaining underneath the fingernails. Review of the clinical record failed to evidence documentation of refusal of care during the dates of observations documented above. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that residents fingernails were evaluated during care provided each day and were cleaned underneath if observed to be dirty. She stated that fingernails were assessed for trimming on shower days and during baths. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the purpose of the care plan was for staff to be able to look at it and see what the needs of the resident were. She stated that the care plan should be implemented because that its purpose was to be useful to care for the resident. LPN #3 stated that residents fingernails were assessed on shower days or when observed when working with the resident. She stated that the residents nails were cleaned underneath during daily care and if the resident refused it would be documented. LPN #3 observed R89's fingernails and stated, I see what you mean. LPN #3 asked R89 if they would allow them to clean underneath their nails and R89 stated yes. On 7/11/2024 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. The facility policy Care Planning dated 11/1/19 documented in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient . No further information was presented prior to exit. 2. For Resident #13 (R13), the facility staff failed to implement the comprehensive care plan to provide oxygen as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/24, the resident scored 7 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section O documented R13 receiving oxygen at the facility. The comprehensive care plan for R13 documented in part, Respiratory: [Name of R13] is at risk for respiratory complications secondary to supplementary oxygen requirement. Created on: 01/08/2024. Revision on: 01/08/2024. Under Interventions it documented in part, .administer oxygen as ordered. Date Initiated: 01/08/2024 . The physician orders for R13 documented in part, Oxygen Therapy - Oxygen at 2L/min (liters per minute) via NC (nasal cannula) every day and night shift. Order Date: 01/08/2024. On 7/8/24 at 1:07 p.m., an observation was made of R13 in their room. R13 was observed in bed wearing a hospital gown and an oxygen nasal cannula. The nasal cannula was observed to be attached to a portable oxygen tank placed in a rolling carrier beside R13's bed. Observation of the portable tank revealed the tank flow dial set at zero and the tank oxygen gauge reading empty. R13 was not able to be interviewed due to their cognition level. Additional observation of R13's nasal cannula attached to the portable oxygen tank set at zero was made on 7/8/24 at approximately 1:30 p.m. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the purpose of the care plan was for staff to be able to look at it and see what the needs of the resident were. She stated that the care plan should be implemented because that its purpose was to be useful to care for the resident. LPN #3 stated that oxygen concentrators were used in resident's rooms and they used the portable oxygen tanks when residents were going out for appointments or going for therapy or activities. She stated that anytime a resident was using a portable tank they should get a full tank and it was checked every two hours to ensure that it was running low or empty. She stated that she was not sure why R13 was on the portable tank in their room and that perhaps the concentrator had malfunctioned but the portable oxygen should not have been empty or set to zero. On 7/11/2024 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit. 31753 3. For Resident #106 (R106), the facility staff failed to implement the resident's comprehensive care plan for physician notification of a change in condition. R106's comprehensive care plan dated 3/27/24 documented, CARE NEEDS: (Name of R106) has the following basic care needs: HX (History) of DM (Diabetes Mellitus) Type 1 .MD/NP/RP (Medical Doctor/Nurse Practitioner/Responsible Party) will be notified of the appropriate change in condition. A review of R106's clinical record revealed a physician's order dated 4/15/24 that documented to administer Lispro insulin (used to treat diabetes) based on a sliding scale dependent on the resident's blood sugar before meals and at bedtime. The order further documented to contact the physician if R106's blood sugar was greater than 400 or less than 60. A review of R106's June 2024 and July 2024 MARs (medication administration records) revealed the following blood sugars on the following dates: 6/2/24 11:00 a.m.- 450 6/9/24 11:00 a.m.- 441 6/10/24 7:30 a.m.- 401 6/10/24 4:00 p.m.- 432 6/11/24 4:00 p.m.- 448 6/12/24 4:00 p.m.- 410 6/17/24 9:00 p.m.- 425 6/19/24 4:00 p.m.- 448 6/23/24 9:00 p.m.- 404 6/25/24 11:00 a.m.- 449 7/3/24 9:00 p.m.- 450 7/6/24 9:00 p.m.- 419 Further review of R106's clinical record (including the June 2024 and July 2024 MARs, nurses' progress notes, and change in condition notes) failed to reveal the facility staff contacted the physician regarding any of R106's above blood sugars that were greater than 400. On 7/10/24 at 1:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated the purpose of the care plan is, so staff is able to go in and see the issues with the resident. RN #3 stated the care plan tells the story of the resident and nurses have access to review residents' care plans to ensure they are implemented. RN #3 stated that if a resident has a physician's order to contact the physician for a blood sugar greater than a specified parameter, then when the nurse takes the blood sugar and the blood sugar is over the parameter, the nurse needs to call the physician to get new orders or maintain current orders, depending on what the physician wants to do. RN #3 stated nurses should evidence the physician notification by documenting a progress note or change in condition note. On 7/11/24 at 8:52 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 27660 4. For Resident #86, the facility staff failed to implement the care plan for pressure injury (1) care. The comprehensive care plan dated, 3/1/24, documented in part, Focus: Skin Impairment: The resident has a skin impairment: R/L (right/left) groin necrotizing fasciitis post-surgical, R/L ABD (abdominal) rash, L axilla hidradenitis, L/R scrotum hidradenitis, R lateral groin post-surgical necrotizing fasciitis, L groin post-surgical necrotizing fasciitis, sacrum pressure. The Interventions documented in part, Notify MD (medical doctor) as indicated. Observe area for signs of improvement or decline. Treatment as ordered. The wound care nurse practitioner note dated 5/20/24 documented in part, Sacrum scar tissue. The wound care physician notes dated, 5/31/24, documented in part, Sacrum - stage 2 (2) measuring approximately 1x1x 0.1 cm (centimeters) in size. The physician order dated 5/31/24, documented, Sacrum: Cleanse with wound cleanser, pat dry. Apply silver alginate and cover with border gauze dressing every day shift for Pressure Stage 2. The TAR (treatment administration record) for May, June and July 2024, documented the above order. The treatment was documented as having been administered as ordered. The Skin Observation forms dated the following documented: 5/19/24 - no documentation of a sacrum pressure injury. 5/27/24 - no documentation of a sacrum pressure injury. 6/3/24 - sacrum - pressure - no measurements or stage. 6/10/24 - sacrum - pressure - stage II - no measurements. 6/17/24 - sacrum - pressure - no measurements or stage. 6/24/24 - sacrum - pressure - no measurements or stage. 7/1/24 - sacrum - pressure - no measurements or stage. 7/8/24 - sacrum - pressure - no measurements or stage. 7/9/24 - sacrum - pressure - stage II - no measurements. An interview was conducted on 7/10/24 at 10:15 a.m. with LPN (licensed practical nurse) #3, she stated the purpose of the care plan is for staff to be able to look at it and see what the needs of the resident are. It should be implemented because that its purpose to be useful to care for the resident. ASM #1, the administrator, ASM #2, ASM #3, the regional director of clinical services, and ASM #4, the regional vice president of operations, were made aware of the above concern on 7/11/24 at 9:00 a.m. No further information was provided prior to exit. (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. (2) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. 49369 5. For Resident #56 (R56), the facility staff failed to implement a comprehensive care plan regarding splints. R56 was admitted to the facility on [DATE] with diagnosis of traumatic brain injury, persistent vegetative state, seizures, and contractures of right and left hand. On 7/8/24 at 3:20 p.m., 7/9/24 at 9:15 a.m., and on 7/10/24 at 10:15 a.m., R56 was observed lying in bed without the splint in her right or left hand. A review of R56's care plan revealed, Nursing/Rehab Restorative: Splint, PROM (passive range of motion) first then apply splint. See pictures for BUE splints located in room, staff inservice provided. Wear all splints/positioner for four hours each shift (8 hours daily, as tolerated). Check for skin irritation/pain. It also revealed, BUE, as ordered/tolerated. Splint Trial. On 7/11/24 at 10:23 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated that the resident is contracted and should be wearing the splints but is not. She also stated that the purpose of the care plan is to be able to know what care to provide for a specific resident. On 7/11/24 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator), ASM#2 (the director of nursing), ASM #3 (regional director of clinical services) and ASM #4 (regional vice president of operations) were made aware of the above concern. A review of the facility policy, Care Planning, revealed in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote or maintain the highest level of well being for two of 50 residents in the survey sample; Residents #269 and #151. The findings include: 1. For Resident #269, the facility staff failed to evidence that an IV antibiotic medication that was available, was administered as ordered on six occasions, on 7/13/23 (two doses), 7/14/23 (two doses) and 7/15/23 (two doses). Resident #269 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was coded on the admission MDS dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS. A review of the physician's orders and the MAR (Medication Administration Record) for July 2023 revealed the following regarding a medication Teflaro (1): An order dated 7/11/23 for Teflaro IV (intravenous) 400 MG (milligrams) every 8 hours. A review of the MAR revealed this was scheduled for 12:00 AM, 8:00 AM, and 4:00 PM. It was documented that on 7/12/23, this medication was not administered at 12:00 AM, was administered at 8:00 AM, and was discontinued before the 4:00 PM dose was due. An order dated 7/12/23 for Teflaro IV 400 MG three times a day. A review of the MAR revealed this was scheduled for 11:00 AM, 1:00 PM, and 9:00 PM. It was documented that on 7/12/23, this medication was administered at 1:00 PM and 9:00 PM. Between this order and the above previous order, the resident received all three doses due on 7/12/23 (at 8:00 AM, 1:00 PM, and 9:00 PM). Further review of the MAR revealed that on 7/13/23, this medication was not administered at the 11:00 AM dose, was administered at 1:00 PM, and was discontinued before the 9:00 PM dose. An order dated 7/13/23 for Teflaro IV 400 MG three times a day. A review of the MAR revealed this was scheduled for 12 AM, 6 AM, and 12 PM daily; and as documented above, the resident only received one of three doses on 7/13/23. The resident did not receive a morning dose (as evidenced by a blank spot on the MAR) or evening dose (as evidenced by an X marking out spots on the MAR), for either order / schedule that covered the date of 7/13/23. Further review revealed documentation for all doses on 7/14/23 and the first two doses on 7/15/23 as U-SA. This coding was not in the legend. On 7/10/24 at 3:00 PM, ASM #3 (Administrative Staff Member) the Regional Director of Clinical Services, stated that this code means Unwitnessed self-administration which she stated was not possible given the medication and route, and that it must have been entered into the system incorrectly. She presented a nurse's note dated 7/14/23 at 2:38 PM which would account for the third dose due that date, which documented, MAR would not allow me to sign off on 1200 (noon) Teflaro While this validated that the one dose was administered on 7/14/23, there were no notes to validate the other two doses on 7/14/23 were administered or the first two doses on 7/15/24, before this administration coding was corrected. Therefore, out of the five doses that contained this coding error, there was no evidence that four of the doses were administered. All together, the above reflected a total of six doses of the medication that were not evidenced as being administered. On 7/10/24 at 2:22 PM, an interview was conducted with LPN #8 (Licensed Practical Nurse). She stated that she did not recall the resident. She stated that the only reason why it would not be administered would be if the facility does not have the medication. She stated that when the medication comes it will get started on that day so that the resident does not miss a dose. She stated that if the facility does not have it they let the Nurse Practitioner know the medication is not available and she would call the pharmacy upon admission to notify them of the medication that is needed and when it is next due so that they can send it immediately. On 7/10/24 at 3:31 PM an interview was conducted with LPN #9. She stated that when a resident is admitted , they make sure the medication list from the hospital is approved through the Nurse Practitioner and then entered into the electronic medical record system. She stated that any orders for IV medications are printed out and faxed over as a stat delivery. She stated that if residents are not getting their doses they are not getting proper treatment. She stated that missed doses can impact the effectiveness of the treatment. She stated that the rights of medication administration, the right patient, right time, right dose, right medication, and right route was not being followed if there were missed doses. On 7/10/24 at 3:00 PM, ASM #3 (Administrative Staff Member) the Regional Director of Clinical Services, provided the pharmacy delivery manifest of Teflaro. Based on the date, times, and quantity that was delivered, this evidenced the medication was available to be administered during the times above where there was no evidence that it was administered per order. The facility policy, General Guidelines for Medication Administration documented, At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration Medications are administered in accordance with written orders of the prescriber On 7/1/24 at 9:00 AM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were made aware of the findings. No further information was provided by the end of the survey. (1) Teflaro is an antibiotic medication administered by injection (intravenously). Information obtained from https://medlineplus.gov/druginfo/meds/a611014.html 49369 2. For Resident #151 (R151), the facility staff failed to provide care and services for a skin tear on the right arm. On the following dates and times, R151 was observed lying in bed with a dried blood on her left Geri sleeve by the inside elbow crease: 7/8/24 at 3:00 p.m. and 7/9/24 at 12:33 p.m. On 7/8/24 at p.m., R151 was interviewed. She stated that the dried blood spot on her sleeves has been there longer than a day and that it is from a skin teary. She stated that it could possibly be due to the wheelchair. A review of R151's physician's orders dated 6/14/24 revealed, Wound Consult PRN (as needed). A review of R151's facility document, Skin Observation Tool-V2 dated 7/8/24, revealed R151 has a skin tear on the left elbow. A review of R151's care plan revealed, Skin: [R151] has actual skin impairment with the potential for further skin impairments .Geri-Sleeves as tolerated .Treatment as ordered. On 7/11/24 at 10:23 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated that when a resident has a skin tear, they have to assess the tear, clean it and treat it. She also stated that they would notify the nurse and the supervisor. She also stated that if it is a new skin tear that they should let the nurse practitioner know. She added that for treatment they typically use a wound cleanser or whatever is ordered for the resident. On 7/11/24 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator), ASM#2 (the director of nursing), ASM #3 (regional director of clinical services) and ASM #4 (regional vice president of operations) were made aware of the above concern. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to prevent one of 50 residents in the survey sample, Resident #269, from a significant medication error. The findings include: 1. For Resident #269, the facility staff failed to ensure that Resident #269 was free of significant medication error on six occasions, on 7/13/23 (two doses), 7/14/23 (two doses) and 7/15/23 (two doses). Resident #269 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was coded on the admission MDS dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS. A review of the physician's orders and the MAR (Medication Administration Record) for July 2023 revealed the following regarding a medication Teflaro (1): On 7/10/24 at 3:00 PM, ASM #3 (Administrative Staff Member) the Regional Director of Clinical Services, provided the pharmacy delivery manifest of Teflaro. Based on the date, times, and quantity that was delivered, this evidenced the medication was available to be administered during the times below where there was no evidence that it was administered per order, resulting in a significant medication error. An order dated 7/11/23 for Teflaro IV (intravenous) 400 MG (milligrams) every 8 hours. A review of the MAR revealed this was scheduled for 12:00 AM, 8:00 AM, and 4:00 PM. It was documented that on 7/12/23, this medication was not administered at 12:00 AM, was administered at 8:00 AM, and was discontinued before the 4:00 PM dose was due. An order dated 7/12/23 for Teflaro IV 400 MG three times a day. A review of the MAR revealed this was scheduled for 11:00 AM, 1:00 PM, and 9:00 PM. It was documented that on 7/12/23, this medication was administered at 1:00 PM and 9:00 PM. Between this order and the above previous order, the resident received all three doses due on 7/12/23 (at 8:00 AM, 1:00 PM, and 9:00 PM). Further review of the MAR revealed that on 7/13/23, this medication was not administered at the 11:00 AM dose, was administered at 1:00 PM, and was discontinued before the 9:00 PM dose. An order dated 7/13/23 for Teflaro IV 400 MG three times a day. A review of the MAR revealed this was scheduled for 12 AM, 6 AM, and 12 PM daily; and as documented above, the resident only received one of three doses on 7/13/23. The resident did not receive a morning dose (as evidenced by a blank spot on the MAR) or evening dose (as evidenced by an X marking out spots on the MAR), for either order / schedule that covered the date of 7/13/23. Further review revealed documentation for all doses on 7/14/23 and the first two doses on 7/15/23 as U-SA. This coding was not in the legend. On 7/10/24 at 3:00 PM, ASM #3 stated that this code means Unwitnessed self-administration which she stated was not possible given the medication and route, and that it must have been entered into the system incorrectly. She presented a nurse's note dated 7/14/23 at 2:38 PM which would account for the third dose due that date, which documented, MAR would not allow me to sign off on 1200 (noon) Teflaro While this validated that the one dose was administered on 7/14/23, there were no notes to validate the other two doses on 7/14/23 were administered or the first two doses on 7/15/24, before this administration coding was corrected. Therefore, out of the five doses that contained this coding error, there was no evidence that four of the doses were administered. All together, the above reflected a total of six doses of the medication that were not evidenced as being administered. On 7/10/24 at 2:22 PM, an interview was conducted with LPN #8 (Licensed Practical Nurse). She stated that she did not recall the resident. She stated that the only reason why it would not be administered would be if the facility does not have the medication. She stated that when the medication comes it will get started on that day so that the resident does not miss a dose. She stated that if the facility does not have it they let the Nurse Practitioner know the medication is not available and she would call the pharmacy upon admission to notify them of the medication that is needed and when it is next due so that they can send it immediately. On 7/10/24 at 3:31 PM an interview was conducted with LPN #9. She stated that when a resident is admitted , they make sure the medication list from the hospital is approved through the Nurse Practitioner and then entered into the electronic medical record system. She stated that any orders for IV medications are printed out and faxed over as a stat delivery. She stated that if residents are not getting their doses they are not getting proper treatment. She stated that missed doses can impact the effectiveness of the treatment. She stated that the rights of medication administration, the right patient, right time, right dose, right medication, and right route was not being followed if there were missed doses. The facility policy, General Guidelines for Medication Administration documented, At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration Medications are administered in accordance with written orders of the prescriber On 7/1/24 at 9:00 AM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were made aware of the findings. No further information was provided by the end of the survey. (1) Teflaro is an antibiotic medication administered by injection (intravenously). Information obtained from https://medlineplus.gov/druginfo/meds/a611014.html

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen in a safe and sanitary manner. The findings include: On 7/8/24 at 11:20 AM during the kitchen facility task, observations of food debris including crumbs, onion skins, lettuce and paper on floor of the kitchen. Observations of the freezer temp logs revealed there was no evidence of a second freezer temperature on 7/7/24 and no morning freezer temperature on 7/8/24. An interview on 7/8/24 at 11:30 AM with OSM (other staff member) # 3 the food services manager. When asked about the freezer temp logs, OSM #3 stated, they are to be done at the beginning and end of each shift. These were not done. We are short two staff today. When asked about the kitchen floor cleanliness, OSM #3 stated, it needs swept. When asked if it was cleaned the evening before, OSM #3 stated, it should have been, but I do not know. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. The facility's Food Storage, Cold policy revealed the following, The Dining Services Director monitors that all frozen foods will be stored at temperature maintain frozen state, target temperature is 10 degree or below. The Dining Services Director ensures that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures is recorded. To ensure the provision of high-quality meals and to meet regulations governing temperatures with regard to safety and sanitation. No further information was provided prior to exit.

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for four of four residents in medication administration and one of one infection control program, Residents #45, #25, #132, #118 and the facility. The findings include: 1.The facility staff failed to follow infection control practices for Resident #45. The blood glucose (BG) glucometer was not cleaned prior to or after use on Resident #45's during the medication administration observation. Resident #45 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (DM), vascular dementia and congestive heart failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/28/24, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bed mobility, transfer, hygiene/bathing and supervision for eating. A review of the care plan dated 10/6/23, which revealed, FOCUS: The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus. INTERVENTIONS: Administer medications as ordered. Labs as ordered. A review of the physician orders dated 4/15/24 revealed, Accu-Chek's AC (before meals) and HS (at bedtime). Notify MD for BS (blood sugar) less then 60 and more than 400. On 7/9/24 at 8:15 AM, during medication pass, observed RN (registered nurse) #2, take the blood glucometer (Medline Even Care G3) from the medication cart and perform a fingerstick on Resident #45. Glucometer was not cleaned prior to or after the fingerstick on Resident #45. On 7/9/24 at 8:26 AM, RN #2 was asked the process for cleaning the glucometer. RN #2 stated, it is to be cleaned before and after each resident use. RN #2 took an alcohol wipe and cleaned the glucometer. When asked if what the manufacturers recommended cleaning product is for the glucometer, RN #2 stated, we are to use the bleach wipes. I did not have any so I used the alcohol swab. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. A review of the facility's Blood Glucose Monitoring policy revealed Device must be cleaned and disinfected between patients, according to manufacturer recommendations. According to the Medline Even Care G3 Blood Glucose Monitoring System User's Guide: The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. Cleaning and Disinfecting Procedures for the Meter: The Even Care G3 Meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the Even Care G3 Meter. Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Medline Micro-Kill Wipes with Alcohol, Chlorox HealthCare Bleach Germicidal Disinfectant Wipes and Medline Micro-Kill Bleach Germicidal Bleach Wipes. No further information was provided prior to exit. 2.The facility staff failed to follow infection control practices for Resident #25. The blood glucose (BG) glucometer was not cleaned prior to or after use on Resident #25's during the medication administration observation. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (DM), dementia and atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/26/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bed mobility, transfer, hygiene/bathing and set-up for eating. A review of the care plan dated 9/3/18, which revealed, FOCUS: The resident is at risk for complications related to diagnosis of diabetes mellitus. INTERVENTIONS: Accu-Chek's as ordered. A review of the physician orders dated 2/5/24 revealed, Accu-Chek's every 12 hours. On 7/9/24 at 8:21 AM, during medication pass, observed RN (registered nurse) #2, take the blood glucometer (Medline Even Care G3) from the medication cart and perform a fingerstick on Resident #25. Glucometer was not cleaned prior to or after the fingerstick on Resident #25. On 7/9/24 at 8:26 AM, RN #2 was asked the process for cleaning the glucometer. RN #2 stated, it is to be cleaned before and after each resident use. RN #2 took an alcohol wipe and cleaned the glucometer. When asked if what the manufacturers recommended cleaning product is for the glucometer, RN #2 stated, we are to use the bleach wipes. I did not have any so I used the alcohol swab. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. A review of the facility's Blood Glucose Monitoring policy revealed Device must be cleaned and disinfected between patients, according to manufacturer recommendations. No further information was provided prior to exit. 3. The facility staff failed to follow infection control practices for Resident #132. RN (registered nurse) #2 used her fingers for two medications in Resident #132's medication administration observation. On 7/9/24 at 8:35 AM, during medication pass, observed RN (registered nurse) #2, drop Eliquis 5 milligram (mg) on paper on top of medication cart and use 2 fingers to pick it up and place it in a medication cup. Then RN #2 was observed opening the narcotic box and withdrew the Tramadol 50 mg card and popped 1 Tramadol directly into her hand, then place the Tramadol in the medication cup. When asked the process for withdrawing medications and placing them in a cup, RN #2 stated, they should be popped directly into the cup and not touched. When asked about the Tramadol, RN #2 stated, it was a narcotic, what was I to do, I cannot drop it. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. A review of the facility's Medication Administration policy revealed Medications are administered as prescribed in accordance with good nursing principles and practices. The person administering medications adheres to good hand hygiene which includes washing hands thoroughly. No further information was provided prior to exit. 31753 4. For Resident #118 (R118), the facility staff failed to prepare and administer medications in a sanitary manner. A review of R118's clinical record revealed the following physician's orders: 7/1/24- Klor-Con (potassium chloride) (1) 20 milliequivalents- two tablets by mouth in the morning. 7/8/24- Gabapentin (2) 200 milligrams- one capsule by mouth two times a day. On 7/9/24 at 8:28 a.m., LPN (licensed practical nurse) #3 was observed preparing R118's medications in the hall. While preparing medications, LPN #3 dropped a tablet of Klor-Con and a capsule of Gabapentin on top of the medication cart then picked up the pills (with a gloved hand) and placed the pills in a medication cup. After LPN #3 finished preparing medications, she administered the medications, including the Klor-Con tablet and Gabapentin capsule to R118. On 7/9/24 at 5:37 p.m., an interview was conducted with LPN #3. LPN #3 stated she had cleaned the top of the medication cart but administered medications to two other residents in between cleaning the top of the medication cart and preparing R118's medications. LPN #3 stated she could not be sure that the top of the medication cart was not contaminated when she dropped the pills. LPN #3 stated she should have disposed of the Klor-Con tablet and Gabapentin capsule in the sharps container because the pills were cross contaminated if the top of the medication cart was dirty. On 7/11/24 at 8:52 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. References: (1) Potassium is essential for the proper functioning of the heart, kidneys, muscles, nerves, and digestive system. Usually, the food you eat supplies all of the potassium you need. However, certain diseases (e.g., kidney disease and gastrointestinal disease with vomiting and diarrhea) and drugs, especially diuretics ('water pills'), remove potassium from the body. Potassium supplements are taken to replace potassium losses and prevent potassium deficiency. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601099.html. (2) Gabapentin capsules, tablets, and oral solution are used along with other medications to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html. 32642 5. The facility staff failed to evidence communication with the local health department during outbreaks of communicable diseases. During the facility entrance conference on 7/8/24 at 11:15 a.m., a request was made for the name and contact information of the facility's local health department contact for outbreaks of communicable disease. On 7/10/24 at 4:46 p.m., LPN (licensed practical nurse) #4, the facility infection preventionist, was interviewed. When asked the process for notifying the local health department during a communicable disease outbreak, LPN #4 stated: We haven't been notifying the local health department. She stated she has only been in this position for two weeks, and she does not know whom to contact in the local health department. She stated she had called two different places [on 7/10/24] and had still not been able to get accurate information about whom to contact in the local health department. On 7/11/24 at 9:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, and ASM #4, the regional vice president of operations, were informed of these concerns. A review of the facility policy, Infection Outbreak Standards of Practice, revealed, in part: Outbreaks are to be reported to the Center's local health department. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for two of 50 residents in the survey sample, Resident #89 and Resident #13. The findings include: 1. For Resident #89 (R89), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/18/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R89 not having any impairment in the upper extremities and being dependent on staff for toileting and requiring substantial/maximal assistance for personal hygiene. The comprehensive care plan for R89 documented in part, ADLs (activities of daily living): [Name of R89] has an ADL self-care performance deficit r/t (related to) activity intolerance, muscle weakness, AMS (altered mental status) . Created on: 06/01/2020. Under Interventions it documented in part, .Encourage the resident to use bell to call for assistance. Frequently will not use call bell. Date Initiated: 10/26/2021. Created on: 06/01/2020 Revision on: 06/22/2023 . On 7/9/24 at 9:05 a.m., an observation was made of R89 in their room. R89 was observed in bed with the call bell lying on the floor to the right side of the bed. At this time, an interview was attempted with R89. When asked if they could reach their call bell, R89 stated, I don't know where it is. An additional observations of R89's call bell on the floor was made on 7/9/2024 at approximately 9:38 a.m. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that the call bell should be placed within reach of the resident at all times. She stated that this was to ensure that the resident could call them if they needed anything. She stated that staff rounded on residents at least every two hours and checked call bell placement anytime they went into the room. She stated that they clipped the call bell cord onto the sheet or the bed to make sure it stayed within reach of the resident and did not fall on the floor. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the call bell should be within reach of the resident at all times for them to call if they needed assistance. On 7/11/2024 at approximately 9:12 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. On 7/11/2024 at approximately 11:51 a.m., ASM (administrative staff member) #4, the regional vice president of operations stated that the facility did not have a policy regarding call bell placement. No further information was presented prior to exit. 2. For Resident #13 (R13), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/24, the resident scored 7 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section GG coded R13 not having any impairment in the upper extremities and being dependent on staff for toileting and requiring substantial/maximal assistance for personal hygiene. The comprehensive care plan for R13 documented in part, Long Term Care: [Name of R13] requires assistance with their activities of daily living due to advanced age, chronic health conditions, recent hospitalization . Created on: 01/24/2023. Revision on: 04/08/2024. It further documented, Falls: [Name of R13] is at risk for falls. Created on: 01/23/2023. Under Interventions it documented in part, .remind the resident to use their call light to ask for assistance with ADLs (activities of daily living). Date Initiated: 01/23/2023. On 7/9/24 at 8:24 a.m., an observation was made of R13 in their room. R13 was observed in bed asleep. The call bell was observed to be placed on the upper grab bar hanging down towards the floor behind R13's head out of reach. A staff member was observed entering R13's room at 8:28 a.m. and exited the room at 9:05 a.m. An observation of the call bell on 7/9/24 at 9:07 a.m. revealed the call bell in the same location out of R13's reach. An additional observations of R13's call bell on 7/9/24 at 1:05 p.m. revealed the call bell in the same location. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that the call bell should be placed within reach of the resident at all times. She stated that this was to ensure that the resident could call them if they needed anything. She stated that staff rounded on residents at least every two hours and checked call bell placement anytime they went into the room. She stated that they clipped the call bell cord onto the sheet or the bed to make sure it stayed within reach of the resident. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the call bell should be within reach of the resident at all times for them to call if they needed assistance. LPN #3 observed R13's call bell which was observed to be wrapped on the upper grab bar on the right side of the bed near the resident's head out of reach. LPN #3 stated that the call bell should be placed near the residents hand where they could easily reach it. On 7/11/2024 at approximately 9:12 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the baseline care plan for one of 50 residents in the survey sample, Residents #470. The findings include: The facility failed to implement a baseline care plan to monitor Resident #470's Aspira Drain. Resident #470 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cancer, congestive heart failure and adult failure to thrive. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/10/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bed mobility, transfer, hygiene/bathing and supervision for eating. A review of the comprehensive care plan dated 7/10/24 revealed, FOCUS: Resident has an Aspira drain. INTERVENTIONS: Drain as ordered. Dressing to be changed as ordered. A review of the physician's orders dated 7/8/24, revealed, Right Aspira drain site: Cleanse with NS (normal saline), apply drain sponge and cover with Tegaderm every day shift. On 7/8/24 at approximately 2:00 PM, an interview was conducted with Resident #470. When asked if she was a new admission, Resident #470 stated, yes, a few days ago. I have cancer and have a drain in. An interview was conducted on 7/10/24 at 1:45 PM with LPN (licensed practical nurse) #2. When asked the purpose of the baseline care plan, LPN #2 stated, to identify the issues and care needs of the resident upon admission. When asked if a resident with a drain, should have the drain included in the baseline care plan, LPN #2 stated, yes. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. The facility's Baseline Care Plan policy revealed the following, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient. The baseline care plan is initiated and activated within 48 hours of admission. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan to reflect the residents current status for two of 50 residents in the survey sample; Resident #148 and #120. The findings include: 1. For Resident #148, the facility staff failed to review and revise the comprehensive care plan to reflect the smoking assessment that the resident required supervision for smoking. The care plan documented on 3/8/24 that the resident may smoke independently. Resident #148 was admitted to the facility on [DATE] and was coded on the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/8/24 at 3:00 PM, Resident #148 was observed self-propelling his wheelchair down the main front sidewalk of the facility towards the wooded area. He then turned right onto another sidewalk and entered through a gate into a facility garden area with raised plant beds. He then was observed obtaining a cigarette and lighter from his person and lighting it. At this time he was interviewed and stated that he goes to this area to smoke and he keeps his smoking materials on his person. He was observed to throw his cigarette butt on the ground. On 7/8/24 at 3:24 PM, Resident #148 was still observed to be smoking in garden area. There was no staff present for supervision, no devices for the safe disposal of cigarette butts, no fire blanket and no fire extinguisher was observed in the immediate area. On 7/8/24 at 3:42 PM, in an interview with Resident #148 in his room, he stated that he keeps his lighter and cigarettes on himself at all times. He states that he smokes whenever he wants to and wherever he wants to when outside. A review of the clinical record revealed that Resident #148 was assessed on Smoking Safety Screen dated 3/8/24 and 6/8/24 as requiring supervision for smoking. A review of Resident #148's comprehensive care plan revealed one dated 3/8/24 for (Resident #148) prefers to smoke . This care plan included an intervention dated 3/8/24 for May smoke independently. This intervention did not accurately reflect the resident's Smoking Safety Screen that deemed the resident required supervision to smoke. On 7/10/24 at 3:31 PM, an interview was conducted with LPN #9. She stated that care plans should reflect the resident's condition / status, and care needs, and that nursing can update the care plans as needed. She stated that Resident #148's care plan should have been updated to accurately reflect his status of requiring supervision for smoking, as determined by the Smoking Safety Screen. The facility policy, Care Planning documented, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each resident in order to provide effective, person-centered care .5. Care plans will be updated on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment . On 7/1/24 at 9:00 AM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #120, the facility staff failed to review and revise the comprehensive care plan to address the resident's safety and preference of ambulating offsite independently to a local drug store across the street. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #120 was coded as moderately impaired in ability to make daily life decisions, scoring a 12 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/9/24 at 9:20 AM, Resident #120 states he goes out about three times a week across the street to the local drug store. He stated that he does not tell anyone and does not sign out. He stated that he has no issues with walking, has had no falls, and does not need the assistance of a walker or wheelchair. He stated that he looks out for traffic and is careful about crossing the street. A review of the physical therapy notes revealed the following: On 3/21/23 was documented, Gait training over indoor/outdoor surfaces for distance of 1033 (feet) without AD (assistive device) over concrete/carpet/grass/tile .focusing on directional changes and obstacle negotiation. On 3/27/23 was documented, Pt (patient) ambulated around building on uneven and even surfaces. Patient performed gait training showing ability to maneuver through environment and crouch when needed without LOB (loss of balance) over lvl (level) and unlevl (unleveled) surfaces (grass/concrete) . On 3/30/23 was documented, Pt performed gait training on level and unlevel surfaces both inside and outside for over 1000ft (feet). Also demonstrated ability to ascend and descend stairs to test balance and coordination . On 4/1/23 was documented, Gait training throughout facility over 1000 (feet) .focusing on directional changes and obstacle negotiation . On 4/3/23 was documented, Gait training over indoor/outdoor surfaces (I) (independently) without AD (assistive device) focusing on directional changes and obstacle negotiation with no LOB (loss of balance) noted. The above reflected the resident's ability to safely ambulate over various level and unlevel surfaces for an extensive distance in 2023. A nurse's note dated 4/9/24 documented, He went to (name of drugstore across the street) . A review of the comprehensive care plan revealed one dated 11/20/22 for Self-Directed Activities: the resident prefers to participate in self directed activities such as walking & sitting outside. Further review of the comprehensive care plan failed to reveal any interventions for the resident to go on leave of absence independently to the local drug store across the street. On 7/9/24 at 3:44 PM, an interview was conducted with LPN #3 (Licensed Practical Nurse). She stated that Resident #120 signs himself out frequently, goes to (local drug store across the street). On 7/10/24 at 3:31 PM, an interview was conducted with LPN #9. She stated that care plans should reflect the resident's condition / status, and care needs, and that nursing can update the care plans as needed. She stated that Resident #120's care plan should have been updated to reflect his preference of leaving the facility independently. On 7/1/24 at 9:00 AM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 50 residents in the survey sample, Residents #90, #89 and #151. The findings include: 1. For Resident #90 (R90), the facility staff failed to provide ADL care to assist with personal hygiene. R90 was observed having untrimmed long fingernails on the right hand. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/22/24, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R90 requiring partial/moderate assistance for personal hygiene and supervision or touching assistance for bathing. On 7/8/24 at 3:21 p.m., an observation was made of R90. R90's fingernails on the right hand revealed that they were approximately one-quarter to one-half inch long. At that time an interview was conducted with R90 who stated that they were paralyzed on that side and could not trim their nails themselves. Additional observations of R90's fingernails were made on 7/8/24 at 4:30 p.m. and 7/10/24 at 10:15 a.m. The fingernails remained untrimmed on the right hand. The comprehensive care plan for R90 documented in part, ADL (activities of daily living): [Name of R90] has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Stroke . Created on:10/04/2019. Revision on: 05/28/2020. Under Interventions it documented in part, Personal Hygiene/Oral Care: The resident requires staff assistance. Date Initiated: 10/19/2019 . Review of the clinical record failed to evidence documentation of refusal of care during the dates of observations documented above. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that residents fingernails were evaluated during care provided each day and were trimmed by them if the resident was not diabetic. She stated that if the resident was diabetic the nails were trimmed by the nurses. She stated that fingernails were assessed for trimming on shower days and during baths. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that residents fingernails were assessed on shower days or when observed when working with the resident. She observed R90's fingernails on the right hand and stated that they were long and needed trimming. LPN #3 asked R90 if they would allow her to trim the nails and R90 stated yes and proceeded to show LPN #3 where their nail clippers were kept. On 7/11/2024 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. The facility provided document, Mosby's Textbook for Long-Term Care Nursing Assistants ninth edition, 2024 documented in part, Nail and foot care prevents infection, injury, and odors. Hangnails, ingrown nails (nails that grow in at the side) and nails torn away from the skin cause skin breaks. These breaks are portals of entry for microbes. Long or broken nails can scratch skin or snag clothing . No further information was presented prior to exit. 2. For Resident #89 (R89), the facility staff failed to provide ADL care to assist with personal hygiene. R89 was observed having a brown substance underneath their fingernails on 7/8/24 at 12:47 p.m., 7/9/24 at 9:05 a.m. and 7/10/24 at 9:19 a.m. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/18/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R89 requiring substantial/maximal assistance for personal hygiene and dependent on staff for bathing. On 7/8/24 at 12:47 p.m., an observation was made of R89 in their room. R89 was observed lying in bed. Observation of R89's fingernails revealed that they were approximately one-quarter inch long with a brown substance underneath them. At that time an interview was conducted with R89 who stated that the staff did the best they could to take care of them. Additional observations of R89's fingernails were made on 7/9/24 at 9:05 a.m. and 7/10/24 at 9:19 a.m. Observations revealed the brown substance remaining underneath the fingernails. The comprehensive care plan for R89 documented in part, ADLs (activities of daily living): [Name of R89] has an ADL self-care performance deficit r/t (related to) activity intolerance, muscle weakness, AMS (altered mental status) . Created on: 06/01/2020. Under Interventions it documented in part, . Bathing/Showering: The resident is a staff assist. Date Initiated: 10/26/2021 . Personal Hygiene/Oral Care: The resident is a staff assist. Resident is edentulous. Date Initiated: 10/26/2021 . Review of the clinical record failed to evidence documentation of refusal of care during the dates of observations documented above. On 7/10/24 at 10:10 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that residents fingernails were evaluated during care provided each day and were cleaned underneath if observed to be dirty. She stated that fingernails were assessed for trimming on shower days and during baths. On 7/10/24 at 10:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that residents fingernails were assessed on shower days or when observed when working with the resident. She stated that the residents nails were cleaned underneath during daily care and if the resident refused it would be documented. LPN #3 observed R89's fingernails and stated, I see what you mean. LPN #3 asked R89 if they would allow them to clean underneath their nails and R89 stated yes. On 7/11/2024 at approximately 9:12 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit. 49369 3. For Resident #151 (R151), the facility staff failed to properly groom the resident's fingernails. On the following dates and times, R152 was seen with fingernails one to one and a half inches long that were yellow in color: 7/8/24 at 12:56 p.m. and 7/10/24 at 12:00 p.m. R151 was admitted to the facility on [DATE]. On the admission MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/26/24, the resident was coded as having an upper extremity impairment on both sides. A review of R151's clinical record revealed no evidence that she refused grooming assistance at any time. On 7/11/24 at 10:35 a.m., CNA (certified nursing assistant) #3 was interviewed. She stated that nails should be groomed by CNAs every week. On 7/11/24 at 10:23 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated that the Resident's nails should be groomed and or cut at least every week. On 7/11/24 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator), ASM#2 (the director of nursing), ASM #3 (regional director of clinical services) and ASM #4 (regional vice president of operations) were made aware of the above concern. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to ensure that one of 52 sampled residents, (Resident #33) received timely treatment for [REDACTED]. Resident #33 fell out of bed on 3/9/19 at approximately 7:30 p.m. A mobile right wrist x-ray was obtained and the results were reported to the facility staff on 3/10/19 at 12:35 a.m. The results of the x-ray concluded a fracture through the distal end of the radius and ulna (both lower arm bones). The facility staff failed to send Resident #33 immediately to the hospital for evaluation and treatment when the resident asked to see a physician and the physician on call failed to respond to calls regarding the x-ray results and the resident's pain management. Resident #33's injuries were not evaluated by a physician at the hospital, until 7:40 a.m., on 3/10/19, at which time, the resident was diagnosed with [REDACTED]. The findings include: Resident #33 was admitted to the facility on [DATE]. Resident #33's [DIAGNOSES REDACTED]. Resident #33's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/27/19, coded the resident as being cognitively intact. Section G coded Resident #33 as requiring supervision with bed mobility and transfers. Section J coded the resident as not having sustained any falls since the prior assessment. Resident #33's comprehensive care plan dated 1/29/18 and revised on 3/11/19 documented, FALL: (Resident #33) has an actual fall and is at risk for falls r/t (related to) Deconditioning, episodes of incontinence. The care plan documented multiple interventions including but not limited to: - Assistive Devices -Anticipate and meet the resident's needs -Assist with toileting as needed -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Staff reviewed and revised Resident #33's care plan, revealed after the fall on 3/9/19. A nurse's note dated 3/9/19 documented, Resident noted on the floor between her bed and the wall lying on her left side at about 19:30 (7:30 p.m.) this shift. On assessment, resident is alert and oriented x (times) 3. Resident stated she rolled out of bed while sleep. she (sic) c/o (complained of) pain to her right wrist and stated she thinks it is broken. Resident also noted to have a laceration on the back of her left hand, hematoma on her right wrist, swollen area on the back of her head, and an open area on her lip. resident (sic) assisted to bed by four staff. MD (Medical doctor) (name) notified who gave orders for treatment to left hand, Stat (immediate) X-ray and pain management with Tylenol. Treatment to left hand done as ordered. X-ray called in and resident medicated for pain. Resident's RP (responsible party) (name) always made aware of fall and injuries. Resident is resting in bed at moment. Review of Resident #33's (MONTH) 2019 MAR (medication administration record) revealed the resident was administered 500 milligrams of as needed Tylenol per physician's orders [REDACTED]. Further review of the resident's clinical record revealed physician's orders [REDACTED]. A wrist x-ray result with an examination date of 3/9/19 at 7:57 p.m. and a reported date of 3/10/19 at 12:35 a.m. documented a slightly displaced angulated fracture through the distal end of the radius and ulna (both lower arm bones) with soft tissue swelling. A nurse's note documented as a late entry, signed by RN (registered nurse) #1, dated 3/10/19, documented, Patient had a fall on Saturday 03/ 9 on 3-11 shift. An X-ray was ordered and performed between 11:00 pm (03/09/2019) and 00:00 am (12:00 a.m.) (03/10/2019) at about 0030 (12:30 a.m.), imaging faxed results indicating that patient had a right wrist and right ulnar fracture on (sic). Notified MD (medical doctor), (name of ASM (administrative staff member) #5) and patient about the results at 00:50 (12:50 a.m.) Around midnight, as I always do checked with patient about the need for stronger pain medication (she is on Tylenol prn (as needed)) as I gave Tylenol to her roommate. Patient declined Tylenol and said she would wait for a stronger pain medication. She did ask if she could be seen by a doctor and I told her that I will find out about what the doctor will says (sic) and a possibility to see a podiatrist as well and that she will get adback (sic). I notified MD about the need for a review of the pain management plan as the patient wanted a stronger pain medication. I rechecked her for pain when I notified her about the order for ER (emergency room ) visit in the morning when I received the order to send her to the hospital and patient denied the need for Tylenol. At that time there was no new order for pain medication. When I came back for the 11-7 shift, the medication was supplied and as soon as I got it, I gave it to her crushed in apple sauce per her preference. This patient has a chronic back pain and I always check on her at midnight. about 3:00 am in the middle of the shift and in the morning to make sure her pain is controlled and she is aware of this. Review of Resident #33's pain assessments revealed the following: -3/9/19 at 7:44 p.m.: pain level 10 -3/9/19 at 8:10 p.m.: pain level 9 -3/9/19 at 9:25 p.m.: pain level 5 There were no further documented pain level assessments until after the resident's return from the hospital. A nurse's note dated 7/10/19 at 10:46 a.m. documented Resident #33 had been sent to the ER (emergency room ) but failed to document the specific time of the transfer. A hospital history and physical dated 3/10/19 documented Resident #33 was received at the hospital on [DATE] at 7:36 a.m. The form documented, [AGE] year-old female with PMHx (past medical history) of arrives via EMS (emergency medical services) and presents with concerns of a fractured right wrist after falling out of bed last night around 8 or 9pm. Associated sx (symptoms) of right knee pain that is secondary to her fall. Her pain is described as constant and rated 10/10 in severity . 0841 (8:41 a.m.): Per nursing home, the patient fell last night around 8:40 pm. The nurses state they wanted to send the patient to ED (emergency department) but could not send the patient without the doctor's approval . The hospital documentation further documented Resident #33 presented with steri strips on a bruised left hand, a fractured right fourth finger, a right wrist fracture that required closed reduction under procedural sedation, and a right knee abrasion measuring three centimeters that required four sutures. Resident #33 was administered two milligrams of [MEDICATION NAME] via IV (intravenous) line while at the hospital and discharged back to the facility on [DATE]. (Note: review of Resident #33's nursing facility clinical record failed to reveal any documentation regarding an injury to the resident's right knee). On 11/4/19 at 8:58 a.m., an interview was conducted with Resident #33. The resident was sitting in a wheelchair in her room. The resident's right wrist bone was observed as being deformed (bulging out from the wrist area) and the resident reported she cannot write as good as she used to. Resident #33 was asked to describe what she could remember about the night she fell out of bed on 3/9/19. Resident #33 stated she thought she fell out of bed between 10:00 p.m. and 12:00 a.m. and an x-ray was obtained but she did not go to the hospital until the next morning. Resident #33 was asked to describe her pain after she fell and stated, It was pretty bad. I was crying and bleeding from my head and face. Resident #33 was asked what the facility staff did to assist her and stated, I don't remember but they let me lie there; a lot of nurses standing over me. After a while, they picked me up and put me back to bed. I'm sure they gave me pain pills 'cause I was hollering because I was hurting. Resident #33 stated she begged staff to take her to the hospital and the staff said help was on the way. Resident #33 stated the pain pill did help her pain and she fell asleep. When asked to rate her pain, Resident #33 stated her pain was a seven or eight when she fell and probably a five or six shortly before she was transferred to the hospital. On 11/4/19 at 10:19 a.m., a phone interview was attempted with the CNA (certified nursing assistant) who cared for Resident #33 during the evening on 3/9/19. The CNA did not answer the phone. On 11/4/19 at 10:51 a.m., a phone interview was conducted with CNA #1 (the CNA who cared for Resident #33 during the night of 3/9/19 into 3/10/19). CNA #1 was asked to describe Resident #33's condition after she fell on [DATE]. CNA #1 stated she could not recall much information but she had to assist Resident #33 with the bed pan and put briefs on the resident during the night on 3/9/19 into 3/10/19 because the resident was too weak to walk to the bathroom. CNA #1 stated she also remembered the resident's arm being very swollen and on a pillow throughout the night. On 11/4/29 at 11:04 a.m., a phone interview was conducted with LPN (licensed practical nurse) #3 (the nurse who cared for Resident #33 when she fell on [DATE]). LPN #3 stated she recalled the fall but did not recall any further details. On 11/4/19 at 11:15 a.m., a phone interview was attempted with RN (registered nurse) #1 (the nurse who cared for Resident #33 during the night of 3/9/19 into 3/10/19). RN #1 did not answer the phone. On 11/4/19 at 2:30 p.m., an interview was conducted with LPN #4 (unit manager). LPN #4 stated she was not in the facility the day Resident #33 fell or the next day. LPN #4 stated she reviewed Resident #33's chart and from what she read, Resident #33 was assessed after she fell and complained of pain to her right wrist. The nurse gave her as needed Tylenol, the doctor was notified, and ordered a stat (immediate) x-ray and the x-ray was completed between 11:00 p.m. and 12:00 a.m. then the doctor was notified of a positive fracture around 12:30 a.m. and the nurses received orders to send Resident #33 to the emergency room in the morning. LPN #4 was asked why Resident #33 was not sent to the hospital until the following morning on 3/10/19 when she had requested to be sent. LPN #4 stated Resident #33 denied Tylenol during the night and when Resident #33 was sent to the hospital, she did not require surgery. LPN #4 stated the resident was later evaluated by an orthopedist and she did not require surgery, only splint management, repositioning and stronger pain medication. When asked again, why Resident #33 was not sent to the hospital until the morning of 3/10/19, LPN #4 stated she could not fully speak to the situation but staff monitored Resident #33 during the night, managed her pain, the resident's representative was made aware of the situation and the resident slept during the night. When was asked what time Resident #33 was sent to the hospital, LPN #4 stated she thought the resident was transferred around 6:05 a.m. on 3/10/19. On 11/4/19 at 5:00 p.m., a phone interview was conducted with ASM (administrative staff member) #5 (Resident #33's physician and the on-call physician for the night of 3/9/19 into 3/10/19). ASM #5 stated he did not remember details but most likely, the nurse called and left him a voicemail at 1:00 a.m. or 1:30 a.m. on 3/10/19. ASM #5 stated he received the voicemail around 6:00 a.m. and said to send Resident #33 to the hospital. ASM #5 stated there was no reason for him to keep the resident sitting around for several hours, especially with a fracture. When asked what the nurses should do if he does not answer his phone, ASM #5 stated this rarely happens and he usually answers his phone. When asked if staff are allowed to obtain medical treatment if he cannot be reached, ASM #5 stated, Yeah. When asked if nurses can send a resident to the hospital if a resident requests to go, ASM #5 stated, Yes. ASM #5 stated the goal is to do what is best for the patient. On 11/4/19 at 5:43 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was made aware of Resident #3's fracture after the resident had been sent to the hospital. On 11/4/19 at 6:31 p.m., ASM #1 (the administrator), ASM #2, ASM #3 (the corporate nurse consultant) and ASM #4 (the assistant administrator) were made aware of the above concern and the concern for harm. ASM #2 stated she had further information to present. On 11/5/19 at 7:44 a.m., a phone interview was conducted with RN #1 (the nurse caring for Resident #33 during the night of 3/9/19 into 3/10/19). RN #1 stated he arrived at the facility at 11:00 p.m. on 3/9/19. RN #1 stated he obtained shift report and then went straight to Resident #33's room because he had received information that the resident had sustained a fall. RN #1 stated he completed an assessment and Resident #33's mental status was intact. RN #1 stated the resident was due for Tylenol at midnight and the resident said she was not in extreme pain and did not want to take Tylenol. RN #1 stated Resident #33 was in bed and rated her pain between a three and a four. RN #1 was read the portion of his note that documented, Patient declined Tylenol and said she would wait for a stronger pain medication. RN #1 stated if he could correctly remember, the physician put in an order for [REDACTED].#1 was made aware that per the clinical record review, the only pain medication ordered on the night of 3/9/19 into 3/10/19 was Tylenol and [MEDICATION NAME] was not ordered until the resident's return from the hospital. RN #1 stated he asked Resident #33 if she was used to narcotics and the resident was not showing any overt signs of pain. RN #1 stated he completed rounds and assessed Resident #33 for pain every two hours. RN #1 stated during his rounds, the resident was asleep and that was a sign that the pain was not excruciating. RN #1 was asked what was done when the right wrist x-ray results were reported to him. RN #1 stated he called ASM #5 and received no response so he left a voicemail. RN #1 stated he applied his critical judgement so he continued to assess Resident #33 and make sure she was comfortable. RN #1 stated he did not see any critical signs or changes that would urge him to do anything besides continuing to assess and making sure the resident was comfortable. RN #1 stated he assessed Resident #33's mental status, breathing, pain and circulation. RN #1 stated the resident did not present with any numbness, tingling or bleeding. RN #1 stated he saw a skin tear covered with a dressing on one of the resident's arms. RN #1 was asked if Resident #33 presented with any injury to her right knee. RN #1 stated he did not recall any injury to the knee. RN #1 stated he assessed all of Resident #33's extremities and there was no swelling, or bleeding. Nothing that would warrant any clinical change to demonstrate the need to send the resident to the hospital. RN #1 was asked if a resident request to see a doctor and a fractured arm warranted a transfer to the hospital. RN #1 stated this depended on the effect of the fracture. RN #1 stated that as a nurse, he knows that a fracture can warrant a hospital transfer but in some other situations does not warrant a hospital transfer. RN #1 stated if the fracture was open then this could cause a blood clot and would warrant a hospital transfer. RN #1 stated Resident #33 did not have an open fracture and he made sure the resident did not have chest pain, tingling or numbness. RN #1 stated if he had seen those kind of signs then he would have called 911 right away. RN #1 stated that from his clinical judgement, there was no clinical change and Resident #33's pain was controlled so he did not send the resident to the hospital. RN #1 was asked if he explained to Resident #33 that he called the physician and the physician did not answer the phone. RN #1 stated he updated the resident about the progress of her care and let her know that a doctor would be able to see her some time. RN #1 stated Resident #33 was okay and very happy that the doctor would be able to see her some time. RN #1 was read the portion of his note that documented, I notified MD about the need for a review of the pain management plan as the patient wanted a stronger pain medication and asked was asked to explain. RN #1 stated sometime in the middle of the night, he called the doctor as soon as Resident #33 verbalized pain. RN #1 stated the doctor did not answer the phone so he continued to monitor the resident's pain. RN #1 was asked if he notified anyone else besides the physician about Resident #33's right wrist x-ray. RN #1 stated he does not necessarily call the director of nursing or manager regarding x-ray results but he would have called if he had found a clinical change. RN #1 could not recall if he called anyone else. RN #1 was asked what prompted Resident #33's transfer to the hospital during the morning on 3/10/19. RN #1 stated he thought the physician called back around 6:00 a.m. RN #1 was asked what the physician stated when he called. RN #1 stated, I don't remember his message but he did invite to send her for a further exam. When asked to clarify if that meant to send the resident to the hospital, RN #1 stated, Yeah. For further exam. I did all arrangements. When asked what Resident #33's pain level was when the resident was transferred to the hospital, RN #1 stated the resident did not complain of pain or ask for pain medication. RN #1 stated he did his best to offer his care in the conditions he was working in. On 11/5/19 at 8:21 a.m., an interview was conducted with LPN #5. LPN #5 was asked what should be done if a resident falls and an x-ray confirms a fracture. LPN #5 stated, Notify the doctor first, make sure non-pharmacological interventions should be in place and they are comfortable and manage their pain. LPN #5 was asked what should be done if the nurse calls the doctor and he doesn't answer the phone. LPN #5 stated, We are going to send the patient out, notify the responsible party and get the patient over to the hospital. LPN #5 was asked if the resident should be transferred to the hospital if the nurse can't reach the doctor and the resident does not present with any other significant clinical changes besides the x-ray. LPN #5 stated, Yes. I feel that is an emergent situation and something where a fracture is confirmed by x-ray. If we can't get ahold of the doctor, we should send them out to make sure more measures are taken and so they are not in pain. I still feel like they need to be sent out whether they are showing changes or not; that it needs to be followed up by a physician; the best possible situation for the patient. We still need to follow up with a physician and not wait until the morning. I would communicate with the managers. We have a manager on call, and make sure the rp (responsible party) is aware. On 11/5/19 at 9:59 a.m., another interview was conducted with ASM #2. ASM #2 confirmed residents who present with a positive fracture from an x-ray should be transferred to the hospital if the physician does not answer the phone. ASM #2 stated staff had been education regarding this matter and she had further information to provide. On 11/5/19 at 10:20 a.m., ASM #2 presented an action plan that documented, In addition to the performance improvement plan on fall, there is the need to further strengthened (sic) staff intervention during off-shift for falls with injury requiring medical intervention within or outside of the facility. An example of the above was noted on 3/9/2019 for a patient with a fracture during an off-shift, who was subsequently transferred out to the ER the next day shift for further evaluation. Consequent to the above, there appears to have been staff rigidity in the interpretation of them requiring doctor's order for patient transfer to the ER. As a result of the above, the following action will be implemented. 1. Review post-fall intervention process with the staff, particularly when there is a potential presentation of an injury. 2. Review ER transfer with the nursing staff s/p (status [REDACTED]. 3. Review with staff pain management for patient with fall related injury to include both pharmacological and non-pharmacological interventions. 4. Review all subsequent post fall interventions during the fall committee meeting to ensure adequate management of fall related change of condition. 5. Date of compliance 3/15/2019. An in-services completed with the facility nurses on 3/11/19 documented, If a patient/resident falls and diagnostic testing indicates a fracture is present, notify MD or NP immediately. If you do not get a response from the MD or NP on call, send the patient/resident to the hospital as soon as possible. When MD or NP returns your call make them aware of transfer to the hospital for fall with fracture. Use pharmalogical and non-pharmalogical interventions to make patient/resident comfortable until transport to hospital arrives. Notify responsible party if applicable. The action plan was verified onsite. The survey team conducted interviews with random nurses, a total of eight, on all three shifts. All staff interviewed were able to state the above information. Review of all documentation of the in-services including staff signatures was completed. Review of documentation weekly monitoring by facility staff was completed and confirmed. Review of all other residents failed to reveal any residents that were not provided timely treatment for [REDACTED]. No further information was presented prior to exit. COMPLAINT DEFICENCY PAST NON-COMPLIANCE

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure two of 29 residents in the survey sample, (Residents #26 and #11) were free from unnecessary medications for 1. The facility staff administered [MEDICATION NAME], a medication to lower blood sugar, to Resident #26. Resident #26 did not have a [DIAGNOSES REDACTED]. As a result of receiving the [MEDICATION NAME], Resident #26's blood sugar levels became dangerously low on 8/8/15. He became unresponsive, and required treatment at the facility and transportation by EMS (emergency medical services) to a local hospital emergency room , where he received treatment for [REDACTED]. 2. Facility staff failed to ensure Resident #11 was free from an unnecessary blood pressure medication on 7/8/16. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the admission nursing assessment dated [DATE], he was documented as being alert to person and to situation, but not to time and place. He was documented as being confused for cognition. He was documented as being resistive and as having disorganized thinking for mood and behavior concerns. In the section of this assessment entitled Other Relevant Dx (diagnoses)/Concerns, the box beside Diabetes was not checked. A review of the discharge summary from a local hospital dated 8/7/15 revealed no evidence of diabetes (1) as a [DIAGNOSES REDACTED]. Further review of the summary revealed a section entitled Medications on Discharge. A review of this section revealed no evidence of [MEDICATION NAME] (2) as a current medication for Resident #26. (1) Diabetes means your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn't good for your health. This information is taken from the website http://nihseniorhealth.gov/diabetes/diabetesdefined/01.html. (2) [MEDICATION NAME] is used along with diet and exercise, and sometimes with other medications, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] is in a class of medications called sulfonylureas. [MEDICATION NAME] lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently. This medication will only help lower blood sugar in people whose bodies produce insulin naturally. This information is taken from the website <https://medlineplus.gov/druginfo/meds/a 0.html> Precautions: General: [DIAGNOSES REDACTED] (low blood sugar): All sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED]. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=37a18bd1-034f-4366-8323-ec4e1c52ac1e A review of Resident #26's medication orders revealed the following order, written 8/8/15 as a verbal order from ASM (Administrative Staff Member) #10, the attending physician, by LPN (licensed practical nurse) #13, who is no longer employed by the facility: [MEDICATION NAME] Tablet 10 mg (milligrams). Give 2 tablet (sic) by mouth one time a day for diabetes. The order was signed on 8/8/15 by a nurse practitioner, who was unavailable for interview during the time of the survey. A review of Resident #26's clinical record revealed a physician's admitting history and physical progress note dated 8/8/15 and signed by ASM (administrative staff member) #10, the attending physician. This progress note did not include evidence of a [DIAGNOSES REDACTED].#26. A review of the Medication Administration Record [REDACTED]. The nurse who administered the medication is no longer employed by the facility. A review of the nurses notes for Resident #26 revealed, in part, the following; - 8/8/15 at 9:57 p.m.: Situation: This note is associated with a .change of condition evaluation .The signs/symptoms of this change of condition are: Unresponsiveness. This started on 8/8/15 during the night. Background: The patient is in the center for Post-Acute Care with a [DIAGNOSES REDACTED].[MEDICAL CONDITION] .[MEDICAL CONDITION] (3), .Assessment (RN) (registered nurse) /Appearance (LPN) (licensed practical nurse): The issues appears (sic) to be: low Glucose level*-47. This note was written by RN #4. * Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (deciliter) is considered low. Blood sugar at or below this level can be harmful. The medical name of low blood sugar is [DIAGNOSES REDACTED]. Possible Complications: Severe low blood sugar is a medical emergency. It can cause [MEDICAL CONDITION] and brain damage. Severe low blood sugar that causes you to become unconscious is called insulin shock. This information was obtained from the website: <https://medlineplus.gov/ency/article/ 6.htm> - 8/8/15 at 10:45 p.m.: Upon entering residents (sic) room to administer night time meds (medications) resident was unresponsive. Vitals were (127/72 (blood pressure), O2 (oxygen) 96 (%), pulse 74, temp (temperature) 98.7. Residents (sic) blood sugar was 46 after administration of orange juice and [MEDICATION NAME] (sic) repeat blood sugar was 73. Resident was send (sic) out for unresponsiveness and [DIAGNOSES REDACTED] (low blood sugar). This note was written by LPN #3. A review of the EMS report dated 8/8/15 revealed, in part, the following: Dispatched for a [AGE] year old male unresponsive with a low blood sugar. (Name of EMS team) arrived on scene and were advised by staff that patient had original blood glucose of 43. Staff advised that they gave the patient half tube of oral glucose and that raised it to 73. Family was present on scene and stated that patient was at his normal baseline 20 minutes prior to incident. Patient skin cool and moist and he has a patent airway. Patient will grimace with painful stimuli. (Name of EMS team) placed patient on stretcher and moved to unit. Patient unresponsive and glucose found to be at 50 at this time. Baseline vitals (vital signs) obtained. IV (intravenous) access gained. Patient given 25 grams of [MEDICATION NAME] (sugar) IVP (IV push). Patient transported without incident to (name of local hospital). A review of the ER (emergency room ) report for Resident #26 dated 8/8/15 at 10:41 p.m. and continuing through 8/9/15 at 6:06 a.m. revealed, in part, the following: Patient is [AGE] year-old male who was sent here from a local nursing home because of unresponsiveness, facial twitching and blood sugar 47. The patient was given oral glucose and EMS was called. Upon EMS arrival D50 ([MEDICATION NAME], a sugar solution) was given with improvement. However when he awoke he was agitated and sent here for further evaluation and improvement .Of note is that patient is not diabetic and has not had problems with [DIAGNOSES REDACTED]. Further review of the clinical record for Resident #26 revealed the following nurses notes: - 8/9/15 at 1:48 p.m.: Patient returned from hosp (hospital) this am (a.m.). No new orders noted. - 8/10/15 at 10:10 a.m.: [MEDICATION NAME] Tablet 10 mg. Give 2 tablet (sic) by mouth one time a day for diabetes. This medication held d/t (due to) medication review. Further review of the medical record revealed an order written [REDACTED]. A review of a facility document entitled Medication Error Report dated 8/11/15 regarding Resident #26 revealed, in part, the following: Medications ordered: None. Medications given: [MEDICATION NAME] 10 mg. Describe the error: Wrong medication was entered into (name of computer software) for this patient. The script from (name of local hospital) had another patient's name written on it .What was the effect of the error on the resident? Resident blood sugar level dropped to 43 mg/dl (milligrams per deciliter) and he became unresponsive. 911 (EMS) was called and he was taken to the ER. Corrective measures taken for resident: Hospital transfer, medication discontinued, close monitoring. On 7/13/16 at 9:35 a.m., RN #5, the unit manager for Resident #26 at the time of the incident, was interviewed. She stated when the resident was admitted to the facility on [DATE], the discharging hospital faxed medication orders. She stated: All of them were his except for the [MEDICATION NAME]. It had another patient's name on it. She stated that the admitting nurse is no longer employed at the facility, and that she entered the [MEDICATION NAME] into the electronic order system for Resident #26 in error. She stated the resident received the [MEDICATION NAME] at 9:00 a.m. on 8/8/15, and the nurse was making rounds on the evening shift of 8/8/15, he found the resident to be unresponsive. She stated EMS (emergency medical services) was called and the facility staff realized the resident's blood sugar was low. RN #5 stated at that time, the facility staff checked the chart and realized the resident did not have a [DIAGNOSES REDACTED].#5 stated at that time, they double-checked all of the resident's orders. When asked about the physician's/nurse practitioner's role in the process of ordering medications for a newly-admitted resident, RN #5 stated: The doctor should review the medications and [DIAGNOSES REDACTED]. We often do the admission orders [REDACTED]. RN #5 stated: He obviously should never have received the [MEDICATION NAME]. At this time, RN #5 was asked to locate the order for [MEDICATION NAME] from the discharging hospital (containing the wrong patient name). On 7/13/16 at 1:05 p.m., OSM (other staff member) #22, the consulting pharmacist, was interviewed. She stated that when orders are entered by a facility staff member and transmitted to the pharmacy, most all of the work is done electronically. She stated she did not believe that the pharmacists were involved in double-checking [DIAGNOSES REDACTED]. On 7/13/16 at 1:20 p.m., OSM #20, the front end manager for the facility pharmacy, and OSM #21, the pharmacist, were interviewed. OSM #20 stated that the pharmacy receives most admission medication orders electronically from facilities, with the exception of controlled substances and extremely complicated orders. OSM #20 stated that a pharmacy technician initially checks the order for errors to make sure there is nothing wrong with the way it is written. Once the orders are checked by a technician, the technician sends them to the pharmacist. OSM #21 stated the pharmacy looks at the order to make sure it contains the required elements of date of birth, resident name, drug name, strength, and directions for administration. OSM #21 stated the pharmacist reviews the [DIAGNOSES REDACTED]. OSM #21 stated: We do not check the diagnoses. When asked the consequences for administration of 20 milligrams of [MEDICATION NAME] to a resident who is not diabetic, OSM #21 stated the standard starting dose for anyone on [MEDICATION NAME] is usually 5 (five) milligrams daily. OSM #21 stated: That much [MEDICATION NAME] could definitely really lower someone's blood sugar. On 7/13/16 at 2:45 p.m., LPN (licensed practical nurse) #9 was interviewed regarding the process of obtaining admission medication orders. She stated the admissions director provides the nurse with a packet of information about the resident, including discharge [DIAGNOSES REDACTED]. LPN #9 stated most often, the physicians are not present in the building, and that the nurse pages the physician and verbally goes over the orders by telephone. She stated the nurse is responsible for making sure the orders are for the correct resident and that both the physician and the nurse are responsible for making sure the [DIAGNOSES REDACTED].#9 stated: The [DIAGNOSES REDACTED]. That information is available in the packet that the admissions director provides from the discharging hospital. She stated the nurse also reviews the resident's allergies [REDACTED]. When asked what should be done once an issue like [MEDICATION NAME] being administered to a non-diabetic resident is identified. LPN #9 stated the physician should be notified right away and the medication should be discharged immediately. When shown the nurses notes referenced above, which stated the [MEDICATION NAME] was not discontinued for Resident #26 until 8/10/16, LPN #9 stated: It should have been discontinued as soon as he got back from the hospital. On 7/13/16 at 3:50 p.m., RN #4 was interviewed. She stated she was administering meds (medications) on another hallway on the evening of 8/8/15. She stated LPN #3 was a very new nurse, and had only been working three or four evenings. RN #4 stated he went to her and asked her about an order for [REDACTED].#4 stated then she assisted the staff to call 911 and to get paperwork together regarding Resident #26 for the EMS staff. On 7/13/16 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, administrator of a sister facility, ASM #4, director of nursing at a sister facility, ASM #5, a corporate nurse, ASM #6, a corporate nurse, and ASM #7, vice-president of operations, were informed of these findings. These staff members were informed of the survey team's concern for harm regarding these findings. The staff members were requested to provide a copy of the order for [MEDICATION NAME] from the discharging hospital (containing the wrong patient name). The staff members were also requested to provide the facility's professional standard for nursing practice. On 7/14/16 at 8:00 a.m., the facility staff informed the survey team that the facility uses textbooks by Potter and Perry, and by Lippincott, as their standards of nursing practice. On 7/14/16 at 9:55 a.m., LPN #3 was interviewed. He stated he remembered the incident with Resident #26. He stated he remembered finding the resident to be unresponsive, checking his blood sugar and finding it to be very low and getting help from other staff to call EMS. LPN #3 stated he remembered discovering that the resident had received 20 milligrams of [MEDICATION NAME] and was not a diabetic. On 7/14/16 at 10:20 a.m., ASM #10, the attending physician, was interviewed. He stated that for new admissions, the physician will often call him from the local hospital to tell him about new patients being discharged to the facility. He stated the staff at the facility later calls him and goes over medications for the new residents. He stated: The nurses tell us the medical problems, and I either approve the medication orders or ask them to clarify them. Then I see them within 24 or 48 hours. When asked what would be required for him to approve a telephone order for [MEDICATION NAME], he stated: We would go over the [DIAGNOSES REDACTED].#26, he stated: Yes. When asked if he recalled being informed of the [MEDICATION NAME] on the resident's admission, he stated: The nurse must have given me erroneous information. When asked what is involved in performing and documenting an admission history and physical for a resident, ASM #10 stated: I look at the hospital discharge summary. That's what I look at. I look over the medications the patient is on. I would not have ordered it unless the medication was on the discharge paperwork. When informed that he had, in fact, verbally approved the order for [MEDICATION NAME], and had, later that same day, signed and dated an admission history and physical report for Resident #26, and that neither the hospital discharge records nor his own history and physical contained any evidence of Resident #26 being diabetic, he stated: I think I will have to look over the paper record. He stated his signature does indicate that he has reviewed the hospital discharge record and the resident's medications. He stated: It must be an error. There are over 4000 medication orders entered under my name every month. This was bound to happen sometime. A review of the facility policy entitled Physician/Prescriber Authorization and Communication of Orders to Pharmacy revealed, in part, the following: Facility should verify transfer/transition and admission orders [REDACTED]. A review of the facility policy entitled Medication Management revealed, in part, the following: Nursing staff members are to reference the established contracted provider's Pharmacy Services and Procedures Manual regarding medication orders, delivery, monitoring and other related processes for promoting efficiency and consistency in medication administration and standards of best practice. A review of the facility policy entitled General Dose Preparation and Medication Administration revealed, in part, the following: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. A review of the facility policies entitled Admissions Policy and Scope of Care revealed nothing related to the concerns of a resident receiving unnecessary medications. No further information was received prior to exit. The following information is provided in Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360) was used as a reference for medication administration. A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR indicated [REDACTED]. When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation In Fundamentals of Nursing, 6th edition, 2005, Patricia A. Potter and Anne Griffin Perry, Mosby, Inc; Page 419: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients. COMPLAINT DEFICIENCY 2. Facility staff failed to ensure Resident #11 was free from an unnecessary blood pressure medication on 7/8/16. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/26/16. Resident #11 was coded as being severely impaired in cognitive status scoring 4 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Resident #11 was coded as requiring extensive assistance from staff to being dependent on staff with most ADLS (Activities of Daily Living). Review of Resident #11's clinical record revealed the following active order, Irbesartan Tablet 150 MG (milligram) Give 1 tablet by mouth one time a day related to essential primary hypertension (high blood pressure). There were no orders for blood pressure parameters. Review of Resident #11's July 2016 eMAR (electronic medication administration record) documented the following blood pressure and pulse on 7/8/16 at 9:00 a.m., BP 88/44, Pulse 41. The nurse who documented these vital signs also documented that she had administered Resident #11's blood pressure medication on 7/8/16 at 9:00 a.m. Review Resident #11's care plan dated 4/29/16 under focus area CARE NEEDS documented the following: Care Needs Related to: .essential [MEDICAL CONDITION](high blood pressure) .Interventions .Monitor vital signs, Notify MD (medical doctor)/RP (responsible party) of significant changes in condition. On 7/13/16 at 1:41 p.m., an interview was conducted with ASM (administrative staff member) #11, the nurse practitioner. When asked when nursing would hold a blood pressure medication she stated that it is standard nursing practice to hold to a blood pressure medication when a blood pressure is 100/60 or below. She stated that if a blood pressure happened to be obtained and it was low, nursing should have held the medication and notified the physician. On 7/13/16 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. She stated that it is good nursing practice and judgement to hold blood pressure medication if a resident's blood pressure is less than 100/60 and pulse less than 60. She stated that this holds true even when blood pressure parameters are not ordered. When shown LPN #9, Resident #11's blood pressure readings on 7/8/16 she stated, Yes that was documented as given and her blood pressure was low. Her pulse was also low. She stated that the medication should have been held and the physician and RP notified. On 7/14/16 at 2:51 p.m., an interview was conducted with RN (registered nurse) #7. When asked what check marks meant on the eMAR she stated that it meant a medication was administered. When asked when a blood pressure medication should be held she stated that a blood pressure medication should be held if the systolic pressure is 100 or below and the Diastolic pressure is 60 or below. When asked when to hold a medication that could lower the pulse she stated that a medication should be held if the pulse is less than 50. When asked if she had given Resident #11's Irbesartan medication on 7/8/16, she stated, If it was checked it was given then I must have gave it. When asked if that was the blood pressure that day she stated that if it was documented then it must have been. When asked if the medication should have been given with a blood pressure and pulse reading that low she stated, Absolutely not. On 7/14/16 at 1:30 p.m., ASM #3, the administrator, ASM #4 the DON (Director of Nursing from a sister facility), and ASM #6, the corporate nurse, were made aware of the above concerns. Facility policy did not address the above concern. No further information was presented prior to exit. (1) Irbesartan is used alone or in combination with other medications to treat high blood pressure. It works by blocking the action of certain natural substances that tighten the blood vessels, allowing the blood to flow more smoothly and the heart to pump more efficiently. Symptoms of overdose include fast or slow heartbeat, dizziness or [MEDICAL CONDITION]. This information was obtained from the National Institutes of Health. https://medlineplus.gov/druginfo/meds/a 9.html.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the physician failed to supervise the care of residents to provide safely-administered medications for one of 29 residents in the survey sample, Resident #26. The physician failed to verify a [DIAGNOSES REDACTED]. The physician verbally approved an admission order for [MEDICATION NAME], a medication to lower blood sugar, to Resident #26. Resident #26 did not have a [DIAGNOSES REDACTED]. As a result of receiving the [MEDICATION NAME], Resident #26's blood sugar levels became dangerously low on 8/8/15. He became unresponsive, and required treatment at the facility and transportation by EMS (emergency medical services) to a local hospital emergency room , where he received further treatment for [REDACTED]. The findings include: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the admission nursing assessment dated [DATE], he was documented as being alert to person and to situation, but not to time and place. He was documented as being confused for cognition. He was documented as being resistive and as having disorganized thinking for mood and behavior concerns. In the section of this assessment entitled Other Relevant Dx (diagnoses)/Concerns, the box beside Diabetes was not checked. A review of the discharge summary from a local hospital dated 8/7/15 revealed no evidence of diabetes (1) as a [DIAGNOSES REDACTED]. Further review of the summary revealed a section entitled Medications on Discharge. A review of this section revealed no evidence of [MEDICATION NAME] (2) as a current medication for Resident #26. (1) Diabetes means your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn't good for your health. This information is taken from the website http://nihseniorhealth.gov/diabetes/diabetesdefined/01.html. (2) [MEDICATION NAME] is used along with diet and exercise, and sometimes with other medications, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] is in a class of medications called sulfonylureas. [MEDICATION NAME] lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently. This medication will only help lower blood sugar in people whose bodies produce insulin naturally. This information is taken from the website <https://medlineplus.gov/druginfo/meds/a 0.html> Precautions: General: [DIAGNOSES REDACTED] (low blood sugar): All sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED]. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=37a18bd1-034f-4366-8323-ec4e1c52ac1e A review of Resident #26's medication orders revealed the following order, written 8/8/15 as a verbal order from ASM (Administrative Staff Member) #10, the attending physician, by LPN (licensed practical nurse) #13, who is no longer employed by the facility: [MEDICATION NAME] Tablet 10 mg (milligrams). Give 2 tablet (sic) by mouth one time a day for diabetes. The order was signed on 8/8/15 by a nurse practitioner, who was unavailable for interview during the time of the survey. A review of Resident #26's clinical record revealed a physician's admitting history and physical progress note dated 8/8/15 and signed by ASM (administrative staff member) #10, the attending physician. This progress note did not include evidence of a [DIAGNOSES REDACTED].#26. A review of the Medication Administration Record [REDACTED]. The nurse who administered the medication is no longer employed by the facility. A review of the nurses notes for Resident #26 revealed, in part, the following; - 8/8/15 at 9:57 p.m.: Situation: This note is associated with a .change of condition evaluation .The signs/symptoms of this change of condition are: Unresponsiveness. This started on 8/8/15 during the night. Background: The patient is in the center for Post-Acute Care with a [DIAGNOSES REDACTED].[MEDICAL CONDITION] .[MEDICAL CONDITION] (3), .Assessment (RN) (registered nurse) /Appearance (LPN) (licensed practical nurse): The issues appears (sic) to be: low Glucose level*-47. This note was written by RN #4. * Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (deciliter) is considered low. Blood sugar at or below this level can be harmful. The medical name of low blood sugar is [DIAGNOSES REDACTED]. Possible Complications: Severe low blood sugar is a medical emergency. It can cause [MEDICAL CONDITION] and brain damage. Severe low blood sugar that causes you to become unconscious is called insulin shock. This information was obtained from the website: <https://medlineplus.gov/ency/article/ 6.htm> - 8/8/15 at 10:45 p.m.: Upon entering residents (sic) room to administer night time meds (medications) resident was unresponsive. Vitals were (127/72 (blood pressure), O2 (oxygen) 96 (%), pulse 74, temp (temperature) 98.7. Residents (sic) blood sugar was 46 after administration of orange juice and [MEDICATION NAME] (sic) repeat blood sugar was 73. Resident was send (sic) out for unresponsiveness and [DIAGNOSES REDACTED] (low blood sugar). This note was written by LPN #3. A review of the EMS report dated 8/8/15 revealed, in part, the following: Dispatched for a [AGE] year old male unresponsive with a low blood sugar. (Name of EMS team) arrived on scene and were advised by staff that patient had original blood glucose of 43. Staff advised that they gave the patient half tube of oral glucose and that raised it to 73. Family was present on scene and stated that patient was at his normal baseline 20 minutes prior to incident. Patient skin cool and moist and he has a patent airway. Patient will grimace with painful stimuli. (Name of EMS team) placed patient on stretcher and moved to unit. Patient unresponsive and glucose found to be at 50 at this time. Baseline vitals (vital signs) obtained. IV (intravenous) access gained. Patient given 25 grams of [MEDICATION NAME] (sugar) IVP (IV push). Patient transported without incident to (name of local hospital). A review of the ER (emergency room ) report for Resident #26 dated 8/8/15 at 10:41 p.m. and continuing through 8/9/15 at 6:06 a.m. revealed, in part, the following: Patient is [AGE] year-old male who was sent here from a local nursing home because of unresponsiveness, facial twitching and blood sugar 47. The patient was given oral glucose and EMS was called. Upon EMS arrival D50 ([MEDICATION NAME], a sugar solution) was given with improvement. However when he awoke he was agitated and sent here for further evaluation and improvement .Of note is that patient is not diabetic and has not had problems with [DIAGNOSES REDACTED]. Further review of the clinical record for Resident #26 revealed the following nurses notes: - 8/9/15 at 1:48 p.m.: Patient returned from hosp (hospital) this am (a.m.). No new orders noted. - 8/10/15 at 10:10 a.m.: [MEDICATION NAME] Tablet 10 mg. Give 2 tablet (sic) by mouth one time a day for diabetes. This medication held d/t (due to) medication review. Further review of the medical record revealed an order written [REDACTED]. A review of a facility document entitled Medication Error Report dated 8/11/15 regarding Resident #26 revealed, in part, the following: Medications ordered: None. Medications given: [MEDICATION NAME] 10 mg. Describe the error: Wrong medication was entered into (name of computer software) for this patient. The script from (name of local hospital) had another patient's name written on it .What was the effect of the error on the resident? Resident blood sugar level dropped to 43 mg/dl (milligrams per deciliter) and he became unresponsive. 911 (EMS) was called and he was taken to the ER. Corrective measures taken for resident: Hospital transfer, medication discontinued, close monitoring. On 7/13/16 at 9:35 a.m., RN #5, the unit manager for Resident #26 at the time of the incident, was interviewed. She stated when the resident was admitted to the facility on [DATE], the discharging hospital faxed medication orders. She stated: All of them were his except for the [MEDICATION NAME]. It had another patient's name on it. She stated that the admitting nurse is no longer employed at the facility, and that she entered the [MEDICATION NAME] into the electronic order system for Resident #26 in error. She stated the resident received the [MEDICATION NAME] at 9:00 a.m. on 8/8/15, and the nurse was making rounds on the evening shift of 8/8/15, he found the resident to be unresponsive. She stated EMS (emergency medical services) was called and the facility staff realized the resident's blood sugar was low. RN #5 stated at that time, the facility staff checked the chart and realized the resident did not have a [DIAGNOSES REDACTED].#5 stated at that time, they double-checked all of the resident's orders. When asked about the physician's/nurse practitioner's role in the process of ordering medications for a newly-admitted resident, RN #5 stated: The doctor should review the medications and [DIAGNOSES REDACTED]. We often do the admission orders [REDACTED]. RN #5 stated: He obviously should never have received the [MEDICATION NAME]. At this time, RN #5 was asked to locate the order for [MEDICATION NAME] from the discharging hospital (containing the wrong patient name). On 7/13/16 at 1:05 p.m., OSM (other staff member) #22, the consulting pharmacist, was interviewed. She stated that when orders are entered by a facility staff member and transmitted to the pharmacy, most all of the work is done electronically. She stated she did not believe that the pharmacists were involved in double-checking [DIAGNOSES REDACTED]. On 7/13/16 at 1:20 p.m., OSM #20, the front end manager for the facility pharmacy, and OSM #21, the pharmacist, were interviewed. OSM #20 stated that the pharmacy receives most admission medication orders electronically from facilities, with the exception of controlled substances and extremely complicated orders. OSM #20 stated that a pharmacy technician initially checks the order for errors to make sure there is nothing wrong with the way it is written. Once the orders are checked by a technician, the technician sends them to the pharmacist. OSM #21 stated the pharmacy looks at the order to make sure it contains the required elements of date of birth, resident name, drug name, strength, and directions for administration. OSM #21 stated the pharmacist reviews the [DIAGNOSES REDACTED]. OSM #21 stated: We do not check the diagnoses. When asked the consequences for administration of 20 milligrams of [MEDICATION NAME] to a resident who is not diabetic, OSM #21 stated the standard starting dose for anyone on [MEDICATION NAME] is usually 5 (five) milligrams daily. OSM #21 stated: That much [MEDICATION NAME] could definitely really lower someone's blood sugar. On 7/13/16 at 2:45 p.m., LPN (licensed practical nurse) #9 was interviewed regarding the process of obtaining admission medication orders. She stated the admissions director provides the nurse with a packet of information about the resident, including discharge [DIAGNOSES REDACTED]. LPN #9 stated most often, the physicians are not present in the building, and that the nurse pages the physician and verbally goes over the orders by telephone. She stated the nurse is responsible for making sure the orders are for the correct resident and that both the physician and the nurse are responsible for making sure the [DIAGNOSES REDACTED].#9 stated: The [DIAGNOSES REDACTED]. That information is available in the packet that the admissions director provides from the discharging hospital. She stated the nurse also reviews the resident's allergies [REDACTED]. When asked what should be done once an issue like [MEDICATION NAME] being administered to a non-diabetic resident is identified. LPN #9 stated the physician should be notified right away and the medication should be discharged immediately. When shown the nurses notes referenced above, which stated the [MEDICATION NAME] was not discontinued for Resident #26 until 8/10/16, LPN #9 stated: It should have been discontinued as soon as he got back from the hospital. On 7/13/16 at 3:50 p.m., RN #4 was interviewed. She stated she was administering meds (medications) on another hallway on the evening of 8/8/15. She stated LPN #3 was a very new nurse, and had only been working three or four evenings. RN #4 stated he went to her and asked her about an order for [REDACTED].#4 stated then she assisted the staff to call 911 and to get paperwork together regarding Resident #26 for the EMS staff. On 7/13/16 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, administrator of a sister facility, ASM #4, director of nursing at a sister facility, ASM #5, a corporate nurse, ASM #6, a corporate nurse, and ASM #7, vice-president of operations, were informed of these findings. These staff members were informed of the survey team's concern for harm regarding these findings. The staff members were requested to provide a copy of the order for [MEDICATION NAME] from the discharging hospital (containing the wrong patient name). The staff members were also requested to provide the facility's professional standard for nursing practice. On 7/14/16 at 8:00 a.m., the facility staff informed the survey team that the facility uses textbooks by Potter and Perry, and by Lippincott, as their standards of nursing practice. On 7/14/16 at 9:55 a.m., LPN #3 was interviewed. He stated he remembered the incident with Resident #26. He stated he remembered finding the resident to be unresponsive, checking his blood sugar and finding it to be very low and getting help from other staff to call EMS. LPN #3 stated he remembered discovering that the resident had received 20 milligrams of [MEDICATION NAME] and was not a diabetic. On 7/14/16 at 10:20 a.m., ASM #10, the attending physician, was interviewed. He stated that for new admissions, the physician will often call him from the local hospital to tell him about new patients being discharged to the facility. He stated the staff at the facility later calls him and goes over medications for the new residents. He stated: The nurses tell us the medical problems, and I either approve the medication orders or ask them to clarify them. Then I see them within 24 or 48 hours. When asked what would be required for him to approve a telephone order for [MEDICATION NAME], he stated: We would go over the [DIAGNOSES REDACTED].#26, he stated: Yes. When asked if he recalled being informed of the [MEDICATION NAME] on the resident's admission, he stated: The nurse must have given me erroneous information. When asked what is involved in performing and documenting an admission history and physical for a resident, ASM #10 stated: I look at the hospital discharge summary. That's what I look at. I look over the medications the patient is on. I would not have ordered it unless the medication was on the discharge paperwork. When informed that he had, in fact, verbally approved the order for [MEDICATION NAME], and had, later that same day, signed and dated an admission history and physical report for Resident #26, and that neither the hospital discharge records nor his own history and physical contained any evidence of Resident #26 being diabetic, he stated: I think I will have to look over the paper record. He stated his signature does indicate that he has reviewed the hospital discharge record and the resident's medications. He stated: It must be an error. There are over 4000 medication orders entered under my name every month. This was bound to happen sometime. A review of the facility policy entitled Physician/Prescriber Authorization and Communication of Orders to Pharmacy revealed, in part, the following: Facility should verify transfer/transition and admission orders [REDACTED]. A review of the facility policy entitled Medication Management revealed, in part, the following: Nursing staff members are to reference the established contracted provider's Pharmacy Services and Procedures Manual regarding medication orders, delivery, monitoring and other related processes for promoting efficiency and consistency in medication administration and standards of best practice. A review of the facility policy entitled General Dose Preparation and Medication Administration revealed, in part, the following: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. A review of the facility policies entitled Admissions Policy and Scope of Care revealed nothing related to the concerns of a physician supervision of resident care. No further information was received prior to exit. In Fundamentals of Nursing, 6th edition, 2005, Patricia A. Potter and Anne Griffin Perry, Mosby, Inc; Page 419: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients.