Every finding on record at Edgecombe Health Center by Harborview

Based on record review and interviews with staff, the Physician and Nurse Practitioner (NP), the facility failed to ensure that Nurse Practitioner visits were comprehensive and included a review of the Medication Administration Records (MARs). On [DATE], an emergency room (ED) physician prescribed Lasix (furosemide) 20 milligrams (mg), (diuretic/water pill) daily for 3 days and Prednisone 20 mg, 3 tablets daily for 5 days for dyspnea (shortness of breath), Chronic Obstructive Pulmonary Disease exacerbation (long term lung conditions that cause irreversible damage to the airway), and fluid overload (retention of water and sodium). On [DATE], a nurse entered the Prednisone order into the electronic record but did not activate a 5-day stop date. As a result, the medication remained active and continued to be administered until [DATE]. On [DATE], the NP completed a follow-up visit after the ED encounter and acknowledged the Prednisone and Lasix orders but did not verify the medication administration record. The NP conducted subsequent visits on [DATE] and [DATE] but again did not review the medication administration record. A review of the medication administration record during either visit would have revealed the ongoing Prednisone administration. On [DATE], Resident # 162 developed cold-like symptoms including wheezing, sneezing, nasal congestion, lethargy, and decreased appetite and was treated with Macrobid (antibiotic) for a urinary tract infection. On [DATE] the resident's family requested a hospital transfer due cough, cold symptoms, and non-productive cough. Resident # 162 was admitted to the hospital on [DATE] with a diagnosis of systemic inflammatory response syndrome (SIRS). Resident # 162 did not respond to treatment and expired on [DATE] at 1:33 AM. This deficient practice affected 1 of 8 residents reviewed for Nurse Practitioner review of the Resident's total care, including medications and treatments (Resident # 162). Immediate jeopardy began on [DATE], when the Nurse Practitioner failed to review the medication administration records during the routine visit. The Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident # 162 was admitted on [DATE] with diagnosis including vascular dementia, chronic congestive heart failure (CHF) ( the heart muscle is to weak or stiff to pump blood efficiently), coronary artery disease (CAD) (major blood vessels supplying the heart becomes narrowed or blocked by plaque, restricting the flow of blood to the heart muscle), atherosclerotic heart disease (ASHD) (fatty, cholesterol-rich deposits build up inside the arteries that supply blood to your heart), diabetes mellitus, hypothyroidism (thyroid gland does not produce enough essential hormones), hyperlipidemia, valvular heart disease (conditions affecting the heart and its connected network of blood vessels), chronic obstructive pulmonary disease (COPD) (progressive long term lung conditions that cause irreversible damage to the airway), atrial fibrillation (irregular heartbeat), pulmonary hypertension (small blood vessels in the lungs become narrowed, blocked or destroyed, forcing the heart to work harder), lymphedema ( abnormal persistent swelling caused of protein by a build-up rich lymph fluid in the body's soft tissues), hypertension, cerebral vascular accident (CVA or stroke), and viral pneumonia was diagnosed [DATE]. Resident # 162's nursing progress note written by Nurse # 10 dated [DATE] at 6:48 PM revealed Resident # 162 stated she doesn't feel well and she stated she could not breathe. Vital signs T 97.7 (normal 96.4 to 98.5 Fahrenheit), P 93 (normal 60 to 100), R 18 (normal 20 to 30), BP 124/78 (normal 90/60 to 120/80) and Oxygen saturation (O2 Sat) 97% on 2 liters per minute oxygen (normal is 88-92 for COPD resident). Family at bedside requested Resident # 162 be transferred to the hospital.Review of Hospital After Care Summary dated [DATE] documented Resident # 162 was treated for shortness of breath, dyspnea, COPD exacerbation and fluid overload. The emergency room physician prescribed Prednisone 20 mg, 3 tablets by mouth with breakfast for 5 days; lasix 20mg by mouth each morning for 3 days; and continue oxygen at 2 liters per minute via nasal cannula. Review of nursing progress notes dated [DATE] at 11:34 PM revealed Resident # 162 returned to the facility. Review of the Physician orders entry dated [DATE] at 5:02 AM identified Nurse # 1 transcribed the Prednisone order as Prednisone 20 mg, 3 tablets by mouth with breakfast for 5 days, starting [DATE]; lasix 20 mg, 1 tablet every morning for 3 days; and oxygen at 2 liter per minute via nasal cannula continuously. However, the nurse did not activate a 5-day stop date for Prednisone, allowing the medication to remain active indefinitely. The lasix order was correctly entered for 3 days starting [DATE].Review of the Nurse Practitioner (NP) progress notes dated [DATE] documented a follow-up after the ED visit. The NP observations included Resident # 162 was lying in bed with oxygen on, no obvious distress, no cyanosis (bluish or purple discoloration of the skin) or accessory muscles (neck and chest muscles used to help with breathing). The NP documented the plan to continue: Prednisone 60 mg daily for 5 days and Lasix 20 mg daily for 3 days. The NP also documented reviewing and updating medications, allergies, problem list, and medical, surgical, social and family histories. Record review of Resident #162's Medication Administration Record (MAR) revealed Prednisone 20 mg, 3 tablets by mouth one time a day for COPD, to be taken with breakfast for 5 days starting [DATE]. The Prednisone was documented as administered daily from [DATE] through [DATE] which included the original 5 doses [DATE] through [DATE] then 8 additional unnecessary doses. Review of the NP progress notes dated [DATE] documented a routine visit for medical management of chronic illness. The NP indicated that previous labs and charting were reviewed and that diagnosis were stable. The NP documented reviewing and updating Resident # 162's allergies, medications, problem list, and past medical, surgical, social and family histories as appropriate. However, the NP did not identify that Prednisone 20 mg, 3 tablets daily, continued to be administered. There was no documentation showing review of the medication administration record, and the ongoing error remained uncorrected. Review of Resident # 162's medication administration record revealed Lasix 20mg, one tablet administered on [DATE], [DATE] and [DATE]. Review of Resident # 162's medication administration record revealed that Prednisone 20 mg, 3 tablets daily, ordered for 5 days beginning on [DATE], continued to be administered every day from [DATE] through [DATE], totaling 25 additional doses beyond the already-exceeded 5-day duration. Review of Resident # 162's Nurse Practitioner progress note dated [DATE], the NP completed a follow-up visit on [DATE] related to a change of condition reported the evening before. At the time of the call, staff reported Resident # 162's vital signs included heart rate was 117, blood pressure 89/61, lungs clear bilaterally, no difficulty breathing on oxygen 2 liters/minutes via nasal cannula, and oxygen saturation 94%. Despite conducting the follow-up evaluation, the NP did not review the medication administration record, and the ongoing Prednisone administration remained unidentified. An in-person interview conducted with the Nurse Practitioner on [DATE] at 11:30 AM revealed during his routine visit on [DATE] and follow up note on [DATE], he did not mention the Prednisone in his notes as this was not one of the disease processes he was looking at during that time frame. He stated during his routine visits he reviews the medication administration records, however between November of 2025 through February 2026 there was a glitch in the system. The NP stated his iPad would not open multiple screens, so he was unable to access the MARs. The NP stated the Nurses would have opened the MARs if he had asked them too, however he did not request a nurse to open the MARs to review the current medications being administered to Resident # 162 during his routine or follow-up visits with Resident # 162. He did not report the alleged system issue to the Administrator or the Physician. A review of Resident # 162's medication administration record (MAR) showed Prednisone 20 mg, 3 tablets (60 mg) was administered daily from [DATE] through [DATE]. This includes 5 appropriate doses from [DATE] through [DATE] and 61 additional unnecessary doses from [DATE] through [DATE]. The error remained uncorrected because the initial order did not include a stop date, and Nurse Practitioner visits did not include medication administration record review. Review of the Situation Background Assessment Recommendations written by Nurse # 22 dated [DATE] at 7:12 PM revealed Resident # 162 complained of cold like symptoms (cough, cold and congestion, and a non-productive cough). Nurse # 22 assessed the resident, and family member present requested that Resident # 62 be sent to the ED. Vital signs included blood pressure 124/82, temperature 97.2, pulse 65, respirations 18, blood sugar 118, oxygen saturation 96% on oxygen at 2 liters per minute via nasal cannula. Resident # 162 was sent to the ED per family request. Nurse # 22 was not available for an interview. Resident # 162's ED Physician documentation included resident was examined and presented to the ED with respiratory distress and suspected COPD versus CHF. The ED critical care attestation written by the ED physician on [DATE] stated Resident # 162 had a high probability of life-threatening deterioration in conditions, at the initial presentation or during the ED course due to respiratory failure. Resident # 162 was transferred from the ED and admitted to the medical intensive unit (MIU) for sepsis. Review of Resident # 162's Certificate of Death, with date of death of [DATE] at 1:33 AM, identified the final disease or condition resulting in death as cardiac arrest with pulseless electrical activity, severe sepsis with multi-system organ failure and Respiratory Syncytial Virus. An interview conducted with the Physician on [DATE] at 10:47 AM revealed that steroids given for any length of time can cause bone loss, adrenal issues (adrenal glands make hormones that help keep your metabolism, blood pressure, immune system and stress response in balance) and euphoria and require gradual weaning. The physician reviewed the emergency room notes from [DATE] and stated Resident # 162 had an infection, respiratory distress, and an inflammatory reaction to Respiratory Syncytial Virus. The physician stated Prednisone could have reduced the resident's ability to fight infection and that long-term steroids decrease the immune response and could have contributed to her demise. He stated during routine visits, Physicians and Nurse Practitioners are expected to review allergies, active medications, problem list, and medical, surgical, social and family histories and updated them as appropriate. During a telephone interview on [DATE] at 3:03 PM, the previous Director of Nursing (DON # 2) reported the Nurse Practitioner never informed her that the medication administration system had a glitch preventing medication administration access. The NP had previously asked her to open the medication administration records for other residents when needed, but he did not request assistance opening the medication administration records for Resident # 162 in November or [DATE]. No issues or glitches in the electronic medication system were reported during the time frame the Nurse Practitioner described. The Administrator was notified of the immediate jeopardy on [DATE] at 4:05 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.Resident #162 was admitted to the facility on [DATE] with multiple diagnoses, including COPD, CHF, CAD, diabetes mellitus, atrial fibrillation, vascular dementia, and other chronic conditions.On [DATE], following an Emergency Department visit, Resident #162 was prescribed Prednisone 20 mg, three tablets (60 mg total) by mouth daily with breakfast for five days for COPD. The order was entered into the electronical health record by the nurse and included the prednisone was to be given for 5 days but the nurse did not activate the 5-day duration within the order. As a result, the medication remained active on the Medication Administration Record and Resident #162 continued to receive Prednisone 60 mg daily until [DATE]. Due to the extended administration of the prednisone beyond the intended duration, the resident was at risk for adverse effects associated with prolonged steroid therapy.The Nurse Practitioner conducted routine visits on [DATE] and [DATE]; however, the ongoing Prednisone order was not identified, reviewed, or addressed during those visits. The Nurse Practitioner later reported that a system issue occurred from [DATE] through February 2026 and prevented access to the Medication Administration Records (MARs) for all residents limiting the ability to review active medications during that period. The Nurse Practitioner failed to report this to Administration, and there were no reported glitches within the electronic administration record system during this time.On [DATE], the [NAME] President of Operations completed an audit to ensure all medical providers had appropriate access to the electronic health record system which includes the MARs. The audit revealed no additional concerns related to provider access.Beginning on [DATE] the Nurse Practitioner will review all physician orders and MARs for all current residents from [DATE] through February 2026 to determine if any other residents were affected by the deficient practice or any changes need to be made to their current medical regimen. To be completed by [DATE].Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.On [DATE], the [NAME] President of Operations and Administrator conducted a Root Cause Analysis regarding Resident #162's prolonged prednisone therapy. During an interview [DATE] the Nurse Practitioner admitted to the Administrator and [NAME] President of Operations that he did not check the residents' MARs when completing routine visits from [DATE] through February 2026 due to not being able to simultaneously pull up multiple tabs on his iPad. There was no glitch with the Electronic Medical Record (Point Click Care) from [DATE] through February 2026. The NP indicated he didn't think to communicate it with anyone at the facility or the Medical Director. The Administrator then instructed the Nurse Practitioner to utilize an alternate electronic device if he was to have issues with his iPad in the future.On [DATE], the Administrator began educating by phone/in person all the medical providers including the Medical Director, Physician Assistants and Nurse Practitioners regarding the expectation that Medication Administration Records (MARs) be reviewed during routine resident visits and they will be informed of and educated on the entire regulation: F711. They were instructed to immediately notify the Administrator if they experience any difficulty accessing resident records, including Medication Administration Records, so that corrective action can be taken without delay. They were also instructed that effective immediately, providers will meet with the Director of Nursing or designee at the conclusion of each facility visit to review any medication concerns and verify that medication orders are complete and compliant with facility protocols. Completed by [DATE]. Any newly contracted primary providers will receive education from the Staff Development Coordinator regarding electronic health record access procedures and to report any issues with access to the resident records to the Administrator before providing services within the facility. The facility alleges removal of the immediate jeopardy and compliance on [DATE].Validation of the immediate jeopardy removal plan was conducted on [DATE]. The [NAME] President of Operations completed an audit of the electronic health record system to ensure all medical providers had access to the electronic health records of residents. The Nurse Practitioner reviewed all physicians' orders and medication administration records for all current residents. The [NAME] President of Operations completed a root cause analysis regarding the prolonged prednisone therapy. The Administrator provided education to the Medical Director and Nurse Practitioner regarding Medication Administration Reviews being completed during routing visits. Interviews with medical providers revealed they attended in-services and participated in audits as outlined in the corrective action plan. The immediate jeopardy removal and compliance date of [DATE] was validated.

Based on record review, and staff, Pharmacy Consultant, Pharmacy Quality Assurance Manager, and Physician interviews, the facility failed to have effective systems in place for accurate acquiring of medications and the pharmacy failed to have effective systems in place to prevent refilling a medication order 3 times after the stop date. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, COPD exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days for diagnosis of dyspnea (shortness of breath or difficulty, uncomfortable breathing), chronic obstructive pulmonary disease exacerbation (long term lung diseases that cause inflammation and damage to airways, making it difficult to breathe). Prednisone is a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including respiratory diseases. On [DATE] a Nurse transcribed the order into the electronic medical record for Prednisone 20 mg give 3 tablets at breakfast for 5 days; however, the Nurse did not enter a stop date for the order. This order was transmitted directly to the pharmacy electronically and the pharmacy and the pharmacy also did not enter the 5-day stop date when the order was reviewed. The pharmacy delivered Prednisone 20 mg, 15 tablets on [DATE]. Facility nursing staff ordered 3 refills for the Prednisone without a physician order, and the pharmacy filled and delivered 15 tablets on [DATE], 90 tablets on [DATE], and 90 tablets on [DATE] all after the 5-day stop date. Prednisone 20 mg, 3 tablets (60 mg) were administered to Resident # 162 daily from [DATE] through [DATE], totaling 66 days of administration, 61 days past the medication stop date. Possible negative outcomes of receiving 60 mg of Prednisone longer than 5 days may include hyperglycemia (high blood sugar), psychotic disturbance (loss of contact with reality), fluid retention (excess fluid buildup in the body's tissues), decreased ability to fight infection, and a decrease in inflammatory mediators (small molecules and proteins that coordinate the body's immune response to injury or infection). On [DATE] the resident's family requested a transfer to the hospital due to complaints of cough, cold and congestion with non-productive cough. Emergency Department (ED) vital signs included oxygen saturation 79% on room air (normal range for oxygen saturation for someone with COPD is 88% to 92%) and the resident was immediately placed on BiPAP (bilevel positive non-invasive ventilation). Active hospital problems included SIRS (systemic inflammatory response syndrome- a life-threatening medical condition characterized by a widespread inflammatory response throughout the body triggered by infection), RSV (acute bronchiolitis due to respiratory syncytial virus), hypoxia, and sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Resident #162 was transferred to the medical intensive unit for sepsis and did not respond to treatment and expired on [DATE] at 1:33 AM. This deficient practice affected 1 of 8 residents reviewed for providing pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) (Resident # 162).Immediate jeopardy began on [DATE] when the pharmacy did not enter the 5-day stop date for Resident #162's Prednisone order when the order was reviewed by a pharmacist. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included:1. Review of the facility's Pharmacy Services policy implemented [DATE] and reviewed/revised [DATE] indicated it was the policy of this facility to ensure that pharmacy services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Pharmaceutical Services refers to: the process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and disposing of all medications, biologics, and chemical. Compliance Guidelines included: the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing and administration of all routine medications and emergency drug and biologics to meet the needs of the residents. Resident # 162 was admitted on [DATE] with diagnosis including vascular dementia, chronic congestive heart failure (CHF) (the heart muscle is to weak or stiff to pump blood efficiently), coronary artery disease (CAD) (major blood vessels supplying the heart becomes narrowed or blocked by plaque, restricting the flow of blood to the heart muscle), atherosclerotic heart disease (ASHD) (fatty, cholesterol-rich deposits build up inside the arteries that supply blood to your heart), diabetes mellitus, hypothyroidism (thyroid gland does not produce enough essential hormones), hyperlipidemia, valvular heart disease (conditions affecting the heart and its connected network of blood vessels), chronic obstructive pulmonary disease (COPD) (progressive long term lung conditions that cause irreversible damage to the airway), atrial fibrillation (irregular heartbeat), pulmonary hypertension (small blood vessels in the lungs become narrowed, blocked or destroyed, forcing the heart to work harder), lymphedema (abnormal persistent swelling caused of protein by a build-up rich lymph fluid in the body's soft tissues), hypertension, cerebral vascular accident (CVA or stroke), and viral pneumonia was diagnosed [DATE].Review of Resident # 162's nursing progress note written by Nurse # 10 dated [DATE] at 6:48 PM revealed Resident # 162 stated she doesn't feel well and stated she could not breathe. Family was at bedside and wanted the resident sent out to the hospital. Resident # 162 was sent to the hospital emergency department (ED). Review of Hospital After Care Summary dated [DATE] revealed Resident # 162 was treated for shortness of breath, dyspnea, COPD exacerbation and fluid overload. The emergency department physician prescribed Prednisone 20 mg, 3 tablets by mouth with breakfast for 5 days, and 20mg by mouth in the morning for 3 days. Review of nursing progress notes dated [DATE] at 11:34 PM revealed Resident # 162 returned to the facility. Review of the Physician orders dated [DATE] at 5:02 AM identified Nurse # 1 transcribed an order for Resident # 162 in the electronic medical record physician order system for Prednisone give 3 tablets by mouth one time a day for COPD take 3 tablets by mouth with breakfast for 5 days/ER Provider, start date [DATE] and end date indefinite and this order was transmitted directly to the pharmacy electronically. Record review of the pharmacy medication delivery sheets revealed: Prednisone 20mg, 15 tablets were delivered on [DATE]. Further review of the pharmacy medication delivery sheets revealed the facility continued to request refills and the facility received:Prednisone 20mg, 15 tablets were delivered on [DATE].Prednisone 20mg, 90 tablets were delivered on [DATE].Prednisone 20mg, 90 tablets were delivered on [DATE]. Review of Resident #162's Medication Administration Records (MARs) from [DATE] through [DATE] revealed the Prednisone order appeared on the MARs as follows: Prednisone oral tablet 20 mg give 3 tablets by mouth one time a day for COPD take 3 tablets by mouth with breakfast for 5 days, Start Date [DATE] at 8:00 AM. The Prednisone was documented as administered daily from [DATE] through [DATE]. The MAR revealed 5 doses administered from [DATE] through [DATE], and an additional 61 doses administered from [DATE] through [DATE]. The resident received a total of 66 doses of Prednisone 60 mg. Review of the SBAR written by Nurse # 22 dated [DATE] at 7:12 PM revealed Resident # 162 complained of cold like symptoms (cough, cold and congestion, and a non-productive cough). Nurse # 22 assessed the resident, and family member present requested that Resident # 62 be sent to the emergency department (ED). Resident # 162 was sent to the ED per family request. Review of the emergency medical services (EMS) patient care record dated [DATE] indicated the call was received from the facility at 6:42 PM and EMS personnel was dispatched at 6:44 PM. EMS was at the bedside at 6:50 PM and observed Resident # 162 lying in a fetal position in bed with a cough present. A family member at the bedside stated the facility was treating Resident # 162 for a urinary tract infection and the flu. At 6:58 PM the resident was alert and pulse was 80, respirations 30, oxygen saturation was 70%, and BP was unable to be obtained. At 7:03 PM the resident was alert and her pulse was 124, respirations were 28, oxygen saturation was 84%, and BP was unable to be obtained. The EMS assessment of Resident # 162 included altered mental status, decreased breath sounds, and lower leg swelling 2+ pedal edema (fluid accumulation causing swelling in the feet and ankles). EMS left the facility at 7:12 PM to transport Resident # 162 to the ED. During transportation to the ED, Resident # 162 oxygen saturation remained in the 70's and EMS increased the resident's oxygen to 4 liters per minute. EMS was unable to obtain a blood pressure and the resident had no radial (inside of wrist) pulse. Resident # 162's respirations became labored, and lung sounds decreased. EMS placed the resident on CPAP (continuous positive airway pressure- breathing therapy device that delivers air to a mask worn over the nose and mouth to help consistent breathing), obtained IV access, and started intravenous fluids. Resident continued to decline, and the level of consciousness became altered. EMS removed the CPAP and assisted ventilations with a bag-valve mask (also known as an Ambu bag, is a manual resuscitation method used to deliver oxygen to patients with apnea or severe respiratory failure until advanced airway management can be performed). Upon arrival to the emergency room, EMS gave report and transferred care to the receiving hospital.Review of hospital emergency department (ED) notes dated [DATE] at 7:36 PM revealed Resident #162 was transported by the emergency medical services (EMS) and presented with hypoxia (low levels of oxygen in your body tissues which can cause symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin). The resident was immediately placed on BiPAP (bilevel positive non-invasive ventilation). Physical exam noted leg edema, wheezing and rales without obvious respiratory distress. Musculoskeletal assessment revealed 3 + pitting edema, palpable pulses only at the neck, and cool skin. The ED Physician documented respiratory distress and suspected COPD versus CHF. Active hospital problems included SIRS (systemic inflammatory response syndrome- (a life threatening medical condition characterized by a widespread inflammatory response throughout the body triggered by infection), RSV (acute bronchiolitis due to respiratory syncytial virus), hypoxia, sepsis, elevated liver function tests, cystitis (inflammation of the bladder), lactic acidosis (a serious condition that can disrupt normal physiological functions and requires prompt medical attention), acute respiratory failure, leukocytosis (elevated white blood cell count) , elevated troponin level (elevated levels of troponin are a strong indicator of heart attack), acute kidney injury (sudden decline in kidney function occurring within hours or days), and hyperkalemia (higher than normal levels of potassium in the blood levels may cause life threatening heart arrythmias). ED critical care attestation on [DATE] stated the resident had a high probability of life-threatening deterioration in conditions, at the initial presentation or during the emergency department course due to respiratory failure. Resident # 162 was transferred from the ED and admitted to the medical intensive unit (MIU) for sepsis. Review of Resident # 162's Certificate of Death, with date of death of [DATE] at 1:33 AM, identified the final disease or condition resulting in death as cardiac arrest with pulseless electrical activity, severe sepsis with multi-system organ failure and Respiratory Syncytial Virus. A telephone interview conducted on [DATE] at 9:56 AM with the Pharmacy Consultant revealed the pharmacy should have initiated an automatic stop date when the order was received for Prednisone 20 mg, 3 tabs for five days, and the Pharmacy Consultant was unable to comment on the pharmacy's procedure for this process. A telephone interview conducted on [DATE] at 11:59 AM with the Pharmacy Quality Assurance Manager revealed the pharmacy should have dispensed only 15 tablets of Prednisone for the ordered regimen of Prednisone 20, mg 3 tablets daily for 5 days for Resident # 162. The Pharmacy Quality Assurance Manager stated the pharmacy processed two 15 tablet orders and two 90-day supply orders but should have processed only 15 tablets for the 5-day order. He explained medication orders go through an order entry process in which certain fields, including the stop date, must be manually entered even though the order itself auto-populates. He stated the pharmacist verifies the order, ensures the medication, drug, and dose match, and then populates the quantity and supply date according to the order's directions while also checking clinical appropriateness, before dispensing the medication. He further stated that when the Prednisone order for Resident # 162 was received, a stop date should have been added based on the duration of therapy. The order entry processor should have entered the stop date, and the Pharmacist should have identified the missing stop date during clinical appropriateness review and added it. A telephone interview conducted with the previous Director of Nursing (DON) # 2 on [DATE] at 3:03 PM revealed she served as DON # 2 from [DATE] through [DATE]. DON # 2 stated she was not aware that Prednisone 20 mg, 3 tablets daily for 5 days continued to be administered beyond the ordered 5 days for Resident # 162. DON #2 did not offer an explanation for why the nurses continued to order and administer the medication. She stated that when nurses enter new, updated, or discontinued orders in the electronic medical record physician order system, the system automatically updates the electronic medication administration record (MAR). She reported nurses do not review MARs month- to- month to ensure accuracy. She stated the nurse must select an end date using the system calendar or enter the number of days the medication is to be given so the system can calculate the stop date. If neither was entered, the medication would continue to flag for administration. She stated the nursing leadership team (DON # 2 and unit managers) reviewed new, changed, and discontinued orders the next day for accuracy. However, she could not confirm whether Resident # 162's new orders dated [DATE] were reviewed, noting the order must have been missed since it continued without stopping. An interview conducted on [DATE] at 10:47 AM with the Physician revealed steroids given for any length of time can result in loss of bone, adrenal issues and euphoria, and residents must be weaned off Prednisone. The Physician reviewed the emergency room notes from [DATE] and stated Resident # 162 had an infection, respiratory distress, and an inflammatory reaction to the Respiratory Syncytial Virus. The Physician stated Prednisone could have decreased Residents # 162's potential to fight infection and long-term steroids decrease the immune response and could have contributed to her demise. He stated the Prednisone order should have been followed as written by the emergency room Physicians; Prednisone 20 mg, 3 tablets for five days. A telephone interview conducted with the Pharmacy Quality Assurance Manager on [DATE] at 3:34 PM revealed there is no manufacturer defined maximum dose of Prednisone; however, the typical dose for someone with COPD is 30 to 40 mg for 5 days. He stated that depending on the resident's comorbidities, 60 mg may have been an appropriate dose but only for 5 days and only for a severe COPD exacerbation - not indefinitely. He stated possible negative outcomes of receiving 60 mg of Prednisone longer than 5 days may include hyperglycemia (high blood sugar), psychotic disturbance (loss of contact with reality), fluid retention (excess fluid buildup in the body's tissues), decreased ability to fight infection, and a decrease in inflammatory mediators (small molecules and proteins that coordinate the body's immune response to injury or infection). He reiterated that 60 mg should not have been administered beyond the 5-day regimen. The Administrator was notified of the immediate jeopardy on [DATE] at 4:05 PM. The facility provided the following immediate jeopardy removal plan with a compliance date of [DATE].Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.Resident #162 was admitted to the facility on [DATE] with diagnoses including vascular dementia, CHF, CAD, CVA, diabetes mellitus, valvular heart disease, COPD, atrial fibrillation, pulmonary hypertension, bipolar disorder, and hypertension.On [DATE], following an Emergency Department visit, Resident #162 was prescribed Prednisone 20 mg, three tablets (60 mg total) by mouth daily with breakfast for five days for COPD. The order was entered into the electronical health record by the nurse and included the prednisone was to be given for 5 days but the nurse did not activate the 5-day duration within the order. As a result, the medication remained active on the Medication Administration Record and Resident #162 continued to receive Prednisone 60 mg daily until [DATE]. Due to the extended administration of the prednisone beyond the intended duration, the resident was at risk for adverse effects associated with prolonged steroid therapy. In addition, nursing staff continued to reorder the medication after the 5- day stop date and the pharmacy continued to send refills for the prednisone when requested by the facility without a physician order. On [DATE] the Administrator interviewed the Pharmacy Quality Assurance Manager who stated that when the prescription for prednisone for Resident #162 was received by the pharmacy, a stop date should have been added to the order at that time based on the prescribed duration of therapy. The failure to add a stop date allowed the order to remain active in the pharmacy system and continued to be refilled and dispensed to the facility.An audit of reorders on [DATE] completed by the pharmacy revealed the same nurse reordered the medication 3 times, each time it was refilled in error.On [DATE] at 2:38 PM the facility Chief Clinical Officer indicated in an email that a pharmacy representative stated they did not have any way to audit to determine if there were any other instances where the stop date for a medication had not been entered by the pharmacy and refills were sent to the facility.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.On [DATE] the Regional Nurse interviewed the nurse via phone to question why she reordered the prednisone for Resident #162 even with a stop date of 5 days. The nurse stated that she reordered the medication because it remained active in the system and admitted that she didn't read the order in its entirety prior to reordering. The Regional Nurse educated the Nurse at that time she must read the order in its entirety prior to reordering medications in order to avoid incidents of this nature in the future.The Pharmacy Quality Assurance Manager conducted a root cause analysis on [DATE] that determined that the pharmacy did not enter a stop date upon initial order review and entry on [DATE] that resulted in Resident #162's prednisone being refilled after the prescribed 5 days and without a physician order. The pharmacist that reviewed and entered the order did not populate the stop date during pharmacist verification. The policy that outlines the steps to be followed during the pharmacist verification process was not followed by the pharmacist who reviewed this order. Specifically, upon reviewing the directions ordered for the medication and identifying that an order is for a short-term therapy, the pharmacist must ensure the stop date field in the pharmacy system is populated appropriately. The Pharmacy determined based on the root cause that no systems or processes needed to be revised.Beginning on [DATE], the Pharmacy Quality Assurance Manager and/or Pharmacist-In-Charge started in servicing in-person and via phone all Pharmacists responsible for order entry and medication review regarding the requirement to verify stop dates and enter appropriate stop dates for medications prescribed for a defined duration of therapy. Targeted pharmacist education with an emphasis on the exact field involved that must be populated to prevent subsequent refills. The education for the pharmacists included the expectation that any medication order received without a stop date, but with a specified duration, will be clarified immediately by the pharmacist and assigned an appropriate stop date prior to dispensing. Pharmacy Quality Assurance Manager provided the facility Administrator with a copy of the in-service attendance sheet signifying education regarding the requirement to verify stop dates and enter appropriate stop dates for medications prescribed for a defined duration of therapy. The education will be completed by [DATE]. Any Pharmacist hired after [DATE] will receive the education.Pharmacy leadership will maintain documentation of staff education.On [DATE] the Regional Risk Nurse, Administrator, Staff Development Coordinator, Director of Nursing, Unit Manager and/or [NAME] President of Operations began educating all licensed nurses in-person and via phone regarding importance of ensuring that medications with a stop date are only ordered for the duration within the physicians order and when reordering medications the nurse is to review the order for the medications first to ensure that there is no stop date ordered prior to reordering the medication. All actively working license nurses will be in-serviced by [DATE] regarding the importance of ensuring that medications with a stop date are only ordered/reordered for the duration specified within the physician order.The Staff Development Coordinator will be responsible for tracking nurses not educated by [DATE] or returning from leave to ensure that they are educated prior to taking a resident assignment on the importance of ensuring that medications with a stop date are only ordered for the duration specified within the physicians order and when reordering medications the nurse is to review the order for the medications first to ensure that there is no stop date ordered prior to reordering the medication prior to providing services to any residents. Any nurse hired after [DATE] will receive this education prior to taking a resident assignment.The facility alleges removal of immediate jeopardy and compliance on [DATE]Validation of the Immediate Jeopardy (IJ) removal plan was conducted on [DATE].The Consultant Pharmacy Quality Assurance Manager completed an audit of all prednisone orders dated [DATE] through [DATE]. The Director of Nursing, Regional Nurse, and MDS Nurses completed an audit of all current active medication orders to verify stop dates that were entered on each resident's Medication Administration Record. This audit was completed by [DATE]. The consultant pharmacy Quality Assurance Manager and/or Pharmacist In Charge provided education on [DATE] to all pharmacists, both previous and current, regarding verification and entry of medication stop dates. The Regional Risk Nurse, Administrator, Staff Development Coordinator, Director of Nursing, Unit Manager, and/or [NAME] President of Operations provided education to all facility licensed nursing staff on medication stop dates and proper reordering procedures. This education was completed by [DATE]. Interviews with nursing staff and the consultant pharmacist confirmed they attended required in services and, when necessary, participated in audits. Based on review of documentation, interviews, and confirmed implementation of the corrective actions, the immediate jeopardy removal and compliance of date [DATE] was validated.

Based on record review, staff, Pharmacist and Physician interviews, the facility failed to ensure the Pharmacist provided monthly medication regimen reviews that included a comprehensive review of the resident's medical record, including the medication administration record to identify medication irregularities. The Pharmacist medication regimen review (MRR) dated [DATE] through [DATE] did not identify irregularities related to ongoing Prednisone (a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including allergies, autoimmune disorders, and respiratory diseases) 20 milligrams (mg) order (3 tablets by mouth with breakfast for 5 days starting [DATE]. The medication regimen review dated [DATE] through [DATE] also did not identify irregularities related to the continued administration of Prednisone 20 mg, 3 tablets daily for 5 days starting [DATE]. Prednisone 20 mg, 3 tabs (60 mg) was administered from [DATE] through [DATE]. On [DATE], Resident # 162 developed cold-like symptoms including wheezing, sneezing, nasal congestion, lethargy, and decreased appetite. The resident was started on Macrobid (antibiotic) for a urinary tract infection. On [DATE], the resident's family requested Resident # 162 be transferred to the hospital due to cough, cold, congestion and a non-productive cough. Resident # 162 was transferred and admitted a with diagnosis of Systemic Inflammatory Response Syndrome (SIRS) (a severe life-threatening bodily response to a non-specific insult or stressor). Resident # 162 did not respond to treatment and expired on [DATE] at 1:33 AM. The facility also failed to have an effective system in place for ensuring pharmacy recommendations were reviewed for Resident #139. This deficient practice affected 2 of 8 residents reviewed for monthly medication regimen reviews (Resident # 162 and #139).Immediate jeopardy began on [DATE], when the Pharmacist failed to identify irregularities in the ongoing Prednisone administration during the monthly medication regimen reviews. The Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.Example #2 was cited at a lower scope and severity of D. Findings included: 1. Resident # 162 was admitted on [DATE] with diagnosis including vascular dementia, chronic congestive heart failure (CHF) ( the heart muscle is to weak or stiff to pump blood efficiently), coronary artery disease (CAD) (major blood vessels supplying the heart becomes narrowed or blocked by plaque, restricting the flow of blood to the heart muscle), atherosclerotic heart disease (ASHD) (fatty, cholesterol-rich deposits build up inside the arteries that supply blood to your heart), diabetes mellitus, hypothyroidism (thyroid gland does not produce enough essential hormones), hyperlipidemia, valvular heart disease (conditions affecting the heart and its connected network of blood vessels), chronic obstructive pulmonary disease (COPD) (progressive long term lung conditions that cause irreversible damage to the airway), atrial fibrillation (irregular heartbeat), pulmonary hypertension (small blood vessels in the lungs become narrowed, blocked or destroyed, forcing the heart to work harder), lymphedema ( abnormal persistent swelling caused of protein by a build-up rich lymph fluid in the body's soft tissues), hypertension, cerebral vascular accident (CVA or stroke), and viral pneumonia was diagnosed [DATE]. Review of Hospital After Care Summary dated [DATE] revealed Resident # 162 was treated for shortness of breath, dyspnea (difficult or labored breathing), COPD exacerbation and fluid overload (body retains water). The emergency room physician prescribed Prednisone 20 milligrams (mg), 3 tablets by mouth with breakfast for 5 days. Review of Resident # 162's physician orders dated [DATE] at 5:02 AM showed Nurse # 1 transcribed the order for Prednisone 20 mg, 3 tablets by mouth with breakfast for 5 days starting [DATE]. Review of Resident #162's Medication Administration Records (MARs) from [DATE] through [DATE] identified that the Prednisone order appeared on the MARs as follows: administration, as follows: Prednisone oral tablet 20 mg, give 3 tablets by mouth one time a day for COPD; take 3 tablets by mouth with breakfast for 5 days; Start Date [DATE] at 8:00 AM. The Prednisone was documented as administered daily from [DATE] through [DATE]. Record review of Resident # 162's pharmacy recommendations dated [DATE] through [DATE] revealed there were no recommendations identified for that month. The medication regimen review dated [DATE] through [DATE] did not include recommendations related to Prednisone. During a telephone interview on [DATE] at 9:56 AM, the Pharmacy Consultant stated that during monthly medication reviews, he reviews the physician orders, and he should have identified the Prednisone 20mg, 3 tablets (60 mg) daily order for 5 days remained as an active order. He stated he did not review the medication administration records, only the physician orders, and he should have identified the irregularities based on the physician orders. Review of the Situation, Background, Assessment, Recommendation (SBAR) written by Nurse # 22 dated [DATE] at 7:12 PM revealed Resident # 162 complained of cold like symptoms (cough, cold and congestion, and a non-productive cough). Nurse # 22 assessed the resident, and family member present requested that Resident # 162 be sent to the emergency department (ED). Resident # 162 was sent to the ED per family request. Review of hospital emergency department (ED) notes dated [DATE] at 7:36 PM revealed ED critical care attestation on [DATE] stated the resident had a high probability of life-threatening deterioration in conditions, at the initial presentation or during the emergency department course due to respiratory failure. Resident # 162 was transferred from the ED and admitted to the medical intensive unit (MIU) for sepsis. Review of Resident # 162's Certificate of Death, with date of death of [DATE] at 1:33 AM, identified the final disease or condition resulting in death as cardiac arrest with pulseless electrical activity, severe sepsis with multi-system organ failure and Respiratory Syncytial Virus. Review of the hospital death summary dated [DATE] indicated Resident # 162 presented to the ED on [DATE] with the chief complaint of shortness of breath and was admitted to MIU with a diagnosis of systemic inflammatory response syndrome (SIRS). Resident # 162 did not respond to treatments for SIRS, and prior discussions with resident and/or family indicated a wish for a peaceful passing with dignity. Resident # 162 was without heart rate or pulse, without respiratory, and had fixed and dilated pupils. Resident # 162 was pronounced dead at 1:33 AM on [DATE]. Discharge diagnoses included RSV pneumonia, respiratory failure, and septic shock. During an interview on [DATE] at 10:47 AM, the Physician stated Prednisone (steroids) taken for any length of time can result in loss of bone, adrenal issues and euphoria and that the residents must be weaned off Prednisone. The Physician reviewed the emergency room notes from [DATE] and stated Resident # 162 had an infection, respiratory distress, and an inflammatory reaction to the Respiratory Syncytial Virus. The Physician stated Prednisone could have reduced Residents # 162's ability to fight infection, and that long-term steroid use decreases the immune response, which could have contributed to her demise. The Physician stated the emergency department (ED) orders should have been followed as written; Prednisone 20 mg, 3 tablets daily for five days. The Physician stated he receives and reviews the pharmacy recommendations monthly and would expected the pharmacist would identify irregularities in medication administration. The Administrator was notified of the immediate jeopardy on [DATE] at 4:05 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #162 was admitted to the facility on [DATE] with multiple diagnoses, including COPD, CHF, CAD, diabetes mellitus, atrial fibrillation, vascular dementia, and other chronic conditions. Following an Emergency Department visit on [DATE], the resident was prescribed Prednisone 60 mg daily for five days to treat COPD. The order entered on the electronic Medication Administration Record (eMAR) by the nurse included the prednisone was to be given for 5 days but the nurse failed to schedule the stop date resulting in the medication remaining active and being administered until [DATE]. Due to the extended administration of the prednisone beyond the intended duration, the resident was at risk for adverse effects associated with prolonged steroid therapy. Consultant Pharmacist #1 was responsible for completing monthly Medication Regimen Reviews (MRRs), failed to identify and report the medication irregularity to the facility. A document sent to the facility by the Pharmacist indicated it was created between [DATE] and [DATE], and Resident #162 was listed as having no recommendations. On [DATE], Consultant Pharmacist #1 sent a recommendation regarding Trazodone for Resident #162 but failed to identify the ongoing Prednisone order without a stop date All residents that receive medications have the potential to be affected by the deficient practice. Beginning on [DATE], Consultant Pharmacist #2 (new Pharmacist assigned to the facility) began an audit of all medication orders potentially needing stop dates for all current residents. Once the audit was completed on [DATE] the Consultant Pharmacist submitted the 4 findings / recommendations from the audit to the Regional Nurse. Three of the four residents still remained in facility. The recommendations made for the residents who still remained in the facility were corrected and/or validated with the Provider on [DATE] by the Consultant Nurse and corrected as ordered. Beginning on [DATE], Consultant Pharmacist #2 completed MRRs for November and December of 2025 for all residents that remained in the facility as of [DATE] that will be reflected on the [DATE] Medication Regimen Review Report. Recommendations were sent to facility on [DATE] and reviewed with the Physician. Physician orders for recommendations completed by [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE], the Chief Clinical Officer of consulting pharmacy conducted a root cause analysis and communicated the following. The Chief Clinical Officer for the consultant pharmacy had multiple conversations with Consultant Pharmacist #1 of this facility. The Chief Clinical Officer of the consulting pharmacy believed that the ultimate why is that this was simply a human oversight. Consultant Pharmacist #1 did not identify the stop date for the prednisone when completing the Medication Regimen Reviews in [DATE] and [DATE]. On [DATE] The Chief Clinical Officer for the consulting pharmacy was contacted by the [NAME] President of Operations for the facility and stated it was not that Consultant Pharmacist #1 did not complete the MRRs for all in house residents November/[DATE], he just did not identify the irregularity. Moreover, it was determined that Consultant Pharmacist #1 would benefit from review of all Consultant Pharmacist job responsibilities, additional EHR training and to be put on a Performance Improvement Plan, which has been completed. Training for Consultant Pharmacist #1 and Consultant Pharmacist #2 was started on [DATE] and will be completed by [DATE]. The training includes the following: 1) A live workflow session led by the Chief Clinical Officer, in collaboration with the Consultant Pharmacist focused on pharmacy order entry, MAR review, interventions, allergy review, and documentation requirements. 2) Computer based training that reinforces the responsibilities of the Consultant Pharmacist and improving consistency of use of Electronic Health Record (EHR) with reviewing medication orders. 3) Reinforced that all medications requiring a stop date have a stop date in the order and the range dates are entered into the medication orders. Any new Consultant Pharmacist who comes to the facility will receive this training prior to working in the facility by the Chief Clinical Officer for the consulting pharmacy. These training components will also be incorporated into the standard training modules for all Consultant Pharmacists across the organization moving forward. Beginning [DATE] the Chief Clinical Officer of the Consulting Pharmacy will be working with VP of Quality Assurance of the facility's pharmacy to submit a collaborative QAPI report with root cause analysis and the corrective actions will continue to followed once the full final plan of correction has been accepted. This collaboration is intended to support sustained process improvement with the Consultant Pharmacists. The facility has also implemented an onboarding process for any future Consultant Pharmacists providing services to the facility. Prior to providing consultant pharmacy services, the Consultant Pharmacist will receive education from the Staff Development Coordinator regarding identification of medication regimen irregularities, timely notification to the facility, and expectations related to stop dates and medication duration reviews. On [DATE] the Medical Director and attending physicians were informed by the Administrator of the findings for review and oversight. The facility alleges removal of immediate jeopardy and compliance on [DATE]. Validation of the Immediate Jeopardy (IJ) removal plan was conducted on [DATE]. The pharmacy consultant completed a comprehensive audit of all medication orders for all current residents by [DATE]. Four irregularities were identified. The attending physician was notified for clarification of each irregularity. The consultant pharmacist completed monthly medication regimen reviews for all current residents. Reviews included a comparison of physician orders to the Medication Administration Records for the months of [DATE] through [DATE]. All reviews were completed by [DATE]. The Chief Clinical Officer of the consultant pharmacy conducted in-services and assigned additional training to both previous and current consultant pharmacists serving the facility. All required training was completed by [DATE]. Interviews with consultant pharmacists confirmed that they attended the in-services and completed the additional assigned training. Based on review of documentation, staff interviews, and confirmation of completed corrective actions, the Immediate Jeopardy removal and compliance date of [DATE] was validated. 2. Resident #139 was admitted to the facility on [DATE] with diagnoses that included traumatic brain dysfunction, hypertension, diabetes, hyperlipidemia, Alzheimer's disease, and post-traumatic stress disorder. Review of the medical record revealed an order by the Medical Director dated [DATE] for Duloxetine (brand name Cymbalta) HCI capsule delayed release particles 30 mg (milligrams), give one (1) time a day for depression. Review of the pharmacy recommendation dated [DATE] revealed Resident #139 was prescribed Cymbalta 30 milligrams (mg) QD (every day). The pharmacist recommended a dose reduction to 15 mg at HS (hour of sleep). This recommendation was reviewed and signed by the NP on [DATE]. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE] revealed Resident #139 received Duloxetine 30mg, 1 time a day. Review of the MAR dated [DATE] through [DATE] revealed Resident #139 received Duloxetine 30mg, one (1) time a day. Review of the MAR dated [DATE] through [DATE] revealed Resident #139 received Duloxetine 30mg, one (1) time a day. Review of the MAR dated [DATE] through [DATE] revealed Resident #139 received Duloxetine 30mg, one (1) time a day. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE] revealed Resident #139 received Duloxetine 30mg, one (1) time a day. The NP reviewed the recommendation dated [DATE] on [DATE]. The NP then ordered gradual dose reduction of the Duloxetine 30 with a follow up after 2 weeks. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:20 PM, she stated she would have expected the pharmacy recommendations to be reviewed within 30 days of the recommendation. She added that the pharmacy recommendations were sent to the NP on [DATE] and a gradual dose reduction began on that day per the NP's orders. The DON added pharmacy emailed the recommendations to her; she then printed the recommendations and put them in a folder in the Medical Director's office in the facility for review by the Medical Director or NP. The DON stated she was not employed at the facility on [DATE]. She added there had been several DONs in the past year and this pharmacy recommendation was somehow missed for follow up. An interview with the Pharmacy Consultant on [DATE] at 9:49 AM revealed he would expect a response to his recommendations within 30 days. Typically, if he does not hear back within 30 days he would write another recommendation within 60 days. He went on to add this recommendation dated [DATE] were sent to the DON on [DATE] and must have fallen through the cracks. He stated he didn't feel this delay negatively affected the resident or had the potential to negatively affect the resident. An interview was held with the Medical Director on [DATE] at 11:20 AM. He stated he would expect to see a pharmacy recommendation on the day of the recommendation and a response to be made within 10 days of any pharmacy recommendation. He added he did not feel this situation adversely affected Resident #139. An interview with the Nurse Practitioner was conducted on [DATE] at 11:55 AM who stated he would expect the pharmacy recommendations to be presented to him within 10 days of the pharmacist completion of the recommendations. The NP stated he received Resident #139's pharmacy recommendation dated [DATE] from the DON on [DATE]. An interview with the Administrator was conducted on [DATE] at 2:30 PM, he stated the pharmacy recommendation should have been reviewed within 30 days of when it was written. He added, he felt it was missed as there have been many Directors of Nursing and Administrators in the facility and there had been a lack of accountability.

Based on record review, and staff, Physician, Pharmacy Quality Assurance Manager interviews, the facility failed to have effective systems in place to prevent a significant medication error. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, chronic obstructive pulmonary disease (COPD) exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days. Prednisone is a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including respiratory diseases. Possible negative outcomes of receiving 60 mg of Prednisone longer than 5 days may include hyperglycemia (high blood sugar), psychotic disturbance (loss of contact with reality), fluid retention (excess fluid buildup in the body's tissues), decreased ability to fight infection, and a decrease in inflammatory mediators (small molecules and proteins that coordinate the body's immune response to injury or infection). On [DATE] a Nurse transcribed the order into the electronic medical record for Prednisone 20 mg give 3 tablets at breakfast for 5 days; however, the Nurse did not enter a stop date for the order. As a result, nursing staff continued to administer and Resident #162 was administered 60 mg of Prednisone daily from [DATE] through [DATE], totaling 66 days of administration, which was 61 days beyond the ordered stop date. On [DATE] the resident's family requested a transfer to the hospital due to complaints of cough, cold and congestion with non-productive cough. Active hospital problems included SIRS (systemic inflammatory response syndrome- a life threatening medical condition characterized by a widespread inflammatory response throughout the body triggered by infection), RSV (acute bronchiolitis due to respiratory syncytial virus), hypoxia (low levels of oxygen in your body tissues which can cause symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), and sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Resident #162 was transferred to the medical intensive unit for sepsis and did not respond to treatment and expired on [DATE] at 1:33 AM. This deficient practice affected 1 of 8 residents reviewed for significant medication errors (Resident # 162). Immediate jeopardy began on [DATE] when nursing staff continued to administer 61 daily doses of Prednisone 60 mg to Resident #162 after the 5-day stop date without a physician order. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included:Record review of Hospital Physician's Discharge summary dated [DATE] identified that Resident # 162 was admitted on [DATE] and discharged on [DATE]. On admission, Resident # 162 was found to have acute hypoxic respiratory failure (a sudden inability of the lungs to deliver sufficient oxygen to the blood) due to COPD and viral pneumonia. Hospital management included intravenous Methylprednisolone (a corticosteroid that helps reduce inflammation in the lungs and is beneficial for patients with COPD who develop pneumonia), scheduled nebulizer treatments (a machine that converts liquid medication into a fine mist for inhalation, delivering medications directly into to the lungs) and oxygen titrated as needed. Resident # 162 received ceftriaxone (antibiotic) and doxycycline (antibiotic) for possible superimposed bacterial pneumonia; these antibiotics were discontinued. Intravenous Methylprednisolone was initialed, then changed to oral steroids, and was being weaned at discharge. The Physician Discharge Summary included an order for Prednisone 20 mg 0.5 tablet (10 mg) by mouth in the morning for 3 days (start [DATE]), followed by Prednisone 5 mg for 5 days (start [DATE]).Resident # 162 was admitted on [DATE] with diagnosis including vascular dementia, chronic congestive heart failure (CHF) ( the heart muscle is to weak or stiff to pump blood efficiently), coronary artery disease (CAD) (major blood vessels supplying the heart becomes narrowed or blocked by plaque, restricting the flow of blood to the heart muscle), atherosclerotic heart disease (ASHD) (fatty, cholesterol-rich deposits build up inside the arteries that supply blood to your heart), diabetes mellitus, hypothyroidism (thyroid gland does not produce enough essential hormones), hyperlipidemia, valvular heart disease (conditions affecting the heart and its connected network of blood vessels), chronic obstructive pulmonary disease (COPD) (progressive long term lung conditions that cause irreversible damage to the airway), atrial fibrillation (irregular heartbeat), pulmonary hypertension (small blood vessels in the lungs become narrowed, blocked or destroyed, forcing the heart to work harder), lymphedema ( abnormal persistent swelling caused of protein by a build-up rich lymph fluid in the body's soft tissues), hypertension, cerebral vascular accident (CVA or stroke), and viral pneumonia was diagnosed [DATE]. Review of Resident # 162's Medication Administration Records (MAR) dated [DATE] identified Prednisone 20mg give 0.5 tab (10 mg), ordered daily for 3 days for pneumonia was administered on [DATE], [DATE] and [DATE]. Prednisone 5 mg, ordered daily for 5 days for pneumonia, was administered on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident # 162's, care plan initiated [DATE] identified a risk for alteration in nutrition and hydration and alteration in blood glucose due to diabetes mellitus alteration in blood glucose due to non-insulin dependent diabetes mellitus. Interventions included administering diet as ordered, observe for symptoms of high and low blood sugar, and reporting abnormal finger-stick blood sugar results per Physician parameters/guidelines. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 162 was cognitively intact. Resident # 162 was not coded for shortness of breath (dyspnea) or oxygen use. Review of Resident # 162's nursing progress note written by Nurse # 10 dated [DATE] at 6:48 PM revealed Resident # 162 stated she doesn't feel well and stated she could not breathe. Vital signs included temperature 97.7, pulse 93, respiration 18, blood pressure 124/78, blood glucose 87 (normal 80-130) and oxygen saturation (O2) 97% on 2 liters per minute oxygen. Normal vital sign range for residents with COPD are pulse 60 to 100, respirations 20 to 30, blood pressure BP 90/60 to 120/80, O2 sats 88% to 92%. Family at the bedside requested the resident be sent out for evaluation. Review of Hospital After Care Summary dated [DATE] revealed Resident # 162 was treated for shortness of breath, dyspnea, COPD exacerbation and fluid overload. Vital signs were BP 105/83, temperature 97.8, pulse 90, respiration 18 and oxygen saturation 100%. The emergency room physician prescribed Prednisone 20 milligrams (mg), 3 tablets by mouth with breakfast for 5 days; furosemide (diuretic) 20mg by mouth each morning for 3 days; and continue oxygen at 2 liters per minute via nasal cannula. Review of nursing progress notes dated [DATE] at 11:34 PM revealed Resident # 162 returned to the facility. Review of the Physician orders dated [DATE] at 5:02 AM identified that Nurse # 1 transcribed an order for Prednisone 20 mg, 3 tablets by mouth with breakfast for 5 days starting [DATE]; furosemide 20 mg, 1 tablet every morning for 3 days; and oxygen at 2 liter per minute via nasal cannula continuously. An interview conducted with Nurse # 1 on [DATE] at 11:24 AM revealed she did not remember entering Resident # 162's Prednisone order into the medical record order entry system. She stated that when placing a time-limited medication order, the nurse must identify the day of the first dose then either use the system's calendar to select a stop date or enter the number of days the medication is to be administered so the system can calculate the stop date. Nurse # 1 stated that if the number of days is not entered, the medication will continue without stopping. Review of the Prednisone order confirmed Nurse # 1's electronic signature, and Nurse # 1 acknowledged she was the author of the order and may have entered it without a stop date. Review of Resident #162's Medication Administration Records (MARs) from [DATE] through [DATE] revealed Furosemide 20 mg, one tablet was administered on [DATE], [DATE] and [DATE] as ordered. The Prednisone order appeared on the MARs as follows: Prednisone oral tablet 20 mg give 3 tablets by mouth one time a day for COPD take 3 tablets by mouth with breakfast for 5 days/ER Provider, Start Date [DATE] at 8:00 AM. The Prednisone was documented as administered daily from [DATE] through [DATE]. The MAR revealed 5 doses administered from [DATE] through [DATE], and an additional 61 doses administered from [DATE] through [DATE]. The resident received a total of 66 doses of Prednisone 60 mg. Review of Resident # 162's care plan initiated on [DATE] identified an alteration in respiratory status related to COPD and chronic cough, with a goal of remaining free of COPD exacerbations daily. Interventions included administering medications and treatments as ordered; administering oxygen as ordered per Medical Doctor (MD); elevating the head of the bed to alleviate shortness of breath; observing and documenting respiratory pattern, rate, rhythm, effort and use of accessory muscles; observing for shortness of breath on exertion, monitoring sputum production including amount, color, and odor; and reporting significant findings to the physician. Resident # 162's SBAR written by Nurse # 23 on [DATE] at 10:44 PM revealed the resident had cold-like symptoms including cough, sneezing, nasal congestion and wheezing. Pertinent history indicated Resident # 162 had been more lethargic than usual that day and had a decreased appetite. Vital signs included BP 122/90, pulse 60, respirations 18, temperature 97.8, Blood sugar 271and oxygen saturation 98% on oxygen via nasal cannula. The on-call physician ordered Ipratropium Bromide - Albuterol (a combination bronchodilator used to relax airway muscles and improve breathing in people with COPD and other lung conditions) via nebulizer every 6 hours as needed. Review of Resident 162's medication administration record identified Ipratropium Bromide - Albuterol was administered on [DATE] at 10:49 PM and [DATE] at 4:11 PM. Review of Resident # 162's SBAR written by Nurse # 16 on [DATE] at 2:54 PM revealed Resident # 162 presented with dysuria (pain or discomfort when urinating) and decreased appetite, vital signs blood pressure 122/90, pulse 60, respirations 18, temperature 97.8 Fahrenheit, blood glucose 87, and oxygen saturation 98% with oxygen via nasal cannula. The Nurse Practitioner was notified and ordered Macrobid (an antibiotic used mainly to treat urinary tract infections) 100 mg twice daily for 5 days, and a urinalysis with culture and sensitivity. Review of Resident # 162's physician order dated [DATE] revealed Macrobid oral capsule 100 mg, give 1 capsule by mouth two times a day for urinary tract infection for 5 days. Review of Resident # 162's [DATE], MAR revealed Macrobid oral capsule 100 mg was administered on [DATE] at 8:00 PM, [DATE] at 9:00 AM and 8:00 PM, and [DATE] at 9:00 AM and 8:00 PM. Review of the oxygen saturation flow sheet dated [DATE] at 12:46 PM revealed Resident # 162's O2 saturation was 91%. On [DATE] at 8:42 AM, the O2 saturation was documented as 94%. Review of Resident # 162's oxygen saturation flow sheet revealed the resident's O2 saturation on [DATE] at 12:36 PM was 95%.Review of [DATE] medication administration record identified Macrobid oral capsule100 mg, administered on [DATE] at 9:00 AM. Review of the SBAR written by Nurse # 22 dated [DATE] at 7:12 PM revealed Resident # 162 complained of cold like symptoms (cough, cold and congestion, and a non-productive cough). Nurse # 22 assessed the resident, and family member present requested that Resident # 62 be sent to the emergency department (ED). Vital signs included blood pressure 124/82, temperature 97.2, pulse 65, respirations 18, blood sugar 118, oxygen saturation 96% on oxygen at 2 liters per minute via nasal cannula. Resident # 162 received a nebulizer breathing treatment and denied difficulty breathing but complained of a non-productive cough. Resident # 162 was sent to the ED per family request. Attempts to interview Nurse # 22 by phone on [DATE] were not successful. Review of the emergency medical services (EMS) patient care record dated [DATE] indicated the call was received from the facility at 6:42 PM and EMS personnel was dispatched at 6:44 PM. EMS was at the bedside at 6:50 PM and observed Resident # 162 lying in a fetal position in bed with a cough present. A family member at the bedside stated the facility was treating Resident # 162 for a urinary tract infection and the flu. At 6:58 PM the resident was alert and pulse was 80, respirations 30, oxygen saturation was 70%, and BP was unable to be obtained. At 7:03 PM the resident was alert and her pulse was 124, respirations were 28, oxygen saturation was 84%, and BP was unable to be obtained. The EMS assessment of Resident # 162 included altered mental status, decreased breath sounds, and lower leg swelling 2+ pedal edema (fluid accumulation causing swelling in the feet and ankles). EMS left the facility at 7:12 PM to transport Resident # 162 to the ED. During transportation to the ED, Resident # 162 oxygen saturation remained in the 70's and EMS increased the resident's oxygen to 4 liters per minute. EMS was unable to obtain a blood pressure, and the resident had no radial (inside of wrist) pulse. Resident # 162's respirations became labored, and lung sounds decreased. EMS placed the resident on CPAP (continuous positive airway pressure- breathing therapy device that delivers air to a mask worn over the nose and mouth to help consistent breathing), obtained IV access, and started intravenous fluids. Resident continued to decline, and the level of consciousness became altered. EMS removed the CPAP and assisted ventilations with a bag-valve mask (also known as an Ambu bag, is a manual resuscitation method used to deliver oxygen to patients with apnea or severe respiratory failure until advanced airway management can be performed). Upon arrival to the emergency room, EMS gave report and transferred care to the receiving hospital.Review of hospital emergency department (ED) notes dated [DATE] at 7:36 PM revealed Resident #162 was transported by the emergency medical services (EMS) and presented with hypoxia. The resident was arousable but somewhat somnolent (deep drowsiness or sleepiness). Resident #162 had a history of CHF, coronary artery disease, cerebral vascular accident and hypertension. ED vital signs included oxygen saturation 79% on room air, temperature 91, pulse 77, respiration 19, and blood sugar 98. The resident was immediately placed on BiPAP (bilevel positive non-invasive ventilation). Physical exam noted leg edema, wheezing and rales without obvious respiratory distress. Musculoskeletal assessment revealed 3 + pitting edema, palpable pulses only at the neck, and cool skin. The ED Physician documented respiratory distress and suspected COPD versus CHF. Diagnostic orders included a chest x-ray, respiratory panel, basic laboratory tests, blood cultures, cardiac work up, troponin level (elevated levels of troponin are a strong indicator of heart attack, and lactic acid level. Active hospital problems included SIRS, RSV (acute bronchiolitis due to respiratory syncytial virus), hypoxia, sepsis, elevated liver function tests, cystitis (inflammation of the bladder), lactic acidosis (a serious condition that can disrupt normal physiological functions and requires prompt medical attention), acute respiratory failure, leukocytosis (elevated white blood cell count) , elevated troponin level (elevated levels of troponin are a strong indicator of heart attack), acute kidney injury (sudden decline in kidney function occurring within hours or days), and hyperkalemia (higher than normal levels of potassium in the blood levels may cause life threatening heart arrythmias). Treatment included Intravenous (IV) fluids, and IV antibiotics, insulin, sodium bicarbonate (a sterile hypertonic alkaline solution used to treat severe metabolic acidosis) and calcium gluconate (used treat severe hypocalcemia and to protect the heart during acute medical crisis, such as high potassium levels). ED critical care attestation on [DATE] stated the resident had a high probability of life-threatening deterioration in conditions, at the initial presentation or during the emergency department course due to respiratory failure. Resident # 162 was transferred from the ED and admitted to the medical intensive unit (MIU) for sepsis. Review of Resident # 162's Certificate of Death, with date of death of [DATE] at 1:33 AM, identified the final disease or condition resulting in death as cardiac arrest with pulseless electrical activity, severe sepsis with multi-system organ failure and Respiratory Syncytial Virus. Review of the hospital death summary dated [DATE] indicated Resident # 162 presented to the ED on [DATE] with the chief complaint of shortness of breath and was admitted to MIU with a diagnosis of systemic inflammatory response syndrome (SIRS). Resident # 162 did not respond to treatments for SIRS, and prior discussions with resident and/or family indicated a wish for a peaceful passing with dignity. Resident # 162 was without heart rate or pulse, without respiratory, and had fixed and dilated pupils. Resident # 162 was pronounced dead at 1:33 AM on [DATE]. Discharge diagnoses included RSV pneumonia, respiratory failure, and septic shock.An interview conducted with Nurse # 2 on [DATE] at 2:28 PM, revealed that when entering a medication order into the system, the nurse must select whether the order is indefinite, weekly, or for specific number of days. Nurse # 2 stated that once the start date and number of days were entered, the system automatically calculates the discontinue date. She stated if you do not place the number of days in the box the order will not stop. An interview conducted with Nurse # 3 on [DATE] at 11:00 AM revealed that when entering an order into the electronic medical record, the nurse must enter a start date and calculate the end date and place the end date in the designated order box. A telephone interview conducted with the previous Director of Nursing (DON # 2) on [DATE] at 3:03 PM revealed she served as DON # 2 from [DATE] through [DATE]. DON # 2 stated she was not aware that Prednisone 20 mg, 3 tablets daily for 5 days, continued to be administered beyond the ordered 5 days Resident # 162 and did not offer an explanation for why the nurses continued administering the medication. She stated that when nurses enter new, updated, or discontinued orders in the electronic medical record physician order system, the system automatically updates the electronic medication administration record (MAR). She reported nurses do not review MARs month- to- month to ensure accuracy. DON # 2 stated that when a time-limited order was entered into the medical record order entry system, the nurse must either select an end date using the system calendar or enter the number of days the medication is to be given so the system can calculate the stop date. If neither is entered, the medication will continue to flag for administration. She stated the nursing leadership team (DON # 2 and unit managers) reviewed new, changed, and discontinued orders the next day for accuracy. However, she could not confirm whether Resident # 162's new orders dated [DATE] were reviewed, noting the order must have been missed since it continued without stopping. An interview conducted with the Physician on [DATE] at 10:47 AM revealed that steroids given for any length of time can cause bone loss, adrenal issues and euphoria and require gradual weaning. The physician reviewed the emergency room notes from [DATE] and stated Resident # 162 had an infection, respiratory distress, and an inflammatory reaction to Respiratory Syncytial Virus. The physician stated Prednisone could have reduced Resident 162's ability to fight infection and that long-term steroids decrease the immune response and could have contributed to her demise. The physician stated the Prednisone order should have been followed as written by the emergency room physicians; Prednisone 20 mg, 3 tabs for five days. A telephone interview conducted with the Pharmacy Quality Assurance Manager on [DATE] at 3:34 PM revealed there is no manufacturer defined maximum dose of Prednisone; however, the typical dose for someone with COPD is 30-40 mg for 5 days. He stated that depending on the resident's comorbidities, 60 mg may have been an appropriate dose, but only for 5 days and only for a severe COPD exacerbation - not indefinitely. He stated possible negative outcomes of receiving 60 mg of Prednisone longer than 5 days may include hyperglycemia (high blood sugar), psychotic disturbance (loss of contact with reality), fluid retention (excess fluid buildup in the body's tissues), decreased ability to fight infection, and a decrease in inflammatory mediators (small molecules and proteins that coordinate the body's immune response to injury or infection. He reiterated that 60 mg should not have been administered beyond the 5-day regimen. An in-person interview was conducted with the current Director of Nursing (DON # 1), who began the role in February 2026, on [DATE] at 1:52 PM revealed that nurses must manually enter the stop date when entering a medication order into the electronic system or enter the number of days the medication is to be given so the system will calculate the end date. DON # 1 stated the nurse who entered the limited-time Prednisone order should have used one of these two methods to ensure an appropriate stop date was generated. An in-person interview conducted with DON # 1 on [DATE] at 1:50 PM revealed that if she observed an order being administered longer than 5 days when the order specified 5 days, she would hold the medication, notify the provider of the discrepancy, notify the family, and document the discrepancy as a medication error. The Administrator was notified of immediate jeopardy on [DATE] at 4:05 PM. The facility provided the following credible allegation of immediate jeopardy removal with a compliance date of [DATE]. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.Resident #162 was admitted to the facility on [DATE] with diagnoses including vascular dementia, CHF, CAD, CVA, diabetes mellitus, valvular heart disease, COPD, atrial fibrillation, pulmonary hypertension, bipolar disorder, and hypertension.On [DATE], following an Emergency Department visit, Resident #162 was prescribed Prednisone 20 mg, three tablets (60 mg total) by mouth daily with breakfast for five days for COPD. The order was entered into the electronical health record by the nurse and included the prednisone was to be given for 5 days but the nurse did not activate the 5-day duration within the order. As a result, the medication remained active on the Medication Administration Record and Resident #162 continued to receive Prednisone 60 mg daily until [DATE]. Due to the extended administration of the prednisone beyond the intended duration, the resident was at risk for adverse effects associated with prolonged steroid therapy.All residents that receive medications could be affected by the deficient practice.Beginning on [DATE], a facility-wide audit was initiated by the Director of Nursing, Regional Nurse and Minimum Data Set Nurses of all current active orders for accuracy for all residents remaining in the facility as of [DATE] receiving medications. The audit will ensure that all medication orders were entered accurately and contained appropriate stop dates, and the stop date had been scheduled on the Medication Administration Record. If any medications were given past the stop date or any other issues identified in the audit, they will be addressed with the residents' provider and corrected as ordered. Audits and any corrections to be completed by [DATE]. On [DATE], the Quality Assurance Manager performed an audit of prednisone orders from [DATE] to present. No orders were identified where the stop date was not entered correctly and the medication was refilled after the intended stop date of the order.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.On [DATE], the facility completed a Root Cause Analysis and determined that the primary system failure was a medication transcription error in which the licensed nurse failed to activate the required stop date for a time-limited medication order, and licensed nursing staff failed to read the order in its entirety on the electronic MAR which included the prednisone for Resident #162 was to be administered for five days. This resulted in the medication remaining active beyond the intended five-day course and being administered for an extended period. Contributing factors included inadequate verification of order completeness during transcription and failure to consistently recognize the requirement for stop dates for short-term medications such as prednisone. The facility process was not followed on [DATE]; the nurse did not ensure accuracy when transcribing the order, and the clinical team did not review the order which was to be completed in the facility's clinical meeting with the interdisciplinary team present. The facility failed to enter the order accurately initially and did not complete the secondary check of new orders in the Clinical Meeting.On [DATE], the Regional Risk Nurse provided education to the Director of Nursing, Staff Development Coordinator and Unit Manager on the facility process for order review, which includes the nurse who receives the order confirming the order with the nurse practitioner/physician and a secondary review of new orders in the facility's clinical meeting Monday through Friday with the interdisciplinary team (Director of Nursing, Unit Manager, Staff Development Coordinator, Assistant Director of Nursing, MDS Nurse). Any new orders received over the weekend will be reviewed in the Clinical Meeting on Monday.Beginning on [DATE], the Director of Nursing, Staff Development Coordinator, Unit Manager and/or the Regional Risk Nurse started in person and via phone in servicing all active nurses on the facility process for accurate order entry, which includes confirming the order with the nurse practitioner/physician, reviewing the order prior to entry, entering the order as prescribed by the physician to include scheduling a stop date if applicable, 5 rights of medication administration and a secondary review to ensure accuracy of new orders in the facility's clinical meeting Monday through Friday with the interdisciplinary team (Director of Nursing, Unit Manager, Staff Development Coordinator, Assistant Director of Nursing, MDS Nurse). The nurses will also be in-serviced on reading the order in its entirety prior to administering the medication and prior to reordering the medication as to avoid giving medications incorrectly. Completed by [DATE].The Staff Development Coordinator will be responsible for tracking nurses not educated by [DATE] or returning from leave to ensure that they are educated prior to working their next shift on the facility process for order review, which includes confirming the order with the nurse practitioner/physician, reviewing the order prior to entry, entering the order as prescribed by the physician to include scheduling a stop date if applicable, 5 rights of medication administration and a secondary review to ensure accuracy of new orders in the facility's clinical meeting Monday through Friday with the interdisciplinary team (Director of Nursing, Unit Manager, Staff Development Coordinator, Assistant Director of Nursing, MDS Nurse). The nurses will also be in-serviced on reading the order in its entirety prior to administering the medication and prior to reordering the medication as to avoid giving medications incorrectly. Any nurse hired after [DATE] will receive this education prior to taking a resident assignment.The facility does not currently have agency staff at this time.The facility alleges removal of immediate jeopardy and compliance on [DATE]On [DATE], an onsite validation of the facility's Immediate Jeopardy (IJ) removal plan was conducted. The facility provided documentation showing that a facility wide audit of all active residents' medication orders was completed by the Director of Nursing (DON), Regional Nurse, and MDS Nurse by [DATE]. Reviews of the audit tool confirmed that orders were compared against the Medication Administration Record (MAR) and discrepancies were corrected.The facility also submitted evidence that the Regional Risk Nurse provided education on [DATE] to the DON, Staff Development Director, and Unit Managers on the medication order review processes and the medication reconciliation procedures. This was validated through review of sign in sheets and training materials.All licensed nursing staff employed by the facility completed education on proper medication order entry by [DATE], as provided by the DON, Staff Development Coordinator, Unit Manager, or Regional Risk Nurse. This was verified through staff interviews and review of sign-in sheets.During interviews conducted on [DATE], nursing staff consistently stated they had received the required education and participated in the audits as applicable. Staff were able to describe the updated process for medication order entry and verification.The survey team verified that the corrective actions described in the Immediate Jeopardy removal plan had been fully implemented, were operational, and had addressed the immediate threat.The Immediate Jeopardy removal and compliance date of [DATE] was validated.

Based on record review and staff, Nurse Practitioner (NP) and Physician interviews, the facility failed to obtain daily weights as ordered by the physician. This was for 3 of 8 residents reviewed for the provision of care in accordance with professional standards of practice (Resident #17, Resident #35, and Resident #129). Findings included: a. Resident #17 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF). A physician's order for Resident #17 dated last revised on 12/5/25 with a discontinue date of 4/14/26 revealed daily weights before breakfast. If (Resident #17) gained 3 pounds (lbs.) in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's comprehensive care plan revealed in part a focus area for potential alteration in hydration related to diuretic (fluid pill) use. The goal was for Resident #17 to remain free from signs and symptoms of fluid overload such as edema (swelling), congestion, and sudden weight gain through the next review. Interventions, dated last revised on 1/6/26, were to monitor Resident #17's weight per the physician's order, notify the physician of any significant weight loss or gain, and to observe for, document, and report any signs of fluid overload to the physician. Resident #17's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had no behaviors or rejection of care. She did not have shortness of breath. Her most recent weight was 141 pounds. She did not have weight loss or weight gain of 5 percent (%) or more in the last month or weight loss or weight gain of 10% or more in last 6 months. Resident #17's Medication Administration Record (MAR) for March 2026 revealed a physician's order with a discontinue date of 4/14/26 for daily weights before breakfast. If (Resident #17) gained 3 lbs in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's March 2026 MAR did not reveal any documentation indicating any daily weights had been completed or refused. Resident #17's electronic medical record did not reveal any documentation daily weights were completed or refused on 3/3/26, 3/4/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/19/26, 3/22/26, 3/27/26, 3/29/26, or 3/30/26. Resident #17's Daily Weight Sheet for March 2026 did not reveal any documentation her daily weights were completed or refused on 3/3/26, 3/4/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/19 /26, 3/22/26, 3/27/26, 3/29/26, or 3/30/26. On 5/28/26 at 8:50 AM a telephone interview with Nurse #17 indicated she normally worked the overnight shift from 11:00 PM to 7:00 AM. She reported she was assigned to care for Resident #17 on 3/3/36. She stated she did not recall what happened with Resident #17's daily weight on 3/3/26. She reported the Nurse Aide (NA) assigned to Resident #17 on 3/3/26 on the 11:00 PM to 7:00 AM shift would have been responsible for obtaining Resident #17's daily weight at 6:00 AM before breakfast. Nurse #17 indicated she was not responsible for making sure daily weights were obtained. She stated the charge nurse for the 11:00 PM to 7:00 AM shift was responsible for doing that. On 5/29/26 at 1:14 PM a telephone interview with NA #6 indicated she no longer worked for the facility. She stated back in March 2026 she was working the overnight shift from 11:00 PM to 7:00 AM on 3/3/26 and 3/4/26. She stated she didn't recall Resident #17, but she did recall at one point in March 2026, someone told her she had missed obtaining some daily weights. She stated she had not previously been instructed that she was supposed to be getting them. On 5/28/26 at 8:25 AM a telephone interview with Medication Aide (MA) #3 indicated she worked on the 11:00 PM to 7:00 AM shift four to five nights per week. She reported she had been assigned to administer medications, and care for Resident #17 on 3/7/26, 3/27/26 and 3/29/26. She stated the NA assigned to Resident #17 on these dates would have been responsible for obtaining Resident #17's daily weight at 6:00 AM before breakfast. She indicated if there were no weight documented on Resident #17's Daily Weight Sheet for these dates, that meant the assigned NA had not obtained them. MA #3 went on to say if the daily weight was not completed on the 111:00 PM to 7:00 AM, and the Daily Weight Sheet was left blank, the staff on the 7:00 AM to 3:00 PM shift should see that, and get the weight done before breakfast. On 5/28/26 at 11:01 AM a telephone interview with NA #4 indicated she was assigned to care for Resident #17 on the 7:00 AM to 3:00 PM shift on 3/6/26 and 3/29/26. She stated all residents who needed daily weights, including Resident #17, had a Daily Weight Sheet in the Daily Weight Book that was kept at the nurse's station. She reported that if the 11:00 PM to 7:00 AM had not completed and documented a daily weight on Resident #17's Daily Weight Sheet on their shift, she would have been responsible for completing it before breakfast. NA #4 stated she did not know why Resident #17's daily weight had been missed on 3/6/26 and 3/29/26. A physician's order for Resident #17 with a start date of 4/14/26 was for daily weights before breakfast. If (Resident #17) gained 3 lbs in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's April 2026 Medication Administration Record (MAR) revealed a physician's order with a discontinue date of 4/14/26 for daily weights before breakfast. If (Resident #17) gained 3 lbs in 1 day or 5 lbs in one week, the physician was to be called. An additional physician's order with a start date of 4/14/26 for daily weights before breakfast at 6:00 AM. If (Resident #17) gained 3 lbs in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's April 2026 MAR did not reveal any documentation indicating daily weights had been completed or refused on 4/14/26, 4/16/26 or 4/22/26. Resident #17's electronic medical record did not reveal any documentation her daily weights were completed or refused on 4/14/26, 4/16/26 or 4/22/26. Resident #17's Daily Weight Sheet for April 2026 did not reveal any documentation her daily weights were completed or refused on 4/14/26, 4/16/26 or 4/22/26. Multiple attempts for a telephone interview with Nurse #18, who was assigned to care for Resident #17 at 6:00 AM on 4/14/26 and 4/16/26, were unsuccessful. On 5/29/26 at 12:50 PM a telephone interview with NA #5 indicated she was assigned to care for Resident #17 and would have been responsible for getting Resident #17's daily weight at 6:00 AM on 4/16/26. She stated if there was no weight documented on Resident #17's Daily Weight Sheet for that date, that meant she had not done it. She reported she could not recall the reason why she had not. Resident #17's May 2026 Medication Administration Record (MAR) revealed a physician's order with a start date of 4/14/26 for daily weights before breakfast at 6:00 AM. If (Resident #17) gained 3 lbs in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's May 2026 MAR did not reveal any documentation indicating any daily weights had been completed or refused on 5/4/26, 5/7/26 or 5/15/26. Resident #17's electronic medical record did not reveal any documentation her daily weights were completed or refused on 5/4/26, 5/7/26 or 5/15/26. Resident #17's Daily Weight Sheet for May 2026 did not reveal any documentation her daily weights were completed or refused on 5/4/26, 5/7/26 or 5/15/26. Multiple attempts for a telephone interview with Nurse #18, who was assigned to care for Resident #17 on 5/4/26 and 5/15/26, were unsuccessful. On 5/29/26 at 12:50 PM a telephone interview with NA #5 indicated she was assigned to care for Resident #17 and would have been responsible for getting Resident #17's daily weight at 6:00 AM on 5/4/26. She stated if there was no weight documented on Resident #17's Daily Weight Sheet for that date, that meant she had not done it. She reported she could not recall the reason why she had not. b. Resident #35 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and hypertension (HTN). A physician's order for Resident #35 with a start date of 4/17/26 and a discontinue date of 5/11/26 revealed daily weight for CHF place weight in book. If greater than 3 pounds (lbs.) (weight gain) in 2 days contact (provider) if more than 5 lbs. (weight gain) in a week contact (provider) for further instructions. Weigh every morning at 6:00 AM. If (Resident #35) refuses, document refusal. Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He did not reject care. He did not have shortness of breath (SOB). His most recent weight was 189 pounds. He did not have weight loss or weight gain of 5 percent (%) or more in the last month or weight loss or weight gain of 10% or more in last 6 months. Resident #35's comprehensive care plan revealed a focus area dated as initiated on 4/21/26 of at risk for alteration in cardiovascular status. The goal was for Resident #35 to not have any decline in function due to his cardiac conditions through the next review. Interventions included to assess for shortness of breath (SOB) and edema, monitoring for and reporting any significant changes in condition or weight changes to the physician. Resident #35's April 2026 Medication Administration Record (MAR) did not reveal any documentation indicating daily weights had been completed or refused on 4/17/26, 4/21/26, or 4/25/26. Resident #35's electronic medical record did not reveal any documentation his daily weights were completed or refused on 4/17/26, 4/21/26, or 4/25/26. Resident #35's Daily Weight Sheet for April 2026 did not reveal any documentation his daily weights were completed or refused on 4/17/26, 4/21/26, or 4/25/26. On 5/28/26 at 9:22 AM an interview with Nurse #19 indicated she would have been covering and administering medications to Resident #35 on the 11:00 PM to 7:00 AM shift on 4/17/26, 4/21/26 and 4/25/26. She stated if there were no weights documented on his MAR for those days, that meant the weights weren't done. She indicated there were some Nurse Aides (NAs) who would get the daily weights, and some who would not. Nurse #19 stated she had communicated to the Director of Nursing (DON) that weights weren't getting done daily as ordered, and she got a message back on her phone that daily weights needed to be done as ordered. On 5/29/26 at 4:07 PM a telephone interview with NA #7 indicated she would have been responsible for obtaining Resident #35's daily weight on her shift (11:00 PM to 7:00 AM) on 4/17/26, 4/25/26, and 4/29/26. She reported she knew what residents needed daily weights because she listened to report at the nurse's station and it would be told to her there, looked in the weight book at the nurse's station, or the nurse would tell her. She stated when she got a weight, she either documented it in the weight book or told the nurse. NA #7 reported if there was not a weight documented for Resident #35 on 4/17/26, 4/25/26 or 4/29/26 that meant the weight wasn't done. She stated she could not recall ever having a problem getting a resident's daily weight on her shift. c. Resident #129 was admitted to the facility on [DATE] with a diagnosis of myocardial infarction (heart attack caused by partial blockage of a coronary artery), stroke, and hypertension. A physician's order for Resident #129 dated 4/7/26 revealed daily weights at 6:00 AM. If the resident gained 3 pounds in one day or 5 pounds in one week, the physician was to be called. Resident #129's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She had no behaviors or rejection of care. She did not have shortness of breath. Her most recent weight was 92 pounds. She did not have weight loss or weight gain of 5 percent (%) or more in the last month or weight loss or weight gain of 10% or more in last 6 months. Resident #129's comprehensive care plan revealed that she was at risk for impaired cardiovascular status related to hypertension and hyperlipidemia. Interventions, dated last revised on 5/11/26, were to monitor Resident #129's weight and notify the physician of any significant weight loss or gain. Resident #129's Medication Administration Record (MAR) for April 2026 revealed a physician's order for daily weights at 6:00 AM. If the resident gained 3 pounds in one day or 5 pounds in one week, the physician was to be called. Resident #129's weights were not documented on the MAR. Resident #129's electronic medical record did not reveal any documentation daily weights were completed or refused on 4/8/26, 4/9/26, 4/10/26, 4/13/26, and 4/14/26. Resident #129's Daily Weight Sheet for April 2026 did not reveal any documentation her daily weights were completed or refused on 4/8/26, 4/9/26, 4/10/26, 4/13/26, and 4/14/26. On 5/29/26 at 8:20 AM a telephone interview with Nurse #19 indicated she normally worked the overnight shift from 11:00 PM to 7:00 AM. She reported she was assigned to care for Resident #129 on 4/8/26 and 4/9/26. Nurse #19 stated that Nurse Aides were responsible for obtaining weights, and she would record the weight value in the MAR. She further stated if there were no weights documented on the MAR for the mornings of 4/8/26 or 4/9/26, that meant the weights were not done. She indicated there were some Nurse Aides who would get the daily weights, and some who would not. Nurse #19 indicated she had communicated to the Director of Nursing #1 that weights were not getting done daily as ordered, and she got a message back on her phone that daily weights needed to be done as ordered. Multiple telephone interview attempts were made to Nurse Aide #8, who was assigned to Resident #129 from 11:00 PM on 4/7/26 until 7:00 AM on 4/8/26; however, she was unable to be reached during the investigation. On 5/29/26 at 9:51 AM an interview with Nurse Aide #9 revealed that she was assigned to Resident #129 from 11:00 PM on 4/8/26 until 7:00 AM on 4/9/26 and from 11:00 PM on 4/9/26 until 7:00 AM on 4/10/26. She indicated that some weights could be done with a wheelchair and others needed the mechanical lift. Nurse Aide #9 stated that Resident #129 required the mechanical lift for daily weights. There was a time (dates unknown) when she did not know Resident #129 required daily weights. However, as soon as she was informed, she collected the daily weight measurements as ordered. Nurse Aide #9 reviewed the missing daily weights on 4/9/26 and 4/10/26, Nurse Aide #9 indicated that she might have forgotten to write down the weight values on the Daily Weight Sheet at the nurses' station, but there was ample time and opportunity to retrieve daily weights during the overnight shifts. Multiple telephone interview attempts were made to Nurse #18, who was assigned to Resident #129 from 11:00 PM on 4/9/26 until 7:00 AM on 4/10/26 and 11:00 PM on 4/13/26 until 7:00 AM on 4/14/26; however, she was unable to be reached during the investigation. Multiple telephone interview attempts were made to Nurse Aide #10, who was assigned to Resident #129 from 11:00 PM on 4/12/26 until 7:00 AM on 4/13/26; however, she was unable to be reached during the investigation. Multiple telephone interview attempts were made to Nurse Aide #11, who was assigned to Resident #129 from 11:00 PM on 4/13/26 until 7:00 AM on 4/14/26; however, she was unable to be reached during the investigation. On 05/29/2026 at 10:26 AM a telephone interview with Nurse #13 revealed that he worked with Resident #129 from 11:00 PM on 4/12/26 until 7:00 AM on 4/13/26. He indicated that Nurse Aides retrieved the daily weights, and he documented the values in the MAR. Nurse #13 could not recall the details of 4/13/26 or why the MAR was blank for daily weights on that day. Resident #129's May 2026 MAR revealed a physician's order with a start date of 4/7/26 for daily weights at 6:00 AM. If the resident gained 3 pounds in one day or 5 pounds in one week, the physician was to be called. Resident #129's May 2026 MAR did not reveal any documentation indicating any daily weights had been completed or refused on 5/4/26. Resident #129's electronic medical record did not reveal any documentation her daily weights were completed or refused on 5/4/26. Resident #129's Daily Weight Sheet for May 2026 did not reveal any documentation her daily weights were completed or refused on 5/4/26. On 5/29/26 at 10:08 AM a telephone interview with Nurse Aide #13 indicated she was assigned to care for Resident #129 and would have been responsible for getting Resident #129's daily weight at 6:00 AM on 5/4/26. She normally retrieved the daily weights when she arrived for her shift at 11:00 PM because it was more difficult to do so during rounds at 6:00 AM. Nurse Aide #3 indicated she floated to all halls and was not aware that Resident #129 required a daily weight. Multiple telephone interview attempts were made to Nurse #24, who was assigned to Resident #129 from 11:00 PM on 5/3/26 until 7:00 AM on 5/4/26; however, he was unable to be reached during the investigation. On 5/28/26 at 9:44 AM an interview with the Director of Nursing (DON) #1 indicated if a resident had a physician's order for a daily weight, the night shift nurse or Nurse Aide normally obtained this at 6:00 AM. She reported the daily weight result would be documented on the residents Daily Weight Sheet that was kept in the Weight Book at the nurse's station. She stated if the resident's daily weight was not obtained by the night shift (11:00 PM to 7:00 AM), the nurse or NA on the day shift (7:00 AM to 3:00 PM) should obtain the resident's weight before breakfast. The DON indicated she was aware that there were residents whose daily weights had been missed and had spoken with some night shift nurses and NAs regarding ensuring the weights got done. She stated that the purpose of daily weights was to monitor fluid weight gain in resident's who had a diagnosis of congestive heart failure (CHF). She reported that in addition to daily weight monitoring, nurses also monitored these residents for any shortness of breath or other signs of fluid overload such as edema and would notify a provider immediately of these symptoms. On 5/28/26 at 12:15 PM an interview with the Nurse Practitioner (NP) indicated daily weights were important for residents who were diagnosed with CHF as they tracked whether a potentially significant fluid increase was happening which would allow him to address the issue before any complications would arise. He reported that he knew which residents needed daily weights, and he looked at the weight book himself five days per week when he was present in the facility. He indicated he had at times noticed missing daily weights for residents who had daily weights ordered. He stated if there was a resident that was particularly fragile and he didn't see a daily weight he spoke with the staff. The NP indicated he was not aware of any resident who had an exacerbation of congestive heart failure that required hospitalization or any harm to a resident because a daily weight was not obtained. He reported that the nurses were very good at monitoring other signs of fluid overload such as edema or shortness of breath and notifying him immediately. On 05/28/2026 at 12:28 PM an interview with Resident #17's, Resident #35's, and Resident #129's Physician revealed daily weight monitoring for residents with CHF was important because rapid weight gain indicated worsening fluid overload status. He stated this information could alert the provider who could then determine what other measures or further testing might be needed. He reported that the NP was in the facility five days per week and followed residents with CHF closely. The Physician stated the nurses were very good about immediately notifying a provider if a resident had signs of worsening CHF, or fluid overload such as shortness of breath, or edema. He indicated he was not aware of any resident that required hospitalization or any harm to a resident because a daily weight was not obtained. On 05/29/2026 at 2:12 PM an interview with the Administrator indicated he was relieved to hear that the providers had not determined any adverse consequences because of missed daily weights. He reported that there was never any instance where the facility was not staffed or mechanically equipped to get residents' daily weights as ordered by the Physician. He stated the facility needed structures and a process implemented to hold staff accountable for following physician's orders. On 05/29/2026 at 2:40 PM a follow-up interview with the Administrator indicated he had been aware that there were issues with residents not having daily weights completed. He stated the facility did not have a plan of correction in place for the issue but were working on it.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of nutritional approaches (Resident #79) and intravenous (into a vein) access (Resident #180). This was for 2 of 62 residents whose MDS assessments were reviewed. Findings included: 1. Resident #79 was admitted to the facility on [DATE]. A Hydration Evaluation (an assessment of dehydration risk) form for Resident #79 dated 3/24/26 revealed in part Resident #79 was at risk for dehydration related to medications received, the need for feeding assistance, and the presence of a pressure wound. The evaluation indicated she would benefit from additional hydration support. A physician's order for Resident #79 with a start date of 3/24/26 was for Resident #79 to receive Sodium Chloride 0.9 percent (%) solution use 60 milliliters per hour (ml/hr) intravenously for the diagnosis of rehydration for 1 day, total of 1000 ml. Discontinue dermoclysis (a medical technique for administering fluids or medications via needle infusion into subcutaneous (the layer of fat just under the skin) tissue when IV access was difficult to establish) upon completion. A nursing progress note for Resident #79 dated 3/24/26 at 12:51 PM written by Nurse #20 revealed in part while Resident #79 was lying in bed, a dermoclysis infusion needle was placed in her left abdomen. It flushed without difficulty. Normal (0.9%) Saline (Sodium Chloride) fluids were initiated at 11:10 AM. Resident #79 tolerated this well. Resident #79's March 2026 Medication Administration Record (MAR) revealed documentation by Nurse #16 on 3/24/26 at 3:05 PM that 200 ml of Sodium Chloride Solution 0.9 % was administered to Resident #79 via dermoclysis. Resident #79's quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate she had received nutritional approaches of parenteral (anything situated or occurring outside the digestive tract) or intravenous (within a vein) feeding. On 5/29/26 at 9:09 AM an interview with Nurse #16 indicated Nurse #20 was the facility's IV therapy nurse. She reported Nurse #20 initiated the dermoclysis for Resident #79 on 3/24/26 in accordance with the physician's order. Nurse #16 stated after the initiation of the therapy, she monitored the administration of the fluids and documented the amount infused on Resident #79's MAR on 3/24/26. On 5/29/2026 at 8:53 AM an interview with the MDS Coordinator indicated she coded the nutritional approach section of Resident #79's MDS assessment dated [DATE]. She reported that the facility had an audit of their MDS process by an outside company. She stated that as a result of this audit, she had been instructed that she was not allowed to code this section unless a resident had a critical blood urea nitrogen (BUN is a laboratory test that measures the amount of a waste product in blood created by the liver). The MDS Coordinator indicated that because Resident #79 did not have any laboratory testing done during the look back period, she did not code Resident #79's MDS assessment dated [DATE] to reflect the fluids she received via dermoclysis on 3/24/26. On 5/29/26 at 2:12 PM an interview with the Administrator indicated MDS assessments should be coded accurately. 2. Resident #160 was admitted to the facility on [DATE]. Her active diagnoses included respiratory failure, anemia, hypertension, peripheral vascular disease, malnutrition, dysphagia, and hypokalemia. Resident #160's orders revealed on 4/14/26 an order was written to insert peripheral intravenous (IV) catheter (a small, flexible tube that healthcare providers insert into a vein) one time only for hydration. On 4/14/26 she was also ordered sodium chloride solution 0.9 % use 75 milliliters/hour intravenously for 24 hours for re-hydration for 1 day. Resident #160's Medication Administration Record for 4/2026 revealed this order was on the Medication Administration Record and had a check mark on the order on the date 4/14/26 indicating this order was completed as ordered by the physician. Resident #160's quarterly Minimum Data Set assessment dated [DATE] revealed she was not assessed to have intravenous access within the prior 14-day lookback period. During an interview on 5/27/26 at 10:43 AM MDS Coordinator reported that the facility had an audit of their MDS process by an outside company. She stated that as a result of this audit, she had been instructed that she was not allowed to code this section unless a resident had a critical blood urea nitrogen (BUN is a laboratory test that measures the amount of a waste product in blood created by the liver). She concluded this was why IV Access was not captured on the MDS assessment. During an interview on 5/27/26 at 11:00 AM the Administrator stated MDS assessments should accurately reflect resident intravenous status.

Based on observations, record review, resident, Speech Therapist, and staff interviews, the facility failed to serve food in a form that met the resident's needs for 1 of 1 resident (Resident #14) reviewed. Resident #14 had been ordered food that was pureed texture and was observed to receive a soaked dinner roll.The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), dementia, Alzheimer's disease, and failure to thrive. A physician's order for a pureed texture and thin liquids consistency was ordered for Residet #14 on 4/22/26. A review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident to have the ability to understand others and to make herself understood. The MDS indicated she was severely cognitively impaired and required setup or clean-up assistance when eating. Resident #14 had a swallowing disorder and was on a mechanically altered diet without any weight changes. A review of Resident #14's Care Plan, last revised on 4/27/26, revealed that she was at risk for alternation in nutritional status related to dementia, depression, poor intake, and adult failure to thrive. Interventions included: diet as ordered. An observation and interview with Resident #14 were conducted on 5/26/26 at 12:00 PM. She was observed sitting up in her wheelchair beside her bed with the lunch meal tray in front of her on the bedside table. One of the items did not look puree consistency. The meal ticket called the food item a soaked dinner roll. The top of the soaked dinner roll was hard, and it appeared wet in a clear syrupy liquid. This writer took a fork and attempted to mix the food item, but it remained in whole form. Two family members were in the room and everyone, including Resident #14, did not know what the food item was and never saw it before. Resident #14 did not eat the soaked dinner roll. The soaked dinner roll recipe provided by the facility revealed the following preparation instructions: Remove crust from the bread and lay in a single layer on a shallow pan. Blend commercial thickener with a small amount of water, broth, or milk to meet desired consistency. Pour slurry (liquid mixture) over bread, and ensure edges are completely soaked. Refrigerate for 1-2 hours. Use the Fork Drip Test and Spoon Tilt test to confirm the texture was within the International Dysphagia Diet Standardization Initiative (IDDSI) pureed food specifications and if hard parts formed during sitting. The Fork Drip test should be performed by placing a small amount of food on the prongs of a fork and observe if it drips slowly in dollops for pureed consistency. The Spoon Tilt test should be performed by placing a small amount of food on a spoon and observe if the food holds its shape and falls off cleanly or sticks to the spoon (that would mean the consistency was too thick). On 5/28/26 at 12:09 PM the Dietary Manager was interviewed, and she revealed that the soaked dinner roll was approved by whoever made the menu. She described the food item as a dinner roll soaked in thickener solution, and eventually it was supposed to become soft. On 5/28/26 at 1:19 PM Registered Dietitian (RD) #1 revealed that she was the assigned RD for the facility. She indicated that she did not know what a soaked dinner roll was and had never seen the facility serve this food item. RD #1 stated that her supervisor oversaw the facility menus. On 5/28/26 at 1:21 PM RD #2 was interviewed and revealed that the facility menus were managed by the corporate division of the facility. She indicated that a soaked dinner roll was also called a slurried dinner roll, which was bread soaked in milk. The National Director of Dining Services was interviewed on 5/28/26 at 1:33 PM. She revealed that she was the member of corporate who managed the facility menus. She was in the process of changing the menus from fall/winter cycle to summer/spring cycle. She indicated that a soaked dinner roll used to be called a slurry, which was a dinner roll soaked in milk to make it soft. On 5/28/26 at 1:51 PM the Speech Therapist was interviewed, and she revealed that she had never seen or worked with a soaked dinner roll when evaluating a resident's swallowing ability. She stated if a diet specified puree consistency, then it should be presented as puree consistency. If the food item must be chewed, then it would not be considered puree. Resident #14 was picked up by Speech Therapy because nursing reported that she was having more difficulty with eating. Resident #14 can feed herself but preferred the pureed diet because it was easier for her to chew. She spit out mechanical soft consistency foods or pocketed foods in her cheeks because it was harder to chew mechanical soft foods. The Speech Therapist indicated that Resident #14 was not at risk for a choking incident. She just would not be able to consume the soaked dinner roll calories on the lunch meal tray served on 5/26/26. Nurse Aide #1 was interviewed on 5/28/26 at 2:17 PM. She indicated that she worked Resident #14's hall on 5/26/26 during lunch service. Nurse Aide #1 stated that on 5/26/26, when Resident #14 received a soaked dinner roll on her lunch meal tray, the family members in her room were very upset because they thought it was a choking hazard. They requested for Resident #14 to never receive a soaked dinner roll again. Nurse Aide #1 stated she had never seen a soaked dinner roll served on a meal tray before, and she had fed residents with a puree diet order. Nurse Aide #1 indicated that Nurse Aide #2 delivered the lunch meal tray to Resident #14 on 5/26/26. On 5/28/26 at 2:19 PM Nurse Aide #2 revealed that before 5/26/26, she had never seen a soaked dinner roll served on a resident's meal tray before. She stated it looked like a dinner roll with water filled halfway in a soup dish. The top of the roll was brown and crusty and was still formed but soggy. Nurse Aide #2 stated that she told Nurse #25 about Resident #14's soaked dinner roll, and Nurse #25 instructed another staff member to tell the kitchen to not send anymore soaked dinner rolls for puree diets because it was not the correct consistency.Nurse #25 was interviewed on 5/28/26 at 3:58 PM. She revealed that she was assigned to Resident #14 on 5/26/26 during the lunch meal, but she could not recall any issue related to a soaked dinner roll. Nurse #25 indicated that it was possible another nurse was notified by Nurse Aide #2. On 5/29/26 at 2:08 PM the Administrator revealed that the soaked dinner roll should have been pureed prior to Resident #14's lunch meal delivery. New menus were in process, and the soaked dinner roll has been eliminated.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for anticoagulant use, antiplatelet use, and discharge status for 4 of 27 resident assessments reviewed (Resident #109, Resident #138, Resident #80, and Resident #139). Findings included: 1. Resident #109 was admitted to the facility on [DATE]. Review of Resident #109's MDS assessment dated [DATE] revealed the resident was assessed as having received an anticoagulant medication during the lookback period. Review of Resident #109's medication administration record for December 2024 revealed the resident did not take an anticoagulant medication during the lookback period. During an interview on 3/11/25 at 11:24 AM the MDS Coordinator stated Resident #109 was not on an anticoagulant and the MDS dated [DATE] was coded incorrectly. During an interview on 3/11/25 at 11:46 AM the Administrator stated MDS assessments should accurately reflect the resident's status. 2. Resident #138 was admitted to the facility on [DATE]. Review of Resident #138's discharge planning progress note dated 1/9/25 revealed the social worker spoke with the responsible party and resident regarding resident's discharge and discharge planning. Resident #138 was being discharged from her managed care insurance on 1/10/25 and would be discharged home on 1/11/25. Review of Resident #138 discharge minimum data set assessment dated [DATE] revealed the discharge assessment was coded as an unplanned discharge. During an interview on 3/11/25 at 11:18 AM the MDS Coordinator stated Resident #138 had a planned discharge on 1/11/25 and it was coded incorrectly on the 1/11/25 discharge MDS. During an interview on 3/11/25 at 11:46 AM the Administrator stated MDS assessments should accurately reflect the resident's status. 41009 3. Resident #80 was admitted to the facility on [DATE]. A review of Resident #80's physician's orders revealed an order dated 1/3/25 for aspirin (an antiplatelet medication) 81 milligrams (mg) one tablet by mouth daily for transient ischemic attack (disrupted blood flow to the brain), venous insufficiency (impaired blood flow in the veins), and atrial fibrillation (an irregular heartbeat). A review of Resident #80's February 2025 Medication Administration Record (MAR) revealed documentation aspirin 81 mg was administered to Resident #80 on 2/27/25 and 2/28/25. A review of Resident #80's March 2025 MAR revealed documentation aspirin 81 mg was administered to Resident #80 on 3/1/25 through 3/5/25. A review of Resident #80's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was not coded as taking any antiplatelet medications. On 3/13/25 at 8:22 AM an interview with the MDS Coordinator indicated she coded the medication section of Resident #80's MDS assessment dated [DATE]. She stated she did not code Resident #80 as taking antiplatelet medication on this MDS assessment because she had been instructed not to code aspirin as an antiplatelet medication unless the dosage was 325 mg. On 3/13/25 at 10:18 AM an interview with the Director of Nursing indicated the MDS Coordinator would know more about the coding of MDS assessments than she did. She stated MDS assessments should be an accurate reflection of the medications a resident was taking. On 3/13/25 at 10:23 AM an interview with the Administrator indicated MDS assessments should be coded accurately. 50404 4. Resident #139 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 was discharged to a short-term general hospital. A progress note written by the Social Worker on 1/22/25 at 2:44 PM stated Resident #139 was discharged from the facility at 12:45 PM and was transported home by his friend. During an interview with the MDS Coordinator on 3/12/25 at 1:15 PM, she stated the MDS should have been coded to home and her coding was an error. An interview with the Director of Nursing was held on 3/12/25 at 1:23 PM, at that time she stated the resident was discharged home. During an interview on 3/12/25 at 1:26 PM, the Administrator stated her expectation would have been the MDS information was coded accurately.

Based on observations, staff interviews, and record review the facility failed to attempt to use alternatives prior to installing side rails for 2 of 3 residents (Resident #82 and Resident #119) reviewed for side rails. Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses including seizure disorder and history of cerebral infarction (stroke). A review of Resident #82's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/22/25 and completed by Nurse #1 revealed there was no question on the evaluation regarding attempts to use alternatives before using side rails. Nurse #1 was not able to be reached for interview. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was cognitively intact. The MDS indicated Resident #82 required partial to moderate assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #82 had impairment of one side of upper extremities and impairment of both lower extremities. The MDS indicated Resident #82's siderails were not used as a restraint. A care plan with the latest review date of 3/3/25 revealed no reference to use of side rails for Resident #82. An observation on 3/10/25 at 11:54 AM revealed Resident #82 lying in bed with bilateral one-quarter length side rails in the up position on the bed. An observation on 3/12/25 at 11:40 AM revealed Resident #82 sitting in his bed with the head raised at a 45-degree angle. The side rails were observed to be in the raised position. An interview with Unit Manager (UM) #1 on 3/11/25 at 2:02 PM revealed the Unit Managers completed the quarterly side rail/entrapment risk evaluations. UM #1 stated they did not attempt alternatives before using side rails. She further stated she was unaware this was a requirement. In an interview with the Director of Nursing (DON) on 3/13/25 at 9:16 AM she stated they did not try interventions before using side rails as she was not aware this was a requirement. In an interview with the Administrator on 3/12/25 at 1:15 PM she stated alternative interventions to side rails were not tried before implementation as she was unaware that this was a requirement. 2. Resident #119 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke). A review of Resident #119's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/7/25 and completed by UM #1 revealed no questions regarding attempting alternatives to side rails before implementing them. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #119 was severely cognitively impaired and was dependent on staff for bed mobility. The MDS indicated Resident #119's siderails were not used as a restraint. A care plan with the latest review date 1/10/25 revealed no reference to side rail usage for Resident #119. An observation on 3/11/25 at 1:17 PM revealed Resident #119 lying in bed with bilateral one quarter length side rails in the raised position. An observation on 3/12/25 at 11:39 AM revealed Resident #119 in bed with the one quarter length side rails in the raised position. An interview with Unit Manager (UM) #1 on 3/11/25 at 2:02 PM revealed the Unit Managers completed the quarterly side rail/entrapment risk evaluations. UM #1 stated she completed the quarterly evaluation on 2/27/25 for Resident #119. She further stated they did not attempt alternatives before using side rails. She further stated she was unaware this was a requirement. In an interview with the Director of Nursing (DON) on 3/13/25 at 9:16 AM she stated they did not try interventions before using side rails as she was not aware this was a requirement. In an interview with the Administrator on 3/12/25 at 1:15 PM she stated alternative interventions to side rails were not tried before implementation as she was unaware that this was a requirement.

Based on record review, resident responsible party (RP) and staff interviews, the facility failed to include documentation in the medical record that the facility staff had spoken with the responsible party (RP) or resident regarding advance directives (Resident #110). This was for 1 of 5 residents reviewed for advance directive. The findings included: A review of the facility's policy titled Residents' rights Regarding Treatment and Advance Directives dated 3/1/22 and reviewed/revised on 3/1/24 revealed it is the policy of this facility to support and facilitate a residents' right to formulate an advance directive. On admission the facility will determine if the resident has executed an advance directive, and if not determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Resident #110's medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included stroke, hypertension, and thyroid disorder. The review also revealed the resident code status was a full code. There was no documentation in the record for education regarding formulation of an advanced directive and/or an opportunity to formulate an advance directive was offered. An interview with Resident #110's RP was held in the facility on 3/13/25 at 9:21 AM, at which time he stated, Resident #110 does not have an advanced directive in place. He went on to say a facility employee talked to him about advanced directives, but he was not interested at that time. He did not recall who spoke with him regarding advanced directives. An interview was completed on 3/13/25 at 8:48 AM with the facility Admission Director. She revealed she does not discuss advance directives with residents or responsible parties (RP) as that task would be the responsibility of the Admissions Nurse. An interview with the Admission Nurse was held on 3/13/25 at 9:05 AM, she stated she speaks to code status only as the Social Worker was responsible for discussing advance directives with residents and their RP. An interview with the Social Worker was held on 3/13/25 at 9:45 AM in which she stated typically the Admissions Director would be responsible for the advance directive discussion with residents and RPs. She would not have addressed advanced directives unless a coworker asked her to do so. An interview was completed with the facility Administrator on 3/13/25 at 9:55 AM. At that time, she revealed her expectation would have been that the Social Worker follows up with families that did not have advance directives in place upon admission to educate them and offer assistance and education to establish advance directives if desired. She went on to further state her expectation would have also been that the Social Worker document those conversations in the resident's chart.

Based on observation, record review and staff interviews the facility failed to develop an individualized, person-centered comprehensive care plan to include the use of side rails (Resident #82 and Resident #119) and an anticoagulant (blood thinning) medication (Resident #129). This was for 3 of 27 residents whose comprehensive care plans were reviewed. Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses including history of cerebral infarction (stroke). A review of Resident #82's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/22/25 and completed by Nurse #1 revealed bilateral one quarter length side rails were to be used. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was cognitively intact. The MDS indicated Resident #82 required partial to moderate assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #82 had impairment of one side of upper extremities and impairment of both lower extremities. The MDS indicated Resident #82's siderails were not used as a restraint. A care plan with the latest review date of 3/3/25 revealed no reference to use of side rails for Resident #82. An observation on 3/10/25 at 11:54 AM revealed Resident #82 lying in bed with bilateral one-quarter length side rails in the up position on the bed. An interview with the MDS nurse was conducted on 3/13/25 at 9:08 AM. The MDS nurse stated she was responsible for updating care plans with information she received from other departments such as Nursing. The MDS nurse revealed she was not aware side rails needed to be addressed in a resident's care plan. In an interview with the Director of Nursing (DON) on 3/13/25 at 9:16 AM she stated she was not aware side rails needed to be addressed in a resident's care plan. In an interview with the Administrator on 3/12/25 at 1:15 PM she stated she was unaware side rail usage needed to be addressed in a resident's care plan. 2. Resident #119 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke). A review of Resident #119's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/7/25 and completed by UM #1 revealed the resident was using bilateral quarter length side rails. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #119 was severely cognitively impaired and was dependent on staff for bed mobility. The MDS indicated Resident #119's siderails were not used as a restraint. A care plan with the latest review date 1/10/25 revealed no reference to side rail usage for Resident #119. An observation on 3/11/25 at 1:17 PM revealed Resident #119 lying in bed with bilateral one quarter length side rails in the raised position. An observation on 3/12/25 at 11:39 AM revealed Resident #119 in bed with the one quarter length side rails in the raised position. An interview with the MDS nurse was conducted on 3/13/25 at 9:08 AM. The MDS nurse stated she was responsible for updating care plans with information she received from other departments such as Nursing. The MDS nurse revealed she was not aware side rails needed to be addressed in a resident's care plan. In an interview with the Director of Nursing (DON) on 3/13/25 at 9:16 AM she stated she was not aware side rails needed to be addressed in a resident's care plan. In an interview with the Administrator on 3/12/25 at 1:15 PM she stated she was unaware side rail usage needed to be addressed in a resident's care plan. 41009 3. Resident #129 was admitted to the facility on [DATE] with a diagnosis of atrial flutter (an irregular heartbeat). A review of a physician's order for Resident #129 dated 2/1/25 revealed to administer Eliquis (an anticoagulant/blood thinning medication) 5 milligrams (mg) to Resident #129 by mouth twice daily for atrial flutter. A review of Resident #129's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #129 was taking anticoagulant medication and an indication for the medication was noted. A review of Resident #129's Medication Administration Record February 2025 (MAR) revealed documentation Eliquis 5mg was administered to Resident #129 as ordered by his physician. A review of Resident #129's comprehensive care plan dated last revised on 3/5/25 did not reveal a focus area for or address the risk of bleeding related to receiving anticoagulant/blood thinning medication. On 3/13/25 at 9:23 AM an interview with MDS Coordinator #2 indicated she completed the medication section of Resident #129's admission MDS dated [DATE]. She stated she coded this section to indicate Resident #129 was taking anticoagulant medication. She reported she would have been responsible for ensuring his comprehensive care plan reflected his use of this medication and she had not. She stated this was an error on her part. In an interview on 3/13/25 at 10:18 AM the Director of Nursing stated anticoagulants were high risk medications that required additional safety monitoring. She reported Resident #129's care plan should have reflected his use of the medication so all staff would be aware he was receiving it.

Based on record review and staff interviews, the facility failed to obtain a baseline thyroid function test for a resident who was taking Levothyroxine Sodium for 1 of 5 residents reviewed for unnecessary medications (Resident #123). Findings included: Resident #123 was admitted to the facility on [DATE]. Her active diagnoses included hypothyroidism. Review of Resident #123's physician order dated 11/1/24 revealed the resident was ordered Levothyroxine Sodium oral tablet 25 micrograms, give 1 tablet by mouth in the morning for hypothyroidism. Review of a consultant pharmacist recommendation to the physician dated 11/26/24 revealed the pharmacist recommended a baseline thyroid function test to be completed and repeated yearly while Resident #123 was taking Levothyroxine Sodium. The nurse practitioner wrote an order to obtain the lab as recommended. Review of a consultant pharmacist recommendation to nursing dated 12/18/24 revealed the pharmacist again recommended nursing obtain a baseline thyroid function test for Resident #123 per the order from the previous recommendation on 11/26/24 and place them in Resident #123's medical record. Review of Resident #123's medical record on 3/13/25 at 9:30 AM revealed Resident #123 did not have any thyroid function test results documented in the medical record. During an interview on 3/13/25 at 9:42 AM the Director of Nursing stated pharmacy recommendations come to her, and she places them in the physician's box to have the physician or designee respond to the recommendation. The baseline thyroid function test for Resident #123 was scheduled for 12/4/24 as a response to the 11/26/24 pharmacy recommendation and subsequent order from the nurse practitioner. It was ordered and placed in the lab book scheduled for 12/4/24. About a month later, the next recommendation on 12/18/24 came to her from pharmacy and she noted Resident #123's lab was not done on 12/4/24 and she did not know why. She rescheduled the lab for 12/23/24 and the appointment was placed in the lab book as well. She stated this lab was also not obtained and she did not know the reason why. She stated she expects labs like these, which are not stat labs, to be obtained within a few days of the order being written. She concluded this lab was missed and she did not know why. During an interview on 3/13/25 at 9:58 AM the Nurse Practitioner stated the turnaround for a routine lab should be 1 to 2 weeks. These were routine labs and there were no current reasons to think the thyroid-stimulating hormone level was off. He concluded there was no negative outcome for Resident #123 for these labs being missed. During an interview on 3/13/25 at 10:21 AM the Administrator stated labs should be completed as ordered.

Based on record review and staff and Responsible Party (RP) interviews, the facility failed to provide a Centers for Medicare and Medicaid (CMS) Form 10123-Notice of Medicare Non-Coverage (NOMNC) within the required time frame. This was for 1 of 4 residents (Resident #129) reviewed for Beneficiary Notices. Findings included: Resident #129 was admitted to the facility on [DATE]. Review of Resident #129's NOMNC form revealed the effective date coverage of his current skilled nursing and therapy services service would end was 3/11/25. It further revealed Medicare would probably not pay for his skilled nursing and therapy services after that effective date, and Resident #129 might have to pay for any services he received. The form included Resident #129's rights to appeal the decision. It was dated as signed by Resident #129's RP on 3/12/25. On 3/12/25 at 9:43 AM an interview with the Social Worker (SW) indicated Resident #129 was being discharged from the facility that day. She stated she had multiple conversations with Resident #129's RP throughout Resident #129's stay in the facility regarding his discharge plan. She stated she had not had a chance to provide Resident #129's RP with a NOMNC until 3/12/25. She reported every time she went to provide the form to Resident #129's RP and have it signed, the RP had already left the facility. On 3/12/25 at 10:05 AM an interview with Resident #129's RP indicated she had multiple conversations with the SW regarding Resident #129's discharge from the facility and had caregivers in place for Resident #129 when he got home. She reported she would have liked to have been informed of her rights regarding Resident #129's discharge from the facility before the day of discharge. On 3/12/25 at 10:46 AM a follow up interview with Resident #129's RP indicated she had just spoken with the Business Office Manager, had all her questions answered, and would proceed with taking Resident #129 home that day. On 3/12/25 at 3:40 PM an interview with the Administrator indicated the SW should have ensured Resident #129's RP was provided with the NOMNC form prior to the day of Resident #129's discharge from the facility.

Based on record review and interviews with the resident, Responsible Party (RP), and staff, the facility failed to facilitate the inclusion of a cognitively intact resident and her RP in the care planning process for 1 of 1 residents reviewed for the care planning process. The findings included: Resident #57 was admitted to the facility on [DATE]. The medical record indicated Resident #57's family member was her RP. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #57 was cognitively intact. A review of the care plan for Resident #57 on 1/22/24 at 1:00 PM revealed it was last revised on 2/28/23. A record review for Resident #57 revealed the last care plan meeting note was dated 6/6/23. This note indicated the Social Worker and the Rehabilitation Manager spoke with the Resident's RP and updated her on the Resident's progress. There were no other care planning meeting notes after this date. The record further revealed no evidence the resident or RP were incorporated in the care planning process after 6/6/23. In an interview with Resident #57 on 1/22/24 at 11:13 AM the Resident stated she hadn't been invited to a care plan meeting since last Spring. She believed they were to be held quarterly and was very interested in being involved. She further stated she wanted her RP to be involved as well. On 1/23/24 at 1:13 PM an interview with Resident #57's RP revealed she had received care plan notices in the mail every 3 months. She stated they were always scheduled for 11:30 AM and she could not attend due to work. When she would call back to reschedule for a more convenient time, the Social Worker would tell her she didn't have to attend and it was just a courtesy to invite her, or that there were no other times available. The Resident's RP further stated she had been trying to reschedule each care plan meeting invitation for over a year and they were rarely rescheduled. The last meeting she attended was by phone on 6/6/23. The facility called her for other care such as permission to give the Resident a flu shot, or notification of medical appointments. An interview with the Social Worker on 1/24/24 at 12:21 PM revealed she held care plan meetings upon admission, approximately every three months in conjunction with the MDS assessment schedule and in the event of a significant change in the Resident's health. These meetings were to be documented in care plan notes section of the electronic medical record including everyone that attended the meeting and what was discussed. She further stated any contact, or attempted contact with the Resident or their RP regarding care plan meetings would be documented as well. The Social Worker was unable to state why there were no notes for Resident #57 about care plan meetings since 6/6/23. She further indicated Resident #57 wanted to know when her care plan meetings were scheduled, and she took a written invitation to her room to speak with her about them. The Social Worker stated the Resident declined to attend. She further stated she would leave a voicemail message for the Resident's RP but would not receive a call back, so they were not rescheduled for her to attend. The Social Worker was unable to state the dates of any meetings held since 6/6/23. On 1/24/24 at 1:42 PM an interview with the Administrator revealed Care Plan meetings were held quarterly and annually and were to be documented including all who attended, and the topics discussed. Any contact with the Resident or RP would have been documented in the care plan section of the electronic record. She was unaware there was no documentation related care plan meetings for Resident #57 since 6/6/23.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Preadmission Screening and Resident Review Level II (Resident #18) and oxygen therapy (Resident #41) for 2 of 26 residents reviewed for MDS accuracy. Findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses which included hypertension and depression. The resident's medical record contained a halted Preadmission Screening and Resident Review (PASRR) Level II determination notification dated 9/23/18 with no end date. The annual MDS dated [DATE] indicated Resident #18 was not coded for Level II PASRR. An interview on 1/23/24 at 1:14 PM with MDS Nurse #1 and MDS Nurse #2 revealed they were aware that Resident #18 had a level II PASRR. MDS Nurse #1 stated that it should have been coded as level II PASRR. She also stated that there had been confusion in the past and that the level II halted had been coded as level I in error. An interview on 1/25/24 at 9:35 AM with the Administrator revealed that she expected the MDS to be coded accurately and felt the error was due to staffing changes. 41009 2. Resident #41 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia (low oxygen saturation). A review of a physician's order for Resident #41 dated 8/4/23 revealed may apply oxygen (O2) at 2 liters (l) via nasal cannula as needed (prn) to keep O2 saturation above 90 percent (%). A review of Resident #41's comprehensive care plan revealed a focus area initiated on 10/3/23 of at risk for alteration in respiratory status related to COPD. The goal was for Resident #41 to remain free from COPD exacerbation. An intervention was to administer oxygen as ordered by the physician. A review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in part he was cognitively intact. He did not use oxygen therapy while a resident. On 1/23/24 a review of the vital signs section of Resident #41's electronic medical record revealed in part the following documentation: 12/8/23 11:13 PM 97.0% Oxygen via Nasal Cannula 12/9/23 11:38 AM 97.0% Oxygen via Nasal Cannula 12/9/23 10:14 PM 98.0% Oxygen via Nasal Cannula 12/10/23 2:04 AM 96.0% Oxygen via Nasal Cannula 12/10/23 9:44 AM 96.0% Oxygen via Nasal Cannula 12/11/23 6:28 AM 95.0% Oxygen via Nasal Cannula 12/11/23 6:29 PM 97.0% Oxygen via Nasal Cannula 12/12/23 5:59 AM 97.0% Room Air 12/12/23 5:42 PM 99.0% Oxygen via Nasal Cannula 12/13/23 1:46 AM 95.0% Oxygen via Nasal Cannula 12/13/23 9:07 AM 96.0% Oxygen via Nasal Cannula 12/14/23 2:41 AM 95.0% Oxygen via Nasal Cannula 12/14/23 5:05 PM 96.0% Oxygen via Nasal Cannula On 1/23/24 at 1:45 PM an interview with MDS Nurse #1 indicated she coded the Special Treatments and Programs section of Resident #41's MDS assessment dated [DATE]. She stated the look-back period for coding this section was 14 days. She went on to say she coded the section to indicate Resident #41 did not use oxygen because when she saw Resident #41 on 12/20/23, he was not wearing oxygen. On 1/23/24 at 2:21 PM an interview with Nurse #1 indicated she was the Unit Manager. She stated the documentation in the vital signs section of Resident #41's medical record reflected Resident #41's oxygen saturation and whether or not he was receiving oxygen at the time the oxygen saturation was obtained. On 1/25/24 at 9:35 AM an interview with the Administrator indicated Resident #41's MDS assessment should have been coded accurately. She stated because Resident #41 had not been wearing oxygen when he was observed by MDS Nurse #1, that might explain why she coded that MDS section the way she had.

Based on observation, record review, staff, family, and resident interview the facility failed to complete an assessment with wound measurements when a reopened wound was identified and to transcribe standing orders for wound care into the resident's treatment record to ensure the orders were implemented. This deficient practice was for 1 of 1 resident (Resident #29) reviewed for skin conditions. The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left side, Type II Diabetes Mellitus, and dementia. The standing orders for a skin tear stated clean with normal saline, apply xeroform (a petroleum saturated gauze product) and cover with a dry dressing daily. A review of the care plan dated 1/8/24 revealed there was no care plan for alteration in skin integrity or risk for alteration in skin integrity. A unsigned skin check for Resident #29 completed on 1/16/24 indicated there was some bruising noted to both upper extremities only noted. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired and had no skin impairment. On 1/22/24 at 4:28 PM it was observed that Resident #29 had a wound dressing to her right upper arm that was initialed and dated 1/21/24 by Nurse #3 who applied the dressing. The dressing was white, and blood could be seen having soaked the center. During an interview with Resident #29 on 1/22/24 at 4:30 PM, she stated her skin was very fragile and she got a skin tear. She could not recall how or when the wound happened. The medical record for Resident #29 through 1/21/24 revealed no evidence of any documentation related to the wound that was dressed on her right upper arm. On 1/22/24 at 4:30 PM an interview with Resident #29's husband, who was also a resident and was alert and oriented to person, place, time, and situation, revealed Resident #29 got up and walked around alone, although she was supposed to ask for help with walking. He further stated she often bumped into things and got bruises and skin tears, and this also happened when they lived at home. He did not recall how or when Resident #29 got the wound to her right upper arm. On 1/23/24 at 9:00 AM it was observed that Resident #29 had a wound dressing to her right upper arm that was initialed and dated 1/22/24 by Nurse #3 that applied the dressing. The dressing was white, and blood could be seen having soaked the center. An interview with the Unit Manager on 1/23/24 at 3:44 PM revealed the process for documenting new wounds. The Nurse was to use the communication book to look at standing orders and choose the appropriate treatment from the list on the front of the book. They would document the date, time, Resident, type of wound and treatment in the communication book for the treatment Nurse (Nurse #1) to follow up on. The Nurse would then treat the wound and write the chosen standing order in the electronic record to alert other Nurses to the new wound. The Unit Manager further stated the Nurse was to write a nurses note in the electronic record regarding the wound and its treatment. Nurse #1 would follow up by measuring and assessing the wound, assuring the correct treatment was started, and would follow the wound until healed. A review of Resident #29's chart with the Unit Manager on 1/23/24 at 3:50 PM revealed no documentation of the new wound to Resident #29's right upper arm. During an interview with Nurse #1 on 01/23/24 at 02:35 PM, she revealed she did the wound management for the facility (treatment Nurse), and she was not aware Resident #29 had a wound. She further stated the nurses were to document new wounds in the communication book at the Nurse's station, or the one hanging on her office door and they wrote orders based on the list of standing orders in the book so that she could follow up. She revealed that she did not find documentation for Resident #29's wound care. She further stated when a wound was not documented in the communication book, she would not have known a wound assessment needed to be completed and a dressing change needed to be done. She added that a wound could become infected over time if not treated properly. A review of the communication books on 01/23/24 at 2:45 PM with Nurse #1, both at the Nurse's station and hanging on her door revealed Resident #29's wound had not been reported. An observation of Resident #29's dressing change was made on 1/23/24 at 3:15 PM with Nurse #1. Nurse #1 stated it was the initials of Nurse #3 on the dressing. Nurse #1 stated the wound appeared to be in the beginning stages of healing, as the wound bed was a yellow color but still had blood-tinged drainage. She further stated it was about one inch by one inch in size and appeared to be a skin tear. On 01/23/24 at 04:04 PM an interview with Nurse #3 revealed she did not document an assessment with measurements, or a progress note when she identified the new wound for Resident #97 on 1/21/24. Her reasoning was she forgot. She further stated she did do wound care on 1/21/24 and 1/22/24 and that it was an old wound that had reopened. Nurse #3 noticed the wound on the night of 1/21/24 and stated it was a skin tear. She revealed she knew the process was to write it in the communication book, write an order in the electronic record, write a nurse's note regarding the wound, and notify the Responsible Party and the Physician. She further revealed she understood Nurse #1 would not be able to assess the wound and change the dressing since she was not made aware of the wound. During an interview on 1/25/24 at 11:03 AM, the Administrator stated Nursing staff were trained to document all wounds including orders, and notification of Responsible Party and Physician, as soon as possible after a new wound is discovered.

Based on observations, record review, resident, staff and Medical Director interviews the facility failed to obtain a physician's order for the use of supplemental oxygen for 1 of 3 residents reviewed for respiratory care (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses that included heart failure and oxygen dependent. Review of the medication administration record (MAR) and physician orders revealed that Resident #101 did not have an order for oxygen and oxygen was not listed on the MAR as being administered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #101 was cognitively intact and had a diagnosis of oxygen dependent but was not coded for oxygen use. An observation of Resident #101 was made on 1/23/24 at 8:43 AM, she was resting in bed watching television. Resident #101 had an oxygen canula in her nose with oxygen being delivered at 2 liters per minute. In an interview with Resident #101 on 1/23/24 at 8:43 AM, she stated that she had used oxygen since admission and that she took it off and on by herself when she wanted to. She stated that she thought she received oxygen at 2 liters per minute. In an interview with the Medical Director on 1/24/24 at 11:58 AM he revealed that he was the attending physician for Resident #101. He stated that Resident #101 received oxygen at 2 liters per minute. He further added she received oxygen when she was originally admitted to the facility and attempts to wean her were unsuccessful. The interview further revealed that the Medical Director would expect that a resident would have an order for oxygen use and that it would be on the MAR for continued monitoring. He reviewed Resident #101's order list and stated that there was not an order for oxygen. At 12:19 PM on 1/24/24 an interview with Medication Aide #1 revealed that Resident #101 received oxygen per nasal cannula at 2 liters per minute. He stated that she did not have an order for oxygen use, and it was not listed on her MAR. He stated that it should be on her MAR and there should have been an order for it. On 1/24/24 at 12:21 PM in an interview with Nurse #1 revealed that Resident #101 received oxygen. She stated that when a physician wrote an order for oxygen, the nurse transcribed (transferred) the order to the MAR. She further indicated there was no oxygen order for Resident #101 on the physician order list and it was not listed on the MAR. She stated that Resident #101's oxygen should have been on the MAR and it would be signed by the nurse on each shift to indicate oxygen was administered. The Administrator was interviewed on 1/24/24 at 1:00 PM, she stated that she was not aware that Resident #101 did not have an order for oxygen until the physician made her aware today. She further stated that residents that received oxygen should have a physician's order for oxygen, and it should be on the MAR for nurses to sign off on.

Based on observations, record review, and staff, family and resident interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification and complaint investigation surveys of 12/02/21 and 12/22/22. This was for two deficiencies in the areas of Accuracy of Assessments (F641) and Quality of Care (F684) that were subsequently recited on the current recertification and complaint investigation. The continued failure of the facility during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Preadmission Screening and Resident Review Level II (Resident #18) and oxygen therapy (Resident #41) for 2 of 26 residents reviewed for MDS accuracy. During the recertification and complaint investigation survey on 12/02/21 the facility was cited for failing to accurately code the Preadmission Screening and Resident Review (PASRR) and hospice status of residents. During the recertification and complaint investigation survey on 12/22/22 the facility was cited for failing to accurately code the PASRR. F684: Based on observation, record review, staff, family, and resident interview the facility failed to complete an assessment with wound measurements when a reopened wound was identified and to transcribe standing orders for wound care into the resident's treatment record to ensure the orders were implemented. This deficient practice was for 1 of 1 resident (Resident #29) reviewed for skin conditions. During the recertification and complaint investigation survey on 12/02/21 the facility was cited for failing to obtain daily weights as ordered by the physician and for abruptly discontinuing an antidepressant medication. An interview with the Administrator on 1/25/24 at 10:06AM revealed that staff turnover had resulted in the MDS coding errors, and she did not know what had caused the quality of care repeat deficiency.

Based on observations, record review, and staff interviews the facility failed to implement their infection control policy when Nurse Aide (NA) #1 did not perform hand hygiene during meal delivery and set-up after handling bed linens and moving the overbed table for 1 of 2 NAs observed passing meal trays on 1 of 8 halls. This had the potential to result in the cross contamination of microorganisms between residents. Findings included: A review of the facility's policy titled Hand Hygiene dated last revised on 7/1/23 revealed in part the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. A review of the attached hand hygiene table revealed in part the following: Between resident contacts, After handling contaminated objects, Before and after handling clean or soiled dressings, linens, etc. On 1/22/24 from 12:59 PM to 1:04 PM a continuous observation of the lunch meal tray delivery service was conducted in the facility on the 900 Hall. Hand sanitizing dispensers were observed in place at intervals on the wall of this hall. During this observation NA #1 removed a meal tray from the meal cart, entered Resident #122's room, placed the meal tray on the resident's overbed table, removed the resident's blanket from the resident's legs, and repositioned the resident's overbed table in front of the resident. NA #1 was then observed to exit the room and returned to the meal cart without performing hand hygiene. NA #1 pushed the meal cart farther down the 900 Hall and removed Resident #102's meal tray from the cart. NA #1 was stopped in the doorway of Resident #102's room before she could deliver the meal tray to the resident. On 1/22/24 at 1:04 PM an interview with NA #1 indicated she should have performed hand hygiene after contact with a resident's linen and environment before removing another meal tray from the meal cart. She stated there was hand sanitizer available. She went on to say she had been educated on doing this to prevent the spread of infection. She further indicated she just hadn't been thinking. On 1/22/24 at 1:29 PM an interview with the Assistant Director of Nursing indicated she was the facility's Infection Preventionist. She stated the facility standard was that hand hygiene should be performed after touching a resident's environment and in between passing meal trays to decrease the risk of cross contamination. She went on to say NA #1 participated in a skills fair in November 2023 that included hand hygiene. On 1/25/24 at 9:35 AM an interview with the Administrator indicated NA #1 should have performed hand hygiene in accordance with the facility's policy. She went on to say NA #1 had been educated on this and should have known better.

Based on record review and staff interviews the facility failed to assess Resident #29's ability to be safely seated in a regular wheelchair prior to transfer from the resident's reclining wheelchair. While receiving service from the Beautician, Resident #29 suddenly moved forward and fell hitting her head on the air conditioning unit. Resident #29 was sent to the hospital for evaluation and was diagnosed with a displaced intertrochanteric fracture of the left femur. This deficient practice affected one of one resident reviewed for accidents (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE]. Her diagnoses included Parkinson disease and Alzheimer's disease, and cervical spinal stenosis. Resident #29's care plan dated 3/6/22 revealed she was care planned to be at a risk for falls related to confusion, deconditioning, gait/balance problems, and diseases of musculoskeletal system. The interventions included to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and the resident needs prompt response to all requests for assistance. Resident #29's Occupational Therapy Discharge Summary dated 9/1/22 revealed Resident #29 was recommended a specialty chair due to resident becoming uncomfortable in a regular wheelchair and fidgeting resulting in the resident falling from a regular chair. The specialty chair was in place when the resident discharged from occupational therapy on 9/1/22. Resident #29's Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She had no behaviors and was totally dependent on staff for bed mobility and transfers only occurred once or twice in the lookback period. There was no update to the care plan after the occupational therapy discharge summary and the last MDS with regards to the use of the specialty chair prior to 11/2/22. A nursing note written by Charge Nurse #1 and dated 11/2/22 revealed the Beautician informed this nurse resident fell out of the regular wheelchair. Resident #29 was found on the floor and the Beautician stated resident had appeared to be reaching and slipped out of the wheelchair. The Beautician told the nurse Resident #29 hit her head on the air conditioner unit. Resident #29 was assessed and noted with cut to left eye and no other injuries. Resident #29 was looking around and presented at baseline. Resident #29 was sent to the emergency department for evaluation. The family member, who was in the facility, was notified before the resident left. Review of the discharge summary from the hospital dated 11/7/22 revealed Resident #29 sustained a displaced intertrochanteric fracture (a type of hip fracture) of the left femur (thigh bone). During an interview on 12/21/22 at 8:32 AM the Therapy Director stated when a resident is recommended customized seating per therapy it was their expectation that the staff not alter the intervention without clinical evaluation. She concluded the nurse aide should have notified a clinician for an evaluation from therapy if changes needed to be made to the resident's seating for the resident to get her hair done. During an interview on 12/21/22 at 8:40 AM Nurse Aide #1 stated the Kardex would inform her what specialty equipment was to be used for each resident and therapy in-services the staff regarding specialty equipment required by residents and this had been done for Resident #29. She stated she knew the resident needed to be in the specialty chair for safety which was why she remained with the resident after she placed the resident in the regular wheelchair until the beautician was ready for the resident. She would then transfer the resident back into her specialty chair after her hair was done. She had done this a few times with the resident due to family request as the beautician could not reach the back of the resident's hair in the specialized chair. She stated she did not check with anyone prior to transferring the resident out of her specialty chair and into a regular wheelchair. On 11/2/22, per family request, she ensured the line was short at the beautician and then transferred the resident to a regular wheelchair from her specialty chair. She then took the resident to the beautician and stayed with the resident until it was the resident's turn. She positioned the resident for the beautician and then sat in front of the resident. The resident reached for something in the air in front of her that did not exist which resulted in her falling forwards out of her chair. It happened so fast the nurse aide was unable to react to prevent the fall. The resident fell forwards and to the right of the resident, hitting the air-conditioning unit next to her chair, landing on the floor. The resident had a small laceration above the right eye. The resident's mental status was at baseline and did not display signs of pain following the fall. Per facility protocol with a fall with head injury, the resident was sent to the emergency room for evaluation. She stated she was asked to participate in the fall investigation and provided her witness statement. Following the investigation, she was educated about not altering specialty safety equipment without ensuring the resident had been assessed to be safe with the change. She stated she now knew if a family member requests a resident to be placed into a different chair from what the resident was recommended by therapy, she would alert her supervisor to resolve the issue and see what changed could be made to the resident's seating safely. During an interview on 12/21/22 at 9:05 AM the Beautician stated Resident #29 came to the beauty shop in a regular wheelchair as she always did, and she was unaware of any discussions about which chair should be used for Resident #29. The nurse aide then left the resident in the beauty shop with the beautician, and it was just the two of them in the room. She stated she was curling the resident's hair and the resident started reaching her hands out in front of her. The resident was not verbal, so she thought perhaps the resident was trying to communicate something to her and asked the resident to wait a second as she finished placing a roller in her hair. Then, the resident's body suddenly went forward, and she reached out to the resident, placing her hand behind the resident's head as the resident fell . The resident hit the air-conditioning unit with the right side of her head and landed on the floor. She stated it was just her and the resident in the beauty shop at that time. The nurse aide who brought the resident had left the room, but the door was open to the beauty shop, so she yelled for help. Charge Nurse #1 was the first to respond to the fall and took over from there. Resident #29 did not display any signs or symptoms of pain. She concluded by saying she was educated to get help from staff if any resident developed behaviors or was not safe to proceed due to such behaviors and Resident #29 now was to have her hair done in bed. During an interview on 12/21/22 at 9:21 AM Charge Nurse #1 stated she was the charge nurse on the hall at the time Resident #29 sustained her fall in the beauty shop. She stated on 11/2/22 she was walking in the direction of the nursing station when she heard the beautician yell out for help. She immediately responded to the call for help and found Resident #29 was on the floor and the beautician appeared to have been attempting to prevent the resident from hitting her head. Resident #29 had a laceration above her right eye which indicated to the charge nurse that the resident had hit her head during the fall. She stated when she first got there it was just the beautician and the resident in the room. She asked what happened and if the resident had hit her head. The beautician told her the resident fell forward out of the chair and hit her head on the air-conditioning unit. She stated due to the head injury she immediately called 911 to have the resident sent to the emergency department for evaluation following the fall. She stated the resident was smiling and did not display any signs of pain at that time though she was non-verbal. She concluded the resident was sent out for evaluation and found to have sustained a fracture of the left femur from the fall. She stated the chair she observed in the beauty shop was a regular wheelchair and Resident #29 was supposed to be in a specialty chair for safety related to falls. She stated she did not know why the resident was in a regular chair at that time and had been unaware until the fall investigation that Resident #29 had been going to the beautician in a regular wheelchair instead of the specialty chair. She concluded in a situation where a family is requesting a nurse aide alter specialty equipment for the resident, the nurse aide should bring this to her attention so she could address the situation with the family and see what could be done clinically to ensure the resident's safety and accommodate the family request. During a follow up interview on 12/21/22 at 9:37 AM Nurse Aide #1 again stated she was in the beautician's room when the resident sustained her fall and had not left the room until after the fall occurred. During an interview on 12/21/22 at 8:07 AM the Director of Nursing and the Corporate Clinical Director stated on 9/1/22 Resident #29 was discharged from therapy with a recommendation for a specialty chair for comfort. Resident #29 would become uncomfortable in a regular wheelchair which resulted in her fidgeting and ultimately falling from the chair. During the investigation of the fall, it was determined Resident #29 had been transferred to a regular wheelchair from her specialty chair by Nurse Aide #1 per family request to get Resident #29's hair done. Resident #29 had successfully been to the beauty shop a few times without incident in this way, but the specialty chair was the recommendation for her seating and the nurse aide should not have altered the recommended seating. The facility initiated a plan of correction focused on making sure in the future, residents in customized seating had an evaluation to determine if they were safe to alter their seating to go to the beauty shop. She concluded the nurse aide should not have altered the recommended customized seating per family request without ensuring that a clinician had evaluated the resident as to safety. During observation on 12/21/22 at 10:34 AM, Resident #29 was observed in her specialty chair. No concerns were identified. During an interview on 12/21/22 at 11:11 AM Physician #1 stated his understanding was that nurse aides should get an evaluation completed by therapy prior to placing a resident in a chair that was not recommended for them. He concluded falls would be the biggest concern with moving a resident from their recommended chair to a regular wheelchair without getting a clinician to evaluate the resident for safety. The facility provided the following corrective action plan with a completion date of 11/12/22. 1. Resident was in a specialized chair receiving beautician services. Family requested resident to be put in a regular wheelchair to be able to reach her hair better. Nursing assistant accommodated the family request by putting resident in a regular wheelchair and taking her to the beauty shop and handing her off to the beautician. Nursing assistant never left resident alone in her wheelchair and stayed with her until beautician was ready for the resident. Nursing assistant interview revealed resident had completed this task successfully 7-8 times. Today (11/2/22) while beautician was doing the resident's hair resident made a quick and sudden movement by lunging up and fell before the beautician was able to do anything. Root cause: Nursing assistant altered specialized seating per family request without clinical evaluation for safety. 2. All residents that use specialized seating that go to the beauty shop are at risk. 3. Inservice to all nursing staff to not alter specialized seating even if this is a family request without clinician approval. Inservice with beautician to seek assistance if any resident demonstrates restlessness or is not safe to proceed due to such behaviors. Also, in-serviced beautician if resident demonstrates restlessness or is not safe to proceed due to such behaviors. Also, in-serviced beautician if resident in a specialized wheelchair to use extra towels and [NAME] to help keep resident as dry as possible. 4. Facility will monitor resident in specialized seating for four weeks to ensure no alterations or residents receive services in bed. Special Notes: Update Care plans for residents that are in specialized seating and for residents getting hair done in bed. Date of compliance is 11/12/22. This corrective action plan was in place on 11/12/22 by the Administrator. The corrective action plan was verified through record review of the education and monitoring of residents who required specialized seating while receiving beautician services, interviews with facility staff, and observations of Resident #29. Based on observations, interviews, and record reviews the facility's compliance date of 11/12/22 was verified.

Based on observations, record review, interviews with staff, residents, family members of dependent residents, and the facility physician, the facility failed to provide supervision to prevent 1 of 1 sampled residents (Resident #94) from leaving facility property unaccompanied and had no knowledge of Resident #94's whereabouts until family members notified the facility Resident #94 was off the property at a grocery store located 0.2 miles from the facility entrance. No injuries were assessed after Resident #94 was brought back to the facility by staff. Findings included: Resident #94 was originally admitted to the facility on [DATE] and re-entered the facility 4/19/18 from an acute care hospital. Review of a quarterly MDS (Minimum Data Set-a tool used for resident assessment) dated 1/16/18 revealed Resident #94 was severely cognitively impaired, had adequate speech, hearing, and vision, was understood and understood others, had inattention and disorganized thinking continuously present, and displayed no moods, behaviors, or wandering. Rejection of care was present 1-3 out of 7 days and had no acute changes in his mental status. Activities of daily living (ADLs) required limited assistance for locomotion (movement) on and off the unit, supervision for eating, and extensive assistance for all other ADLs. Resident #94 had 1 upper and 1 lower limb impairment, and used a wheelchair for mobility. Active [DIAGNOSES REDACTED]. Resident #94 received anti-anxiety and anti-depressant medications 7 out of 7 days during the look back period. A care plan, last updated 1/5/18, focused on Resident #94's high risk for falls related to (r/t) impulsive behavior and non-compliance with safety precautions. The goal was no fall or related injuries, and interventions included, but were not limited to, continued resident education r/t calls for assistance. No interventions related to supervision were included. Review of a behavioral health consult dated 1/30/18 revealed Resident #94 had recent baseline, progressive decline in overall function/cognition, and had fair to poor insight and judgment. A care plan last updated 2/25/18 had a stated focus Adjustment issues, anxiety disorder. Goals included (monitor) adverse reactions r/t anti-anxiety therapy. Interventions included, but were not limited to, monitor for side effects. Anti-anxiety medications-confusion. Observe the resident for safety. The resident is taking anti-anxiety meds (medications) which are associated with an increased risk of confusion, amnesia, and cognitive impairment that looks like dementia. Observe/record occurrence of for target behavior symptoms pacing, wandering, inappropriate response to verbal communication. No other interventions r/t supervision were included. A care plan last updated 3/1/18 read, in part, I have a serious mental illness (major [MEDICAL CONDITION]) recurrent, severe with psychotic symptoms. The stated goal was to maintain the highest functional and psychological potential and prevent avoidable decline. Interventions included, but were not limited to, observation for behavioral or condition changes. No interventions r/t supervision were included. Review of a behavioral health consult dated 3/27/18 revealed Resident #94 presented with increased anxiety and reported his (FM) no longer worked in the facility. His mood was assessed as anxious, and his insight and judgment were listed as fair to poor. Multiple attempts were made throughout the day on 6/26/18 to conduct an interview with the Nurse Practitioner who completed the behavioral health consults on Resident #94, but the Nurse Practitioner could not be reached for interview. Review of a Brief Interview for Mental Status Assessment (an assessment tool used to establish cognitive impairment) dated 4/20/18 revealed Resident #94 was severely cognitively impaired. Review of the medical record revealed Resident #94 had been in bed on 4/22/18 (the day he left the facility property) at 11:12 AM. An additional nursing note on 4/22/18 at 1:33 PM read, in part, Resident went outside per his normal and customary routine. On this day resident rolled his wheelchair to (grocery store) which is situated to the left of the facility. A friend of his (FM) saw him in the parking lot and phoned his (FM). His (FM) alerted us via phone. Review of a facility incident report dated 4/22/18 and subsequent investigation dated 4/23/18 read, in part, Resident is alert and verbal and able to make his needs known. Thorough (throughout) his long stay in the facility (he was originally admitted [DATE]) he has always sat outside for short periods of time without direct supervision without incident. BIMS (Brief Interview for Mental Status-an assessment tool used to determine cognitive status) has fluctuated between 2 (severely cognitively impaired) and 11 (moderately impaired). The most recent assessment on 4/20/18 a score of 7 (severe cognitive impairment). Resident's family does assist him at times to sit (out) and enjoy the weather. In fact, he was observed 4/21/18 (the day before he left the property) outside by the Administrator. He was observed rolling to end of walkway and returned to the porch. On 4/22/18 resident did go into the parking lot at the (grocery store) which is located beside the center. Observed by a friend of the family and they called the family but did not stay with resident. (FM) called the facility and staff went to the parking lot and assisted the resident back in the facility. The investigation report also revealed Resident #94 was last seen inside the facility at 11:55 AM and the facility received a phone call for the FM at 12:15 PM. An observation of the grocery store parking lot, where Resident #94 was found in his wheel chair, was made on 6/18/18 at 9:45 AM. The grocery store parking lot was paved with black asphalt. Surfaces were observed to be predominantly smooth with some areas to be uneven and cracked. No speed limits were posted, and no stop signs were observed. The front of the grocery store was 0.2 miles from the facility entrance. An interview was attempted and an observation was made of Resident #94 on 6/18/18 at 11:00 AM. He was not able to appropriately answer questions r/t his supervision needs. An interview was conducted with resident #94's FM on 6/18/18 at 2:39 PM. She stated Resident #94 had not left the property before, but was not cognitively aware enough to be outside unsupervised and was concerned the facility had not known Resident #94 had left the property on 4/22/18. An additional observation and interview was conducted with Resident #94 on 6/19/18 at 3:00 PM. The resident was in bed and stated he had been able to go outside by himself until the day he left the property to look for his (FM) who used to work at the facility. He stated, I was looking for my (FM). She used to work here. I was on the side of the store where my (FM) lives. I was angry so I went to look for her. An interview was conducted on 6/19/18 at 3:15 PM with a nursing assistant (NA #1) who typically cared for resident #94. He stated Resident #94 displayed inappropriate behaviors. He stated Resident #94 requested to get out of bed, then requested to get back into bed 5 minutes later. He also stated if his needs were not immediately met he became agitated and his mental status would change. He stated he had no recall of Resident #94 ever being supervised inside or outside the facility. An interview was conducted with Nurse #1 on 6/19/18 at 3:35 PM. She stated Resident #94 was non-compliant and compulsive at times. She also stated a (FM) used to work at the facility, but when she left Resident #94 became upset and his anger and behaviors increased r/t a lack of FM visits. Nurse #1 also stated when Resident #94 was returned to the facility by staff on 4/22/18 he had verbalized he was looking for his FM when he left the facility property. She also stated he had not had any supervision while outside the front of the facility prior to 4/22/18. An interview was conducted on 6/20/18 at 9:45 AM with the facility Medical Director (MD). He stated Resident #94 had childlike behaviors and juvenile impulse control. He also stated Resident #94 knew right from wrong and was angered after his (FM) abruptly left the employ of the facility. The MD also stated he believed Resident #94 would leave the facility property again without supervision, so the facility placed an alarming bracelet on his wrist and wheelchair. He was not aware of any other supervision interventions. An interview was conducted with the Social Worker (SW #1) on 6/20/18 at 10:15 AM. She stated when resident #94 left the facility property on 4/22/18 he was angry at his (FM). She stated the FM had abruptly stopped work at the facility a couple of weeks before he left (4/22/18) and had not visited him after he re-entered the facility (4/19/18) from the hospital. She also stated his cognition and mental status fluctuated, he was manipulative at times, was attention seeking, and childlike in his behaviors. The facility had not provided any supervision prior to the day Resident #94 left the facility property, and placed an alarming bracelet on his wrist and wheelchair after he was returned to the facility on [DATE]. She had not included any other interventions r/t supervision. An interview was conducted on 6/21/18 at 11:25 AM with the Administrator and Director of Nursing (DON). The Administrator stated Resident #94 had never gone further than the end of the walkway before. She stated he had always turned around and returned to the facility when he reached the end of the walkway. She stated this had been his usual and customary routine until the day he was angry with his FM and left the facility property (4/22/18). On the day he left (4/22/18) he had not told anyone he was going further than the end of the walkway. When staff were called and told Resident #94 was seated in his wheelchair at the grocery store staff went to the grocery store and returned Resident #94 to the facility. Resident #94 told staff he was looking for his (FM) who used to work at the facility. The Administrator also stated Resident #94 was childlike in his thinking and behavior. The DON stated Resident #94 typically had erratic behavior, like a child, and she was very close to him. She also stated she had worked with him since his admission in 2004 and he had a big mood change since his (FM) abruptly stopped working at the facility at the end of (MONTH) (YEAR). On 6/26/18, the facility provided the following Allegation of Compliance (A[NAME]) with a compliance date of 4/27/18: Allegation of compliance 1. On 4/22/18 at approximately 12:00 pm Resident #94 exited the facility via the front door onto the porch in his usual and customary manner. The front door opens automatically unless it is diverted by a Wander guard signal. Resident #94 propels himself in his wheelchair without assistance. At approximately 12:15pm Nurse #1 received a call from Resident #94's Responsible Party, stating that a friend saw Resident #94 seated in his wheelchair in the parking lot of the grocery store adjacent to the facility. Resident #94 had explained to the friend that he was looking for his sister. Nurse #1 and the Unit Secretary immediately went to the grocery store parking lot and assisted Resident #94 back in the facility. Nurse #1 completed a head to toe assessment of Resident #94, after returning to the facility, with no signs of injury noted. Resident #1 explained to Nurse #1 and Nurse Supervisor #2 that he was looking for his sister. The Administrator (NHA) and the Director of Nursing (DON) were informed by Nurse #1 at 12:30 pm. The NHA contacted the responsible party for Resident #94 at approximately 12:53 pm to alert her that Resident #94 was returned to the facility without any evidence of injury. The NHA discussed the initiation of a Wander guard with the responsible party as an immediate intervention, as well as, supervised visits outside going forward. Nurse #1 and the Nurse Supervisor #2 explained the use of the Wander guard to Resident #94 and he was agreeable. Nurse #1 notified the on call physician and received new orders for Wander guard placement at 2:00 pm on 4/22/18. Resident #94 was continuously monitored by Nurse #1 until the Wander guard was placed. Resident #94 was previously assessed as no risk for elopement on every prior assessment with the most recent one with assessment date of 4/19/18. He has resided in this facility for over [AGE] years and part of his daily routine has included safely sitting on the front porch unsupervised without any attempts to leave or without ever expressing any desire to leave the facility. He had a BIMS of 7 most recently assessed on 4/20/18 by the Social Worker. On 4/22/18 Nurse #2 completed a new elopement assessment now identifying Resident #94 at risk for elopement based on this event. Nurse #1 placed a Wander guard on the left wrist of Resident #94, initiated ongoing monitoring of the device and updated the care plan to reflect this new behavior of wandering. Resident #94 is offered and upon request to sit on the porch supervised by facility staff. An incident report was completed by Nurse #1 on 4/22/18. The interdisciplinary team (IDT) which included the NHA, DON, Medical Director, District Director of Clinical Services, Social Worker, Assistant Director of Nursing, MDS Nurse, Activities Director, Wing Nurse Manager, Business Office Director, Housekeeping Supervisor, and Rehab (Rehabilitation) Manager met on 4/23/18 and 4/24/18 to conduct a root cause analysis of the events surrounding Resident #94 exiting the facility's front porch without supervision on 4/22/18. The IDT determined that Resident #94 had no prior history of wandering or exit seeking behaviors, expressing a desire to leave the facility, or exhibiting behaviors that would indicate poor decision making related to remaining safe on the facility grounds. It was determined, a recent change of condition/circumstances reduced the daily visitation routines of Resident #94's Responsible Party and negatively affected his decision making ability. Resident #94 acknowledged , during an interview with the Social Worker on 4/24/18 that he had feelings of anger towards his family, that they had dumped him at the facility and this made him do crazy things. He again acknowledged that he was looking for his sister. Resident #94 has ongoing Psych Services. The Social Services Director continued to provide ongoing emotional support as well. 2. On 4/22/18 Nurse #2 completed a head count to validate the safe location of all current residents. Nurse #2 verified on 4/22/18 that the current residents with Wander guards were in place and functioning properly. Nurse #2 validated the elopement book was current with accurate information for residents at risk for elopement. An audit was completed by the Social Worker on 4/23/18 to ensure that all residents had an accurate elopement risk assessment completed within the last quarter. The Social Worker and DON reviewed current residents to determine those with a change of condition/circumstance during the last 30 days who exhibit severe cognitive impairment with a BIMS of 7 or lower. The current elopement assessments for these residents were reviewed for accuracy. No other residents were identified at an increased risk for elopement based on this review. This review was completed on 4/23/18. The Social Worker used the Assessment Scoring report, which pulls the most recent completed BIMS for current residents, to review the facility's current BIMS interviews and overall cognition to ensure residents who could be at risk for elopement had measures in place on 4/23/18 to keep them safe. The Social Worker validated that residents at risk for elopement were care planned on 4/23/18. The Maintenance Director painted stop signs on the cement at the end of the front porch walkways that lead into the parking lot to define boundaries on 4/27/18 as additional reminders for the residents that sit out front. The Activity Director offers at least 2 outside activities per week, weather permitting, for residents who require supervision to be outside the facility. On 4/22/18 the Wing Nurse Manager initiated re-education with current facility staff regarding the facility policy for elopement, changes in resident condition, and the abuse and neglect policy. The Staff Development Coordinator, NHA, Wing Nurse Managers, and DON continued with the education. No staff shall work after 4/27/18 before receiving this education. This education has been added to the Facility Orientation program for all new hires to be completed prior to beginning work after 4/27/18. 3. The DON, Nurse Managers and Social Worker will review new admissions and readmissions and review the 24 hour report and the clinical dashboard during the Clinical Morning Meeting 5x weekly to identify residents with a change of condition/circumstance and validate accurate elopement assessments, interventions and care plans are initiated. The Social worker will review current residents assessed at risk for elopement monthly to validate accurate assessments and care plans. The LNHA is responsible for the completion of this credible allegation. Date of compliance: 4/27/18 Validation of the above referenced A[NAME] was completed on 6/26/18 during an extended survey. Validation included staff interviews r/t supervision of residents at risk for accidents/wandering, observations of the functional alarming bracelet system used by the facility and included review of the maintenance logs for April, May, and June, review of updated care plans for residents who required supervision to prevent wandering away from facility property, review of the in-services received by all staff on or before 4/27/18, and the monitoring which occurred 5 times weekly, and continued monthly as stated in the A[NAME].

Based on observations, record review and staff interviews, the facility failed to supervise a resident after lifting the resident to a standing position in a stand up lift that resulted in a fall with injury to the resident for 1 of 4 residents reviewed for falls (Resident #3) and failed to transfer residents with a mechanical lift according to the plan of care for 2 of 4 residents reviewed for falls (Resident #6 and Resident #4). The findings included: 1. The manufacturer ' s instructions for the lift read: passive and active series of lifts are designed for safe usage with one caregiver. There are circumstances, such as combativeness, obesity, contractures etc. of the individual that may dictate the need for a two-person transfer. It is the responsibility of each facility to determine if a one or two person transfer is more appropriate. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident ' s Care Plan dated 8/13/14 noted the resident had a deficit in physical functioning related to mobility impairment and was at risk for falls. The Care Plan was updated on 6/8/15 and the resident was to be transferred with the stand-up lift. The Care Area Assessment (CAA) dated 8/23/16 for Cognitive Status/Dementia revealed the resident had short and long term memory deficits. The CAA for ADLs (activities of daily living) revealed the resident required mostly total assist with ADLs and mobility needs with progression of her dementia. The CAA for Falls revealed the resident was at risk for falls due to being non-ambulatory and dependent on staff for transfers to a wheelchair and had poor safety awareness. The CAA noted the resident was up in a wheelchair daily with staff providing transfers with the use of a mechanical lift. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 11/21/16 revealed the resident had severe cognitive impairment and no behaviors. The MDS noted the resident required total assistance of 2 persons for transfers, was not ambulatory and was not steady during surface to surface transfers and only able to stabilize with human assistance. A Lift/Mobility Assessment for Residents form dated 11/21/16 revealed Resident #3 was re-assessed and the resident was to continue to be transferred with the stand-up lift. An Interdisciplinary Post Fall Review report dated 12/23/16 revealed on 12/23/16 at 4:45 PM a nursing assistant (NA) entered the resident ' s room to provide care and noted the resident had had a bowel movement. The report noted the following: The NA secured the two seat belt straps and made sure the resident ' s knees were against the knee pads and the resident was fine. NA got washcloth off the bed. The NA looked at the resident and the resident was holding on to the bar as she usually did. Because the resident had a large bowel movement the NA went to the bathroom to wet the washcloth and was watching the resident through the crack of the bathroom door. The NA turned off the water and heard the resident fall. The report revealed the physician and the resident ' s responsible party were notified. A nurse ' s note dated 12/23/16 at 5:12 PM revealed Resident #3 had a fall and was noted to have a laceration to the head, the physician was notified and orders given to send the resident to the Emergency Department (ED). A nurse ' s note dated 12/23/16 at 8:20 PM revealed the resident returned to the facility from the ED where the resident received 4 staples to a laceration of the head. The Care Plan for Resident #3 was updated on 12/23/16 for Resident #3 to be transferred with 2 persons with the stand-up lift. On 1/12/17 at 1:30 PM an interview was conducted with the Director of Nursing (DON). The DON stated it had been their policy to use one person for transfers with the stand-up lift and referred to the manufacturer ' s instructions. The DON stated as of January 1, 2017 the policy had changed and transfers with a mechanical lift were to be done with 2 persons. The DON stated the NA involved in the transfer had worked at the facility a long time and prior to the incident on 12/23/16 had received education and had given a return demonstration on correctly using the stand-up lift to transfer residents. The DON stated the NA had the resident in the stand-up lift and the resident had a large bowel movement and the NA stepped away to the bathroom to wet the washcloth and was watching through the crack in the bathroom door and looked away for a minute and the NA heard the resident fall. On 1/12/17 at 3:19 PM an interview was conducted with NA #1 who transferred Resident #3 with the stand-up lift on 12/23/16. The NA stated she had transferred the resident with the stand-up lift many times in the past and had never had any problems. The NA further stated she went to put the resident in bed and had put a gown on the resident while she was sitting in the wheelchair. The NA stated she applied the lift sling to the resident as usual and lifted the resident to a standing position with the resident holding on to both handle bars on the lift. The NA stated she pulled the resident ' s pants down and saw the resident had had a large bowel movement. The NA stated she left the resident standing in the lift beside her bed and went in the bathroom to wet a washcloth so she could clean up the resident. The NA stated she was watching the resident through the crack in the door and turned to wring out the washcloth and heard the resident fall. The NA stated she did not understand what happened to cause the resident to fall but the resident was lying on the floor beside the bed and the sling was still attached to the lift. On 1/13/17 at 4:15 PM an interview was conducted with the Administrator and the DON. The DON stated since the incident, they had in-serviced most of the nurses and the NAs in transfers with the different kinds of lifts, how to use the different kinds of lifts and slings and demonstrated how to apply and operate the lifts with return demonstrations by the staff and stressed to them that all transfers with a mechanical lift were to be done with two people. The DON stated there were a few staff members left to be in-serviced and they would not be allowed to work until they had received the training. The DON stated they had audited all the residents in the building that were transferred with mechanical lifts and compared their transfer assessments to the care plan and to the NA Care Cardex. The DON stated they had developed an audit tool in their QA (Quality Assurance) meeting and had been monitoring 3 transfers a week and would continue to do this for 90 days. There was no information provided in the plan of correction regarding leaving a resident in a mechanical lift unattended. 2. Resident #6 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The resident ' s Care Plan initiated on 6/17/14 noted a self-care/mobility impairment with a revision on 1/10/12 that read: Transfer assistance of 1-2 use of mech (mechanical) lift. The Care Area Assessment (CAA) for Cognitive Status/Dementia dated 7/26/16 revealed the resident had long term memory impairment due to dementia and was oriented to person only. The CAA noted the resident was severely impaired for decision making and decreased safety awareness. The CAA for Falls noted the resident did not attempt to transfer self, had contractures of both lower extremities and was dependent on staff with the use of a mechanical lift. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 12/20/16 revealed the resident had short and long term memory loss and severe cognitive impairment with no behaviors. The MDS noted the resident required extensive assist with transfers with 2 persons and had impairment of both lower extremities. Review of the Resident Cardex Info sheet under transfers read: Maxi-lift. This lift was identified by the facility as a mechanical lift where the resident was lifted in a sling and transferred from one surface (i.e. bed) to another surface (i.e. wheelchair). On 1/12/17 at 10:28 AM NA #2 and NA #3 were observed to transfer Resident #6 from the bed to a reclining wheelchair. The two NAs physically picked up the resident and placed her in the wheelchair. On 1/12/17 at 12:50 PM an interview was conducted with the NA #2 who was assigned to care for the resident. The NA stated there was a sign at the head of the bed that told them what lift to use to transfer the resident. A small square of paper with bold letters read: ML. The NA stated that meant the resident was to be transferred with the Maxi-Lift. The NA was asked why she did not use the lift to transfer the resident and the NA stated: She only weighs 78 pounds. On 1/12/17 at 1:47 PM the Director of Nursing (DON) stated in an interview that the resident ' s Care Plan said to use 1-2 persons with the use of a mechanical lift and the Care Cardex said to use the Maxi-Lift. The DON stated the staff had been in-serviced and if the sign said ML (Maxi-Lift), that was how the staff should be transferring the resident. The DON stated the sign at the head of the bed was part of their plan of correction. 3. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident ' s Care Plan dated 8/13/14 noted a self-care/mobility impairment related to an old CVA with [DIAGNOSES REDACTED] (paralysis on one side), old right fractured humerus, arthritis and osteoporosis. The Care Area assessment dated [DATE] for Falls noted the resident was at risk for falls due to physical limitations, history of CVA and dementia with poor safety awareness and was dependent on staff for assistance with transfers. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 10/18/16 revealed the resident had severe cognitive impairment and no behaviors. The assessment revealed the resident required total assistance with transfers, was not ambulatory and was not steady and only able to stabilize with staff assistance during surface to surface transfers. The MDS revealed the resident had mobility impairment of one upper extremity and one lower extremity. The Care Plan for Resident #4 was updated on 12/31/16 for the resident to be transferred with a stand-up lift. The NAs ' Resident Care Cardex noted the resident was to be transferred with the stand-up lift. On 1/12/17 at 10:30 AM NA #2 was observed to provide care for Resident #4. Upon returning to the room at 10:55 AM the resident was observed to be sitting in a wheelchair in the room with the NA was still in the room providing care. There was not a lift observed in the hall or the room. NA #2 was asked how she transferred the resident and she stated she transferred the resident with the stand-pivot method. On 12/17/16 at 12:45 PM, NA #2 was asked how she knew how a resident was to be transferred and the NA stated there was a sign at the head of the bed that told staff how to transfer the resident. There was a small square of paper on the wall at the head of the resident ' s bed that read: SL (stand-up lift). The NA was asked why she did not use the stand-lift to transfer the resident and the NA stated: Because I had someone to help me and the resident could stand. On 1/2/17 at 1:42 PM the Director of Nursing (DON) stated until recently the resident was a stand/pivot transfer and was changed to a stand-up lift for transfers. The DON Stated the resident had gotten a little weaker and when the quarterly assessment was done the resident was assessed to be transferred with the stand-up lift. The DON stated the staff had just been in-serviced on mechanical lifts and the sign at the head of the bed was part of their plan of correction and the NA should have used the stand-up lift to transfer the resident.