Every finding on record at Fayette Health and Rehabilitation Center

Based on record reviews and interviews it was determined the facility staff failed to conduct a thorough investigation. This was evident for 1 (#2801571) of 5 facility reported incidents reviewed during the survey.The findings include: Facility reported incident #2801571 was reviewed on 4/9/26 at 12:00 PM. The report revealed that on 2/21/26, Resident #7 alleged that $150.00 was stolen by Geriatric Nursing Assistant (GNA) #8. The facility investigation documentation included 7 Resident Interview forms with questions regarding abuse (verbal, physical or sexual). All the boxes were checked No indicating the residents were never abused or witnessed abuse of another resident. There was no evidence that any residents, including Resident #7's roommate, were interviewed regarding missing property/money, having property/money go missing, or concerns related to GNA #8. During an interview on 4/9/26 at 1:35 PM the Director of Nursing (DON) informed the surveyor that the abuse questionnaire forms were the only interviews that were conducted during the investigation. He indicated that Resident #7's roommate was not asked if s/he witnessed or had any knowledge related to Resident #7's missing money allegation. When asked why residents weren't asked questions specific to the allegation, he stated that's what we were told to use.

Based on record review, observation and interviews it was determined that the facility staff failed to provide food that accommodated a resident's allergies, intolerances and preferences. This was evident for 1 (#10) of 14 residents reviewed during the survey. The findings include: Resident #10's record was reviewed on 4/10/26 at 12:26 PM. The resident's diagnoses included Type 2 Diabetes. A physician order was written 10/13/25 for Carbohydrate Controlled Diet (CCD), regular texture, thin liquids consistency, no salt packet. The resident's allergies which included shellfish derived product and caffeine, were included in multiple places throughout the medical record including the interdisciplinary plan of care and Geriatric Nursing Assistant (Kardex). During an interview on 4/10/26 at 12:42 PM Resident #10 indicated that s/he did not eat lunch because s/he did not like the meal that was provided. At approximately 1:20 PM Geriatric Nursing Assistant (GNA) #3 was observed at the doorway of Resident #10's room with the meal cart. She provided Resident #10's declined tray and ticket to the surveyor upon request. The ticket on the tray included Resident #10's name and CCD diet, and Allergies:*Shellfish Allergen*, Caffeine written in bold type. No salt packet, No Juice, No milk; were also noted. At that time GNA #3 asked Resident #10's roommate why s/he hadn't eaten his/her shrimp scampi. Upon hearing this, Resident #10 informed GNA #3 that s/he wanted shrimp scampi too. GNA #3 returned to the cart, removed another tray which contained shrimp scampi, and without reviewing the resident's ticket for his/her prescribed diet, dietary restrictions or allergies asked Resident #10 if s/he wanted the tray while walking toward Resident #10. The surveyor intervened, showed GNA #3 Resident #10's tray ticket pointing out his/her allergies. GNA #3 then informed Resident #10 that s/he was allergic to shellfish, Resident #10 stated it's crabs, not shrimp, I want shrimp scampi. GNA #3 proceeded to deliver the tray to Resident #10 despite a documented allergy to shellfish, and without referring the residents request to a nurse. GNA #3 then took a cup of apple juice from the top of the cart and began to take it to the resident but stopped after the surveyor called her attention to the Juice restriction on Resident #10's ticket. The Interim Director of Nursing (DON) was notified immediately of the above concern. In an interview on 4/10/26 at 2:07 PM the Dietary Manager indicated that shrimp scampi was the entree on the lunch menu, and if a resident had a seafood or shellfish allergy they would have been provided with a substitute entree which was country fried steak.

Based on record review and interviews it was determined that the facility staff failed to document administration of medication at the time of administration, in accordance with accepted professional standards and practices. This was evident for 1 (#10) of 14 residents reviewed during the survey. The nursing standard of practice for medication administration includes administering time critical medication (which includes insulin) within 30 minutes before or after the scheduled time; and real time charting of when the medication was administered. The findings include: Complaint #2796259 was reviewed on 4/13/26 at 11:26 AM for a concern regarding insulin administration. Resident #10's physicians orders and April 2026 Medication Administration Record (MAR) revealed the resident was prescribed Insulin Aspart 7 Units to be administered before meals at 6:00 AM, 11:00 AM, and 4:00 PM; Insulin Lispro to be administered before meals and bedtime at 6:00 AM, 11:00 AM, 4:00 PM and 8:00 PM with the dosage based on the resident's blood sugar readings; and Insulin Glargine 20 units to be administered at bedtime. A review of the time stamp which reflected when the medications were signed off as administered by the nurses, revealed insulin administration times from 1 hour 50 minutes to 6 hours 38 minutes after the scheduled time for 19 out of 80 insulin doses that were administered between 4:00 PM on 4/3/26 and 11:00 AM on 4/13/26. Additionally, the 4:00 PM and 8:00 PM Lispro insulin doses were signed off as administered at the same time on 4/3/26, 4/6/26 and 4/7/26. No documentation was found in the medical record to account for the deviation from the scheduled administration times.These findings were reviewed with the acting Director of Nursing (DON) on 4/13/26 at 12:15 PM. He was unable to provide any additional documentation or explanation. Interviews were conducted with 2 of the 4 nurses responsible for signing off the late insulin doses. In a telephone interview on 4/14/26 at 1:37 PM Registered Nurse (RN) #7 was asked about her process for administering and signing off insulin. She indicated that she administers the insulin on time but doesn't always sign it off as she gives it; and that she knows better than to do that. In an interview on 4/14/26 at 3:25 PM RN #6 indicated that sometimes he writes them down on paper and signs them off in the electronic MAR later. He indicated that he did not administer 2 doses of the same insulin together as reflected in the documentation, and the time stamps reflect when he signed the insulin off.

Based on Complaint #2625762, employee file reviews, and facility staff interviews, and facility documentation, it was determined that the facility failed to employ Licensed Practical Nurses in accordance with Maryland State laws. This was found evident for 2 (LPN #8 and LPN #14) out of 4 employees reviewed for appropriate licensures during the survey.The facility continued to employ LPN # 8 and LPN # 14 after the initial identification of non-recognized licensure on 4/3/24 through 11/21/25. Residents were at risk for improper care or negligence when their care was not provided by qualified licensed personnel, therefore The Maryland Office of Health Care Quality (OHCQ) determined this concern met the Federal definition of Immediate Jeopardy and the facility was notified in writing on 11/21/25 at 2 PM. The facility submitted a plan for removal of the immediacy on 11/21/25 at 7:20 PM and it was accepted by the state agency at 7:30 PM. The deficient practice remained with the potential for more than minimal harm at a scope and severity of E. The findings include:On 11/19/25 at 7:15 AM, the surveyor reviewed complaint #2625762 which alleged that licensed practical nurse (LPN) #8 was employed as an LPN at the facility without an active license.Surveyors identified that LPN #8 was not licensed to be employed as an LPN during a Recertification survey on 4/3/24 and cited F839. Review of LPN #8's personnel file revealed that she/he currently does not have licensure to practice in Maryland as an LPN.The state of Maryland's Board of Nursing (MBON) does not recognize LPN #8 license due to graduation from a program that is not recognized and approved by the Board.A record review on 11/20/25 at 7:30 AM of LPN #8's personnel file, provided by the Human Resources Representative (HR rep) on 11/19/25 at 11:30 AM, showed LPN #8's State Identification Card issued in Virginia. LPN #8's personnel file also listed his/her primary address as Maryland.An Interview with the Nursing Home Administrator (NHA) on 11/21/25 at 8:20 AM revealed that LPN #8 did not have a primary residence in Virginia. The NHA stated that per conversation with LPN #8 on 11/20/25, LPN #8 could not verify that LPN #8 held primary residence in Virginia since 2022. The Virginia issued state identification card showed that it was issued on 05/10/2024, however, the surveyor requested documentation to show that LPN #8 met the Compact State Licensure requirement to show he/she declared Virginia as his/her primary state of residence. The NHA stated that she will call LPN #8 to retrieve all needed documents.On 11/21/25 at 8:30 AM the surveyor conducted a follow up interview with the NHA. The NHA stated that LPN #8 had difficulty attaining a Maryland LPN license due to the closing of the institution where LPN #8 gained her practical nursing education and thus was not able to retrieve his/her transcripts. The surveyor requested the name of the institution and the suggested name was confirmed by LPN#8.During the interview, the surveyor conducted research on MBON's website which revealed that on 11/05/20, this college's Practical Nursing Program graduates receive Maryland LPN licensure because the college's practical nursing program did not meet minimum qualifications for full Practical Nursing licensure in Maryland.The surveyor reviewed MBON's notice about college with the NHA and the NHA stated that effective immediately, he/she would remove LPN #8 from the schedule.On 11/21/25 at 12: 45 PM the surveyor reviewed the facility's statement of deficiencies from their recertification survey dated 4/3/24. The review revealed that the facility was cited for not employing licensed staff according to Maryland State law and LPN #8 was identified as a staff member under that citation.Further review of the facility's plan of correction and credible evidence revealed the facility alleged they met compliance by:- Staff #13 {currently identified as LPN # 8} had moved back to Virginia as their state of primary residence-The HR Director will audit all employee files for appropriate licensure status. Findings will be corrected as appropriate.- Regional HR Director will re-educate the facility's HR Director regarding licensure audit and the use of the electronic portal to track license expirations and Primary State of Residence changes that might affect licensure.- A photocopy of staff #13's {now LPN #8} LPN license issued by Virginia Board of Nursing on 10/29/21with an expiration date 12/21/26.The facility was aware of this deficient practice from 4/3/24 through 11/21/25. The facility failed to correct the deficiency. Residents were at risk for improper care or negligence when their care was not provided by qualified licensed personnel, therefore an Immediate Jeopardy was determined on 11/21/25 at 2 PM. On 11/21/25 at 2:05 PM the surveyors conducted an in person interview with the NHA and Regional Director of Clinical Operations (RDCO) who were notified of the identified Immediate Jeopardy and findings, verbally and in writing, at that time. The surveyors remained at the facility until an acceptable abatement plan was confirmed.On 11/21/2025 at 2:51 PM the surveyor interviewed LPN #8 via telephone call, who confirmed his/her first and last name and stated that he/she worked at the facility since May 2022 as an LPN. LPN #8 continued to state that their primary state of residence was Maryland for several years and that he/she did not know that they were required to obtain a Maryland LPN license since he/she resided in Maryland.On 11/21/25, at 4:30 PM, surveyors reviewed the documentation related to licensure audits conducted by the facility as part of their plan of correction from a survey on 4/3/24. The review revealed the facility identified LPN #14's licensure was captured as a compact LPN license without compact status verification at that time. The surveyor shared this info with the NHA and RDCO at the time of discovery.On 11/21/25 at 6:25 PM the NHA and RDCO submitted their abatement plan for the identified practice. This plan was rejected, and the facility submitted a revised abatement plan on 11/21/25 at 6:45 PM. The surveyors reviewed the plan, and it was accepted on 11/21/25 at 7:20 PM.On 11/21/25 at 7:35 PM the NHA verbally confirmed, during interview with the surveyors, that LPN # 8 was not in the building, and not on the schedule moving forward.On 11/24/25 at 7:30 AM the surveyors reviewed the facility's Plan of Correction which stated:- LPN #8 was removed from the schedule after discovery on 11/21/25- The facility Human Resources representative will audit all licensed nurses' employee files to validate that the nurse has an active Maryland license via the Maryland Board of Nursing Lookup or if they do not have a Maryland license that they have an active Compact License status and have on file the required documentation for compact status by 11/21/25.- Facility Human Resources representatives will be educated on 11/21/25 by the regional Human Resources Director on the process to validate employees' licenses for Maryland and compact state.- Facility Human Resources' representative will ensure there is required documentation included in the employees' file to validate their compact status. This evidence may include but is not limited to a current: (a) driver's license with a home address; (b) voter's registration card with a home address; (c) federal income tax return with a primary state of residence declaration; (d) military form np. 2058 (state of legal residence certificate); (e) from the United States government or any bureau, division, or agency thereof, indicating residence.On 11/24/25 at 7:45 AM the surveyor began to verify the plan of correction. An interview was conducted with the NHA who confirmed that LPN #8 was instructed to not return to the building and was taken off schedule.On 11/24/25 at 8:30 AM the surveyors reviewed the facility's audit of all currently employed licensed staff. The review revealed that LPN #8 and LPN #14 were identified as nurses who held LPN licenses issued in Virginia, and their compact status requirements were not verified.On 11/24/25 at 11:39 AM the surveyor continued to verify the plan of correction on the abatement plan. The surveyor interviewed LPN #14 and asked LPN #14 what his/her role at the facility was, what licensure they currently held, and where he/she primarily resided. LPN #14 replied: I am an MDS Coordinator with my LPN licensure issued in Virginia. I live in Maryland 5 days a week and I file my taxes in Maryland. I vote in Maryland.On 11/24/25 at 12:00 PM the surveyor interviewed the NHA who confirmed that LPN #14's compact status documentation had not yet been received from LPN #14. The surveyor advised the NHA that the alleged date of compliance the facility listed on the abatement plan was in fact not 11/21/25, since they failed to verify LPN #14's documentation on 11/21/25. The NHA and the RDCO then revised the abatement plan and submitted it to the survey team on 11/24/25. The survey team accepted the plan with the additional information as required.The survey team returned to the facility on [DATE] and began to verify the plan of correction for the 11/24/25 abatement plan.The amended abatement plan stated: - LPN number 8 was removed from schedule after discovery on 11/21/25. LPN #14 was removed from schedule after discovery on 11/24/25.- Facility Human Resources representative will audit all licensed nurses' employee files to validate that each nurse has an active Maryland license via the Maryland board of nursing license lookup or if they do not have a Maryland license that they have an active compact license status and have on file the required documentation for compact status by 11/24/25.- Facility Human Resources representatives will be educated on 11/21/25 by the Regional Human Resource Director on the process of validating these licenses for main compact state.On 11/24/25 at 12:45 PM The NHA verbally confirmed that LPN #14 was taken off the schedule.

Based on observations and interviews it was determined that the facility staff failed to ensure that residents had their call bells to notify the staff when assistance was needed. This deficient practice was evidenced in 9 (#16, #27, #48, #51, #52, #69, #89, #112, & #116) of 33 residents screened on Patuxent Hall during the recertification survey.The findings include:On 11/18/25 at 7:30 am during observation rounds on Patuxent Hall the surveyor observed Resident #116 call bell clipped onto the cord on the wall. The resident was in bed. At 7:39 am the surveyor observed Resident #51 in bed with their call bell hanging from the cord on the wall. At 7:42 am Resident #48 call bell was on the floor near the head of the bed and Resident #16 call bell and bed control was on the floor under the head of the bed. At 7:47 am Resident #27 call bell was clipped to the cord on the wall and resident #89 call bell was on the bedside table and the resident was unable to reach the call bell. At 8:03 am Resident #112 call bell was on the floor on the left side of the bed. At 8:15 am the surveyor observed resident #69 did not have access to their call bell. At 8:17 am Resident #52 call bell was clipped on the cord hanging from the wall.On 11/20/25 at 9:20 am the surveyor reported to the Administrator their were multiple resident's located on Patuxent hall who did not have access to their call bell.On 11/24/25 at 11:22 am the surveyor asked Geriatric Nursing Assistant (GNA) # 29 to describe their typical morning when their shift starts. GNA #29 verbalized after receiving their assignment, rounds are completed to make sure the residents are alright. During rounds they make sure each resident has their call bell.

Based on observations and interviews it was determined that the facility staff failed to 1) store and process linen properly and 2)maintain effective infection prevention practices. This deficient practice had the potential to affect all the residents who were in the facility during the recertification survey.The findings include: On 11/20/25 at 10:30 am during a tour of the laundry facilities the surveyor observed clean linen in the laundry area that was not covered, clean linen in the hallway outside the laundry area that was not covered and there were multiple soiled tiles in the laundry storage room. The surveyor observed particles from the tile on the clean laundry. On 10/20/24 at 10:35 am during an interview with Environmental Services Manager #20 verbalized the clean and dirty laundry should not be in the same room and the clean laundry should be covered. Laundry Aid #21 verbalized they were multitasking, and they were about to put the laundry away. On 11/20/25 at 11:56 am Health Services Group District Manager #22 verbalized the linen in the storage room was not covered before the tiles were changed but the covered the linen before the work was done. The surveyor reported that particles were observed on the clean linen. On 11/20/25 at 9:30 AM the surveyor conducted a tour on the third floor with the Nursing Home Administrator (NHA) and the Director of Maintenance. We visited room [ROOM NUMBER] and the surveyor observed: a trash bin on top of a chest of drawers, several used, wet, white washcloths hanging on a bar in the ensuite bathroom. The surveyor also observed that the bathroom was a shared bathroom for up to 6 female residents. The NHA stated that the trash should have been on the floor and never on top of any other surface and the used washcloths were to be placed in the soiled linen bin. On 11/20/2025 at 10:47 AM the surveyor conducted an interview with the Infection Preventionist. The surveyor explained the previous observations made while on tour of the third floor and he/she stated that the expectation is that the washcloths were to be put out for laundry the same day and staff are to conduct frequent rounding to residents' rooms to collect soiled or used linens to be laundered.

Based on observations and interviews it was determined that the facility staff failed to maintain a comfortable, clean and homelike environment for the residents as evidenced of residents not having pillows and residents' clothing not being stored in the closet or armoire. This deficient practice was evidenced in 5 (#116, #40, #51, #27, & #89) of 33 residents residing on Patuxent Hall during the recertification survey.The findings include:On 11/18/25 at 7:30 am during observation rounds the surveyor observed Resident #116 clothes on top of a tall grey basket. There was a soiled gown and a blue article of clothing on the floor in the shared bathroom. At 7:34 am Resident #40 was in bed sleeping and there were two pair of black sweatpants and grey sweatshirt on the right side of the bed on the floor. At 7:39 am the surveyor observed Resident #51 in bed without a pillow. At 7:45 the surveyor observed a large clear plastic bag with clothing on the floor in room [ROOM NUMBER]. At 7:47 am the surveyor observed Resident #27 & Resident #89 in bed without pillows. At 8:07 am the surveyor observed a large black garage bag on the floor in room [ROOM NUMBER].On 11/25/25 at 11:15 am the surveyor reported the findings to Assistant Director of Nursing (ADON) #2. ADON #2 verbalized every resident should have their clothing in the closet, but extra clothing could be taken to storage.On 11/25/25 at 11:45 am Licensed Practical Nurse #27 verbalized every resident should have a pillow. They have plenty of pillows in Central Supply.

Based on record review and interviews it was determined that the facility staff failed to generate person centered care plans for a resident with Dementia, two residents with visual disturbances, and a resident who needed to wear a helmet to protect their brain while out of bed. This deficient practice was evidenced in 2 ( #12, #91) of 5 resident records reviewed for care plans during the recertification survey.The findings include:On 11/19/25 at 8:53 am, during an interview with Resident #12, the resident verbalized their vision was blurred. A review of the resident's diagnoses revealed the resident had a history of Primary Open Angled Glaucoma. A review of the residents' care plans revealed there was not a care plan initiated for vision.On 11/21/25 at 11:12 am, during an interview with the Director of Nursing (DON), the surveyor asked how they ensure residents receive vision care. The DON verbalized Health drive comes to the facility; they have a list of residents that need vision or dental and they will schedule an appointment to come into the facility. The surveyor reported Resident #12 had a history of Glaucoma with blurred vision; the resident did not have a care plan for vision. On 11/25/25 at 12:32 pm, a review of Resident #91 electronic medical record (EMR) revealed the resident's last eye exam was done by Health Drive on 07/24/24 with a recommendation of new glasses. A review of the residents' diagnoses revealed the resident had a history of blindness in one eye. The diagnosis was dated 11/01/24. Further review of the EMR revealed a care plan for the resident's impaired vision was not initiated.During an interview with the Administrator, the surveyor reported the resident was supposed to receive glasses last year and the resident did not have a care plan for impaired vision. The Administrator verbalized the residents are usually seen yearly. The Administrator verbalized an appointment would be made with Health Drive for Resident #91 to receive vision care.On 11/26/25 at 12:57 pm, the surveyor spoke with Resident #91 in their room. The surveyor asked the resident how their vision was and did they receive glasses as recommended during their last eye exam. Resident #91 verbalized being blind in their right eye and their vision was blurred in the left eye due to a cataract. Also, the resident verbalized they never received glasses.

Based on medical record review and interviews it was determined that the facility staff failed to complete quarterly care plan meetings. This deficient practice was evidenced in 1 (#96) of 2 resident records reviewed for care plan meetings during the recertification survey.The finding include:On 11/21/25 at 12:11 pm during an interview with Social Services Director #30 the surveyor asked to explain the process of care plan meetings. Social Services Director #30 verbalized care plan meetings are set up twice a week, on Mondays and Wednesday for long-term care residents. They reach out to the representative for the meeting; they meet in person or via phone. Each department who is related to the resident care attends the meeting. The long-term care meetings are held quarterly and annually. They also have meetings upon request and if there is a significant change as well. On 11/25/25 at 9:42 am a review of Resident #96 electronic health record (EHR) revealed there were no documented care plan meeting notes from 03/20/23-07/24/25. On 11/25/25 12:21 pm the surveyor asked the Administrator to verify if Resident #96 had any care plan meetings. At 1:26 pm the regional Director of Clinical Services verified the resident did not have any care plan meetings and that a house wide audit will be completed.

Based on record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by a resident received hospice care for 12 days without a physician order, the facility staff failed to coordinate the residents' care with the hospice nurse, and a resident was prescribed psychotropic medication without behavioral monitoring or monitoring for extrapyramidal side effects. This deficient practice was evidenced in 1 (#43) of 1 hospice record reviewed and 1 (#10) of 2 records reviewed for extrapyramidal side effects/behavioral monitoring during the recertification survey.The findings include:On 11/19/25 at 8:16 am a review of Resident #43 electronic health record revealed the resident was receiving hospice care with Adoration Hospice. The consent for hospice care was signed 03/14/25. A review of the residents' orders revealed an order was written for hospice care on 03/26/25. Licensed Practical Nurse #31 verbalized the hospice nurse comes to the facility to see the resident twice a week. A review of the paper chart revealed there were no hospice notes in Resident #43 medical record. On 11/21/25 at 10:18 am during an interview with the Director of Nursing (DON) he/she verbalized the patient was already admitted to hospice and they have their own physician in house. They write their own orders and run them by in-house physician. The staff communicate with the hospice nurse by telephone and sometimes they send email. When Resident #43 was admitted he/she was not working in the facility. There was no documentation to verify the staff was communicating with the hospice nurse and there was no order written before the resident received hospice care. On 11/20/25 at 3:40 pm a review of Resident #10 medication administration record (MAR) revealed on 10/24/25 at 6:00 pm the resident was prescribed Risperidone 1 mg by mouth (PO) in the evening for Schizophrenia with dinner. The medication was discontinued on 11/11/25 at 9:21 am. On 11/11/25 at 5:00 pm the resident was prescribed Risperdal 0.5 mg PO daily for Psychosis. Further review of the EHR revealed the resident was not being monitored for extrapyramidal side effects or behavioral monitoring. On 11/20/25 at 4:15 pm the Regional Director of Clinical Services confirmed Resident #10 was not being monitored for extrapyramidal side effects and the staff was not receiving behavioral monitoring.

Based on medical record review, observation and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing podiatry services to get their toenails trimmed on a regular basis. This was evident for 1 of 30 (#119) residents reviewed during the survey process. The findings include:Resident #119 reported that their toenails were extremely long and uncomfortable. He stated he hadn't seen a podiatrist in a while and that the podiatrist tried to break their toenails off instead of trimming them. The resident said that they had told that podiatrist he didn't want to see them again but wanted another podiatrist. The resident stated that they had not had their toenails cut since then and that they were very long. The resident also stated that they were diabetic and knew they should take care of their feet.The surveyor reviewed the medical record and only found one podiatry consult note dated 2022. There was a doctor's order for podiatry consults as needed. The surveyor interviewed the ADON who stated they would review the hard copy chart for possible consult documentation and come back later saying they could not find any. The ADON stated the resident would be put on the podiatry list to be seen the next time the podiatrist was visiting.

Based on record review and interviews it was determined that the facility staff failed to ensure residents who had impaired vision received vision care and a recommended assistive device. This deficient practice was evidenced in 2 (#12 & #91) of 2 resident records reviewed for vision services during the recertification survey.The findings include:On 11/19/25 at 8:53 am, while interviewing Resident #12, they verbalized their vision was blurred. A review of the resident's diagnoses revealed the resident had a history of Primary Open Angled Glaucoma.On 11/21/25 at 11:12 am during an interview with the Director of Nursing (DON) the surveyor asked how they ensure residents receive vision care. The DON verbalized Health Drive comes to the facility; they have a list of residents that need vision care, and they will schedule an appointment for them to come into the facility. The surveyor reported Resident #12 had a history of Glaucoma with blurred vision.On 11/25/25 at 12:32 pm a review of Resident #91 electronic medical record (EMR) revealed the resident's last eye exam was done by Health Drive on 07/24/24 with a recommendation of new glasses. A review of the residents' diagnoses revealed the resident had a history of blindness in one eye. The diagnosis was dated 11/01/24. During an interview with the Administrator the surveyor reported the resident was supposed to receive glasses last year. The Administrator verbalized the residents are usually seen yearly. The Administrator verbalized an appointment would be made with Health Drive for Resident #91 to receive vision care.On 11/26/25 at 12:57 pm the surveyor went to speak with Resident #91 in their room. The surveyor asked the resident how their vision was and did they receive glasses as recommended during their last eye exam. Resident #91 verbalized being blind in their right eye and their vision was blurred in the left eye due to a cataract. Also, the resident verbalized they never received glasses. On 11/26/25 at 1:00 pm the surveyor asked Licensed Practical Nurse # 17 if they ever saw Resident #91 wearing glasses. LPN # 17 verbalized they do not recall seeing the resident wearing glasses.

Based on record review and interviews, it was determined that the facility failed to ensure that Nephrostomy drainage bag care was provided to a resident with a Nephrostomy . This was evident for 1 (#4) of 1 resident reviewed with a Nephrostomy. The findings include: On 11/24/2025 at 11:08 AM, during the initial interview of Resident #4, they stated that the staff did not empty or change their nephrostomy drainage bag and that they were forced to take care of it themselves and that their family provided the bags. On 11/24/2025 at 1:15 PM during a record review, it was noted that on the Task Administration Record (TAR) there is no documentation of the resident's urostomy bag being emptied and changed. On 11/24/2025 at 2:00 PM, The Director of Nursing (DON) was interviewed and he/she stated the urostomy bag was being changed but the staff was not documenting it. The DON was asked that if it wasn't documented how could they be sure that the change had been made and just as importantly how could the facility prove it had been done. The DON acknowledged that they couldn't.

Based on observations and interviews with facility staff, it was determined that the facility failed to maintain proper infection control procedures while serving breakfast. This was evident during the annual rectification survey. The findings include:On November 20, 2025, at 9:06 AM, the surveyor observed Staff #5, a Dietary Aid, while preparing beverages on clean trays for breakfast. Staff #5 knocked a tray onto the floor, then picked up the tray along with the silverware, napkin, and beverages from the floor. Staff #5 placed these items back on the tray and then positioned the fallen tray beside the clean trays on the serving line. Staff #6, another Dietary Aid, informed Staff #5 that this was unacceptable and removed the tray. No staff member cleaned the counter after the fallen tray was removed from beside the clean trays. Staff continued to serve breakfast, sliding clean trays down the service line over the area where the dirty tray had been. Staff #3, the Dietary Manager, was made aware that a tray fell and was picked up with the silverware and beverages, and that the items were placed on the clean serving area. Staff #3 immediately stopped the serving process, removed the trays, and placed them in an area for cleaning. Staff #3 then sanitized the countertop on the service line in the serving area before serving resumed.On November 20, 2025, at 9:15 AM, Staff #3, the Dietary Manager, and Staff #4, the District Manager for Health Care Service, were interviewed and asked if standard practice permits picking up a tray that has fallen on the floor, picking up food and utensils from the floor, and continuing to serve. Both Staff #3 and Staff #4 confirmed that this action was against protocol and presented an infection control risk.

Based on observations and interviews it was determined that the facility staff failed to maintain the facility in a safe operating condition as evidenced by the heating/AC unit front in a resident's room was on the floor, damaged drywall in residents' rooms, a sink wasn't secured to the bathroom wall, holes in residents' bathroom door, an electrical plate was not secured to the wall, a bed control had exposed wires, an armoire with dry rotten wood, damaged tile in the shower room, a hole in the wall in the laundry room & damaged floor tile, multiple soiled ceiling tile in the stored linen room. This deficient practice was discovered in different areas in the facility during the recertification survey.The findings include:On 11/18/25 at 7:30 am during observation rounds the surveyor observed the front of the heating/AC unit was on the floor in room [ROOM NUMBER]. In the shared bathroom in room [ROOM NUMBER] the surveyor observed holes in the bathroom door. At 7:43 am while in room [ROOM NUMBER] the electrical outlet plate was not secured to the wall behind Bed-A. The wood to the armoire was dry rotted in room [ROOM NUMBER]. At 7:55 am while in room [ROOM NUMBER], the surveyor observed damaged drywall, corner bead exposed in the bathroom, and the sink was not secured to wall. At 8:08 am the Central Spa Room located on Patuxent Hall had damaged tile near the drain. At 8:21 am the surveyor observed the armoire in room [ROOM NUMBER] had missing wood trim. On 11/20/25 at 9:21 am during an interview with Maintenance Director #16 the surveyor asked what process is in place to notify maintenance when repairs are needed. Maintenance Director #16 said they have TELS which is a website the staff uses to notify maintenance of problems, and they use word of mouth. The surveyor asked if there is a preventative maintenance schedule. They have a list of things that must be done weekly and monthly. They have tasks that must be completed by the end of the week. They have two techs that assist with maintenance repairs; each is assigned a floor. On 11/20/25 at 9:28 am the surveyor reported the maintenance concerns with Maintenance Director #16 and the Administrator. They were shown pictures to verify the concerns. On 11/20/25 at 10:30 am during a tour of the laundry area the surveyor observed damaged drywall behind the sink, holes in the wall, the eyewash station was not installed, the pipe insulation was damaged, and there were damaged floor tiles. The room where the linen was stored had at least four heavily soiled ceiling tiles and the pipe insulation was soiled.

Based on observations and interviews it was determined that the facility failed to keep a sanitary environment. This was evident for 2 of 2 Residents (Residents # 64 and # 72) rooms observed during the annual recertification survey.The findings include:On 11/18/2025 at 11:27 AM, during the initial observation, a fly strip containing several dead flies and other insects was observed suspended from a cork bulletin board positioned directly above Resident #64's bed. Resident #64 was lying in bed, asleep, beneath the fly strip at the time of the observation.On 11/19/2025 at 10:34 AM, Staff #7, a Licensed Practical Nurse (LPN), was interviewed about the item hanging from the cork bulletin board above Resident #64's bed. Staff #7 identified the item as a fly strip/trap, explaining that Resident #64 had previously complained about flies in the room. When asked about the dead insects on the strip, Staff #7 confirmed, stating, there are dead flies and bugs stuck on the fly trap/strip above the residents bed. Staff #7 acknowledged that having a fly trap with dead insects in the resident's room was unsanitary. Staff #7 then put on gloves and removed the fly trap.On 11/19/2025 at 1:37 PM, a separate surveyor observed a fly strip attached to the cork bulletin board above Resident #72's head. Dead flies were noted adhering to the fly strip. Resident #72 reported experiencing an issue with bugs in their room as well. Maintenance personnel were notified, and the fly strip/trap was subsequently removed.

Based on medical record review and interview, it was determined that the facility's nursing staff failed to ensure that an newly admitted resident (resident #17) had a complete discharge summary from the local hospital. This failure to have a complete discharge summary from the local hospital led to the facility being unsure if they had the complete list of medications needed for the resident's care. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey. The findings include:On 8/12/25 at 8:00am, the surveyor reviewed complaint MD00210531/ IQIES 342276 which alleged that the facility failed to provide continuous oxygen to resident #17 when he/she was admitted to the facility on the evening of 10/3/24. Resident #17 had a family member call 911 for assistance and the resident was transferred to the local hospital on [DATE]. On 8/12/25 at 8:10am, surveyor review of resident #17's medical records revealed the resident was admitted from the local hospital with a portable oxygen tank that was administering 3 liters of oxygen though a nasal cannula. Further review of the medical record revealed that the resident complained of the tank being empty at 11:15pm on 10/3/24. The oxygen tank was replaced and the resident's oxygen saturation levels were measured at 98%. Continued review of resident #17's medical record on 8/12/24 at 8:45am revealed that an emergency transport (911) came to the facility on [DATE] at approximately 4:30am to transport the resident to the local hospital after the resident's family called for assistance. Facility nursing staff assessed the resident and discovered that the resident's oxygen saturation level was 84%. Facility nursing staff exchanged the nasal cannula with a re-breather mask. The resident's oxygen saturation level remained at 84%. The resident was transferred to the local hospital for treatment. Further review of resident #17's medical record on 8/12/24 at 9:00am revealed that the nursing staff consulted a telehealth provider on 10/3/24 at approximately 11:30pm to reconcile the medication list provided on the discharge summary and to order medications necessary for the resident's stay. The provider ordered a breathing treatment that was listed on the resident's discharge summary that was needed every 8 hours. Surveyor review of resident #17's discharge instructions on 8/13/24 at 2:30pm revealed the scanned document was not complete. The surveyor observed that the document was split between two scanned documents. The 1st part of the discharge summary was pages 1-17. The second part of the discharge summary was pages 18-36. The surveyor observed that the 2nd part of the discharge summary was missing pages 21-24 and 25-26. Surveyor review of resident #17's orders revealed no evidence of an oxygen administration order. Surveyor interview of LPN #45 on 8/13/25 at 3:15pm revealed that LPN #45 did not remember resident #17 even after the surveyor reminded LPN #45 that he/she wrote the resident's change in condition note 10/4/24. He/she stated that when new residents are admitted to the facility, the admitting nursing staff would assess the resident for the admission records. If the resident came to the facility after the providers left the facility for the day, nursing staff would call the telehealth provider (Convergence) to verify the medications from the hospital discharge summary, if necessary. The telehealth provider would also order any medications needed for the resident at that time. Surveyor interview of RN #46 on 8/13/25 at 3:55pm revealed that RN #46 also did not remember resident #17 even after the surveyor reminded RN #46 that he/she wrote the admission note on 10/3/24. The surveyor asked RN#46 why would an admitting resident be using an oxygen tank instead of an oxygen concentrator. RN#46 stated that the oxygen tank would be used during the initial assessment of the resident and eventually switched to an oxygen concentrator after the assessment by the provider. During an interview of the Executive Director (ED), Director of Nursing (DON), and Regional Clinical Director #44 on 8/13/25 at 4:15pm, the surveyor stated that a review of resident #17's medical record revealed that the resident did not have an oxygen administration order and the local hospital's discharge summary was missing pages in the scanned version of the discharge summary. The ED stated that the resident's paper records would be searched for the complete discharge summary and the oxygen order. The surveyor asked the group if nursing staff were responsible for ensuring that any discharge summaries were complete. Regional Clinical Director #44 confirmed that it is a shared responsibility for nursing staff and providers to ensure that a resident's discharge summaries are complete. Regional Clinical Director #44 also stated that every resident that required oxygen must have an order for oxygen administration. On 8/14/25 at 9:00am, interview of the ED, DON and Regional Clinical Director #44 confirmed that resident #17's medical records failed to contain an order for oxygen administration and a complete discharge statement from the local hospital. The ED also confirmed that the nursing staff and the provider failed to confirm that the discharge summary from the hospital was complete. The ED also confirmed that the telehealth provider failed to issue an oxygen administrator order for the resident after chart evaluation. The ED then stated that after surveyor intervention, the facility completed an audit of residents that were admitted in the last 30 days with oxygen to ensure that all of these residents had oxygen administration orders. Nurses were re-educated on the importance of ensuring that residents that are admitted with oxygen have a oxygen administration order as needed.

Based on medical record review and interview, the facility's nursing staff and telehealth provider failed to ensure that a newly admitted resident with respiratory issues (resident #17) had an order for oxygen administration. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey. The findings include:On 8/12/25 at 8:00am, the surveyor reviewed complaint MD00210531/ IQIES 342276 which alleged that the facility failed to provide continuous oxygen to resident #17 when he/she admitted to the facility on the evening of 10/3/24. Resident #17 had a family member call 911 for assistance and the resident was transferred to the local hospital on [DATE]. On 8/12/25 at 8:10am, surveyor review of resident #17's medical records revealed the resident was admitted from the local hospital with a portable oxygen tank that was administering 3 liters of oxygen though a nasal cannula. Further review of the medical record revealed that the resident complained of the tank being empty at 11:15pm on 10/3/24. The oxygen tank was replaced and the resident's oxygen saturation levels were measured at 98%. Continued review of resident #17's medical record on 8/12/24 at 8:45am revealed that an emergency transport (911) came to the facility on [DATE] at approximately 4:30am to transport the resident to the local hospital after the resident's family called for assistance. Facility nursing staff assessed the resident and discovered that the resident's oxygen saturation level was 84%. Facility nursing staff exchanged the nasal cannula with a re-breather mask. The resident's oxygen saturation level remained at 84%. The resident was transferred to the local hospital for treatment. Further review of resident #17's medical record on 8/12/24 at 9:00am revealed that the nursing staff consulted a telehealth provider on 10/3/24 at approximately 11:30pm to reconcile the medication list provided on the discharge summary and to order medications necessary for the resident's stay. The provider ordered a breathing treatment that was listed on the resident's discharge summary that was needed every 8 hours. Surveyor review of resident #17's discharge instructions on 8/13/24 at 2:30pm revealed the scanned document was not complete. The surveyor observed that the document was split between two scanned documents. The 1st part of the discharge summary was pages 1-17. The second part of the discharge summary was pages 18-36. The surveyor observed that the 2nd part of the discharge summary was missing pages 21-24 and 25-26. Surveyor review of resident #17's orders revealed no evidence of an oxygen administration order. Surveyor interview of LPN #45 on 8/13/25 at 3:15pm revealed that LPN #45 did not remember resident #17 even after the surveyor reminded LPN #45 that he/she wrote the resident's change in condition note 10/4/24. He/she stated that when new residents are admitted to the facility, the admitting nursing staff would assess the resident for the admission records. If the resident came to the facility after the providers left the facility for the day, nursing staff would call the telehealth provider (Convergence) to verify the medications from the hospital discharge summary, if necessary. The telehealth provider would also order any medications needed for the resident at that time. Surveyor interview of RN #46 on 8/13/25 at 3:55pm revealed that RN #46 also did not remember resident #17 even after the surveyor reminded RN #46 that he/she wrote the admission note on 10/3/24. The surveyor asked RN#46 why would an admitting resident be using an oxygen tank instead of an oxygen concentrator. RN#46 stated that the oxygen tank would be used during the initial assessment of the resident and eventually switched to an oxygen concentrator after the assessment by the provider. During an interview of the Executive Director (ED), Director of Nursing (DON), and Regional Clinical Director #44 on 8/13/25 at 4:15pm, the surveyor stated that a review of resident #17's medical record revealed that the resident did not have an oxygen administration order and the local hospital's discharge summary was missing pages in the scanned version of the discharge summary. The ED stated that the resident's paper records would be searched for the complete discharge summary and the oxygen order. The surveyor asked the group if nursing staff were responsible for ensuring that any discharge summaries were complete. Regional Clinical Director #44 confirmed that it is a shared responsibility for nursing staff and providers to ensure that a resident's discharge summaries are complete. Regional Clinical Director #44 also stated that every resident that required oxygen must have an order for oxygen administration. On 8/14/25 at 9:00am, interview of the ED, DON and Regional Clinical Director #44 confirmed that resident #17's medical records failed to contain an order for oxygen administration and a complete discharge statement from the local hospital. The ED also confirmed that the nursing staff and the provider failed to confirm that the discharge summary from the hospital was complete. The ED also confirmed that the telehealth provider failed to issue an oxygen administrator order for the resident after chart evaluation. The ED then stated that after surveyor intervention, the facility completed an audit of residents that were admitted in the last 30 days with oxygen to ensure that all of these residents had oxygen administration orders. Nurses were re-educated on the importance of ensuring that residents that are admitted with oxygen have a oxygen administration order as needed.

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure residents received showers at least twice a week. This was evident for 4 residents (#81, #111, #116, and #28) out of 48 residents who were part of the survey sample. The findings include: 1) This surveyor interviewed Resident #81 on 3/18/24 at 9:19 AM. The resident stated that he/she has not had a shower in three days and needs one. Resident declared that he/she stinks. Resident stated that he/she has requested showers, but the staff say to just go even though the resident cannot physically go on his/her own. A review of Resident #81's clinical record revealed that the Geriatric Nursing Assistants (GNA) documented only providing bed baths for the resident during the months of February and March. This surveyor interviewed the Unit Manager (Staff #50) on 3/28/24 at 9:06 AM. The lack of showers and the resident's right to showers twice a week was discussed. The Unit Manager said he was not surprised that Resident #81 complained and that he would look into it. 2) Resident #111 was interviewed on 3/18/24 at 1:41 PM. Resident stated they have not been receiving showers. A review of Resident #111's clinical record revealed that the facility's Documentation Survey Report form showed the resident only received baths for the months of February and March. Nurse #13 was interviewed on 3/28/24 at 8:46 AM. She was asked about the resident's statement that they have not received any showers. She replied that the resident received a shower on Friday (3/22/24) and is scheduled to receive a shower on every Monday, Wednesday, and Friday. She repeated that the resident got a shower on Friday but refused one yesterday (3/27/24). This surveyor informed the Administrator and the Regional Director of Clinical Operations (Staff #20) on 4/2/24 of the findings. 3) Resident #116 was interviewed on 3/18/24 at 1:25 PM. Resident #116 stated that he/she has not had weekly showers and has had only one shower in the last 30 days. A review of the resident's clinical record on 3/22/24 revealed that the facility's Documentation Survey Report form showed the resident did not receive a shower in either February or March of 2024. This surveyor interviewed Staff #50 on 3/28/24 at 9:06 AM. He informed me that the previous Unit Manager quit recently but he thought that the resident can do things independently and is free to shower on own. Suggested the resident simply chose not to take showers. This surveyor informed him that the clinical record made no mention of the resident refusing to shower. 49815 4) On 3/17/24 at 12:29 PM the surveyor conducted an interview with Resident #28 who stated that he/she had received 2 showers since being admitted a year ago. Activities of Daily Living (ADL) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating. On 3/29/24 at 8:30 AM the surveyor reviewed the Geriatric Nursing Assistant (GNA) ADL flow sheets for bathing for the period of 12/29/23 through 3/28/24 for Resident #28. There was documentation that the resident received BB which indicated bed bath according to the POC Legend Report for this time period. Further review of the documentation of the ADL flow sheet did not indicate that the resident received a shower during this period. There was documentation of T on the date of 3/18/24 which indicated the resident received a tub bath according to the POC Legend Report. On 4/1/24 at 8:14 AM the surveyor interviewed Resident #28 again and the Resident stated that staff do not offer me showers and that I will take a shower if I get assistance. On 4/1/24 at 8:30 AM the surveyor reviewed the Potomac Hall 7-3 shower list provided by LPN (Licensed Practical Nurse) #6. According to the shower list Resident #28 was scheduled to receive showers on the 7-3 shift every Monday and Thursday. The surveyor interviewed Resident #28's assigned GNA #12 on 4/1/24 at 8:32 AM who confirmed that the resident had not routinely received showers as scheduled. GNA #12 stated that she wanted the residents to get a shower at least monthly. On 4/1/24 at 8:59 AM the surveyor interviewed LPN #6 who conveyed that if a resident refused a shower, the GNA should tell the nurse. Further review on 4/2/24 at 10:10 AM of Resident #28 medical records did not reveal any documentation that the resident refused showers. During an interview conducted on 4/2/24 at 10:23 AM, the Nursing Home Administrator (NHA) and Regional Director of Operations #20 confirmed that the facility expectation is that all residents should receive a shower twice a week. The NHA further stated that the GNAs are expected to document the shower on the ADL flow sheet.

Based on medical record review and interview it was determined that the facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain a proper resident's Advance Directive in the resident's medical record. This was found to be evident for 7 (Resident #27, #64, #61 and #111) out of 9 residents reviewed for advance directives. The findings include: Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that relays instructions between health professionals about patient care. MOLST certifies orders that were agreed to by a patient or a patient's health care agent as named in the patient's advance directive. MOLST determines resuscitation status and includes other 8 sections of treatment choices. An Advance Directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness. An advance directive may also give a person (such as a spouse, relative, or friend) the authority to make medical decisions. 1) During interview, on 03/19/24 at 04:15 PM, Resident #27's legal contact person/family member (per facility's facesheet) revealed that he/she could not remember that the facility staff had a completed MOLST nor an advance directive on admission but the facility had determined this family member as the legal contact person. Record review, on 3/20/24 at 10:31 AM, of Resident # 27's admission record revealed that the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depression, and dementia. During interview, on 03/20/24 at 02:34 PM, Social Worker Staff #16 revealed that Resident #27's advance directive information was built into the facility's internal face sheet section i.e., the legal contact person. Therefore, she was unsure if there was a MOLST or an advance directive on file from the admitted [DATE]. Requested Staff #16 to provide a copy of the MOLST and Advance Directive from the admission period. Record floor chart review, on 3/20/23 at 3:00 PM, revealed that a MOLST form completed on 9/7/23, it stated that Doctor Staff #61 had had a discussion as Resident #27 as he/she mentally competent and informed consent of the patient which it was a mistake. Not only was this MOLST form an error, but the facility staff also failed to comply with and implement a proper MOLST form and an advance directive on admission to avoid the mistake. During interview, on 3/21/24 at 1:37 PM, Staff #16 stated that MOLST form and Advance Directive had not been obtained during the admission period and that she had sent a blank form out yesterday to the legal contact person. Staff #16 admitted it was an omission on her part. During interview, on 3/21/24 at 2:07 PM, the Administrator was notified of the above findings and was made aware that there was a concern. 2) Record review, on 3/20/24 at 10:31 AM, of Resident #64's medical record revealed that the resident had resided at the facility for more than 11 months since 4/28/23. Facility staff identified that the resident needed a representative but no proper documentation of MOLST or Advance Directive were found. Further review of the medical record failed to reveal documentation of advanced directives or that a discussion about advanced directives had occurred with the resident's legal contact person. During interview, on 3/20/24 at 2:34 PM, Social Worker Staff #16 stated that she did not have the MOLST nor the advance directive completed on file because the facility was using their internal face sheet section instead. Record floor chart review, on 3/20/24 at 3:20 PM, unable to find a MOLST nor an advance directive in the medical chart. During interview, on 3/21/24 at 2:07 PM, the Administrator was notified that the facility failed to ensure that copies of the resident's MOLST form and advance directive were in the resident's medical record. After surveyor's interventions, on 3/20/24, facility staff had a MOLST and an affidavit for other relative as surrogate decision maker form completed. 14894 3) A review of Resident #61's clinical record on 3/18/24 revealed that the resident did not have an Advance Directive. Further review showed that the resident and/or their responsible party was not offered an Advance Directive to complete. The Social Work Director (Staff #16) was interviewed on 3/22/24 at 9:20 AM. Staff #16 said that most residents who are their own responsible party (RP) do not have one and that they do not ask them if they want to get one. She added that they have not always documented that in the residents' progress notes. This surveyor informed the Administrator and the Regional Director of Clinical operations (Staff #20) of the findings on 4/2/24 at 10:00 AM. Staff #20 said that the residents often refuse, and he would check to see if it was occurring in this case. 4) A review of Resident #111's clinical record revealed that there wasn't an Advance Directive present nor was there any evidence that facility staff offered to assist the resident with its completion. Further review revealed that on 3/22/24 at 9:03 AM the Social Worker wrote a note Writer spoke with resident about Advance Directive, resident stated [he/she's] well aware of what an Advance Directive is and is not interested in doing one at this time. This surveyor informed the Administrator and the Regional Director of Clinical operations (Staff #20) of the findings on 4/2/24 at 10:00 AM. Staff #20 said that the residents often refuse, and he would check to see if it was occurring in this case.

Based on medical record review and staff interview, the facility staff failed to provide adequate supervision to a resident, who received a recent Narcan administration. This was evident for 1 of 74 residents (Resident #41) reviewed during a complaint survey. As a result of these findings, an immediate jeopardy was declared on [DATE] at 12:00 PM and the immediate jeopardy tool was provided. The facility submitted several versions of a plan to abate the IJ that were rejected by the Office of Health Care Quality. The rejected plans to abate the IJ were submitted on [DATE] at the following times: 4:09 PM, 4:43 PM, 6:21 PM, 6:46 PM, 8:13 PM and 8:27 PM. The facility submitted the final plan to abate the IJ on [DATE] at 9:36 PM. On [DATE] at 10:00 PM, the facility's abatement plan was accepted by the Office of Health Care Quality. On [DATE] at 12:00 PM, after validation of the completion of the plan of correction, the Administrator was informed the IJ was abated. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at a scope and severity of G. The findings include: A review on [DATE] at 10:00 AM of Resident #41's closed medical record revealed the resident was admitted to the facility on [DATE] for orthopedic aftercare after left knee joint replacement surgery. The facility determined on [DATE] that Resident # 41 had no cognitive impairments and was able to make decisions for his/her well-being. An additional review on [DATE] at 10:10 AM of Resident #41's closed medical record revealed the resident was found unresponsive on [DATE] at approximately 3:00 PM. Progress notes revealed the resident was revived with Narcan. Narcan is a drug that is used to treat an overdose of narcotics. A progress note from Behavioral Staff #17 revealed Resident #41 was interviewed after the unresponsive episode and the resident stated he/she took illegal substances because the facility failed to give him/her pain medication to alleviate the pain from the knee joint surgery. A review on [DATE] at 1:00 PM of Resident #41's closed medical record revealed progress notes from on-call Physician Assistant #34 dated [DATE] at 3:03 PM which stated the on-call Physician Assistant #34 ordered nursing staff to monitor the resident closely after the resident refused to go to the hospital after the first unresponsive episode on [DATE]. Additional review on [DATE] at 1:15 PM of Resident #41's closed medical record revealed a neurological evaluation document dated [DATE] which was used by nursing staff to document neurological evaluation of the resident after the unresponsive episode on [DATE] at approximately 3:00 PM. The neurological evaluation form required nursing staff to track the resident 's neurological and physical state. The neurological evaluation form required nursing staff to document resident observations and vital signs over 4 days and 19 hours in the following intervals: every 15 minutes for one hour, every hour for 4 hours, every 4 hours for 16 hours, then daily for 4 days. Resident #41's neurological evaluations started on [DATE] and facility nursing staff only documented two 15-minute intervals and both observations documented the time of the observations as [DATE] at 12:00 AM, before Resident #41's unresponsive episode on [DATE] at approximately 3:00 PM. Additionally, the documented 15 minute observations indicated the resident refused the neurological assessment. The resident's refusals were both documented as being done on [DATE] at 12:00 AM, which was before Resident #41's unresponsive episode on [DATE] at approximately 3:00 PM. The remaining neurological evaluations (hourly, every 4th hour and daily) stated that the resident was out of the facility and dated the observation as [DATE] at 12:00 AM. Based on the neurological evaluation form, the neurological observations should have started on [DATE] at approximately 3:00 PM. The hourly assessments should have started at approximately 4:00 PM. The four-hour assessments should have started at approximately 8:00 PM. The daily should have started on [DATE] at approximately 12:00 PM. Interview with LPN #33 on [DATE] at 1:45 PM revealed LPN #33 was the assigned nursing staff to Resident #41 on [DATE] from 7 AM-3 PM. LPN#33 stated the resident was found unresponsive in his/her wheelchair in his/her room on [DATE] at approximately 3:00 PM. LPN #33 attempted to unsuccessfully wake the resident then LPN #33 started CPR and used two doses of Narcan to revive the resident. The resident refused to speak to LPN #33 and immediately left his/her room and went to the elevator to go to the courtyard. LPN #33 also stated that he/she followed the resident with an iPad so On-Call Physician Assistant #34 could complete the telehealth assessment. The surveyor interviewed LPN #31 on [DATE] at 1:00 PM. The interview revealed LPN#31 worked on [DATE] from 7:00 AM -7:00 PM. The surveyor presented the neurological assessment form dated [DATE] - [DATE]. LPN #31 confirmed that he/she documented his/her neurological assessment of Resident #41 after the resident 's first unresponsive episode on [DATE]. The surveyor pointed out the two assessments signed by LPN #31, the 1st and 4th 15-minute neurological checks, were documented as being completed at [DATE] at 12:00 AM. LPN#31 confirmed the neurological assessments were completed on [DATE] at 12:00 AM. The surveyor pointed out that LPN# 31 stated that he/she worked from 7:00 AM - 7:00 PM on [DATE] and he/she was not in the facility at the time of the documented neurological assessment. LPN #31 was unable to provide an explanation for the time discrepancy. The surveyor also asked LPN #31 about the steps involved in completing a resident 's neurological evaluation. LPN #31 stated that he/she would ask for consent to complete the evaluation. If the resident refused, then LPN #31 would indicate this on the assessment form. If the resident agreed to the evaluation, then a list of tasks would appear including vital signs and observations of mental status. LPN #31 also added that Resident #41 refused all of his/her neurological assessments on [DATE] between the hours of 3:00 PM - 7:00 PM. The survey team interviewed On-Call Physician Assistant #34 on [DATE] at 1:45 PM. The interview revealed On-Call Physician Assistant #34 was unaware that Resident #41 refused a room search and neurological evaluations after the [DATE] unresponsive episode. On-Call Physician Assistant #34 stated facility nursing staff failed to contact him/her about the resident 's refusal of a room search and neurological checks. On-Call Physician Assistant #34 stated that if he/she had known of the resident ' s refusal of interventions then he/she would have ordered one-to-one monitoring of the resident. The surveyor also asked On-Call Physician Assistant #34 about his/her expectation of close monitoring and On-Call Physician Assistant #34 stated that he/she expected facility nursing staff to monitor Resident #41 every 15 minutes to assist in preventing the resident from obtaining illegal substances. The surveyor interviewed GNA #35 on [DATE] at 8:40 AM about Resident #41's unresponsive episode on [DATE]. GNA #35 stated that he/she remembered the episode and he/she worked 3:00 PM - 11:00 PM on [DATE]. The surveyor asked GNA #35 to describe the process of monitoring residents after a Narcan administration. GNA #35 stated it is facility policy to monitor the resident closely after a Narcan administration to deter the resident from taking or acquiring illegal substances. GNA #35 also stated that monitoring closely means to monitor the resident ' s location at all times and not let the resident be alone without supervision whenever possible. GNA #35 stated this is normally done for the shift after the Narcan administration. A review on [DATE] at 10:15 AM of Resident #41 ' s closed medical record revealed the resident was found unresponsive again on [DATE] at approximately 6:45 AM. Facility staff attempted to revive the resident by administering Narcan, performing CPR and using an Automated External Defibrillator or Automated Electronic Defibrillator (AED). An AED is a portable electronic device that is used to regulate an irregular heartbeat in an emergency. All attempts to revive Resident #41 were unsuccessful, and the resident expired in the facility on [DATE]. An interview was held on [DATE] at 1:30 PM with the Director of Nursing (DON) regarding the facility 's process/plan to keep a resident, recently revived by Narcan, safe from possible further use of illegal substances. The DON provided the surveyor with a facility policy titled Resident Substance Abuse in Facility, last revised on [DATE], which stated that the facility would obtain consent for search of a resident 's room when the facility suspected the resident to possibly have illegal substances in their room. Also, the Administrator or Administrator Designee would notify the local police to assist with the removal of any illicit substances found in the facility. After the DON and the surveyor reviewed the facility 's substance abuse policy, the surveyor asked what specific actions, performed by facility nursing staff, are used to monitor their condition and assist in reducing the possibility of a resident's continued illegal substance use after the facility found the resident unresponsive and used Narcan to revive the resident. The DON stated the use of neurological checks and behavioral monitoring are used to reduce the possibility of continued illegal substance use after a resident is revived by Narcan. The surveyor asked the DON about the facility's expectation of close monitoring as ordered by on-call Physician Assistant #34. The DON stated that close monitoring included neurological checks and frequent rounding every hour to ensure the resident is safe from continued illegal substance use. The DON also stated the facility does not have the staff to provide one-to-one monitoring of residents after a Narcan administration. Further review on [DATE] at 1:30 PM of Resident #41's closed medical record revealed facility nursing staff 's last progress note, prior to the second unresponsive episode on [DATE] at approximately 6:45 AM, was documented on [DATE] at 7:01 PM. The last vital signs were documented on [DATE] at 4:35 PM, and last activities of daily living (ADLs) were documented on [DATE] at 10:59 PM. These assessments documented that Resident #41 was in the building, however the resident was documented as being out of the building on the neurological assessment form. The surveyor interviewed GNA #37 about Resident #41's unresponsive episode on [DATE]. GNA #37 stated that he/she normally works on the 11:00 PM - 7:00 AM shift and he/she believed that he/she worked this shift on [DATE]. GNA #37 was unable to remember Resident #41's unresponsive episode on [DATE] or [DATE]. The surveyor asked GNA #37 about the process of monitoring residents after a Narcan administration. GNA #37 was unable to give any information on monitoring residents after a Narcan administration. The surveyor interviewed the DON about the facility 's failure to monitor Resident #41 after his/her [DATE] unresponsive episode leading to another unresponsive episode on [DATE]. The DON provided no additional information. As a result of these findings, an immediate jeopardy was declared on [DATE] at 12:00 PM. The provision of the plan to remove the immediate jeopardy immediacy had a completion date of [DATE] and include the following: The Director of Nursing (DON) conducted an audit on residents who have had an unresponsive episode in the last 30 days to review for appropriate monitoring of the resident including neurological evaluations and documentation of any mental changes from the resident 's baseline. The Administrator amended facility policy to include the following additions: When a resident receives Narcan administration for an overdose and the resident refuses consent to have his/her room search for illegal substances and/or refuses consent for neurological evaluation; the facility will place the resident on one-to-one observation in and around the facility to prevent the resident from obtaining illegal substances that may cause an additional overdose and repeat administration of Narcan. This one-to-one evaluation will continue until provider assessment. The resident 's primary provider or on-call provider will be notified if a resident who recently received Narcan administration refuses a room search, refuses neurological evaluations, or has changes from their usual baseline. The DON educated all nursing employees and agency employees on the changes in resident monitoring policy. All nursing employees must receive this in-service training before working on their next shift. The facility orientation process will be adjusted to include the changes in resident monitoring policy. The facility nursing staff will notify the DON when Narcan is administered. The DON will audit all Narcan administration for compliance to facility policy. These audits will occur daily for twelve (12) weeks. Audit results will be forwarded to the facility 's QAPI 's committee. Audit results will be reviewed monthly at the Quality Assurance meeting for 3 months. After on-site confirmation of the completion of the facility 's plan of removal through record review, and interviews of facility staff, the Immediate Jeopardy was removed on [DATE].

Based on medical record review and staff interview, facility nursing staff failed to sufficiently manage a resident ' s pain (Resident #41), resulting in harm to the resident. This was evident for 1 of 74 residents reviewed during a complaint survey. After review of pain management staff training completed after the incident and changes to facility pain management policy the deficient practice was cited as past non-compliance. The compliance date was [DATE]. The findings include: A review of resident #41 ' s closed medical record on [DATE] at 8:30 AM revealed the resident was admitted to the facility on [DATE] for orthopedic aftercare after left knee joint replacement surgery. A review on [DATE] at 9:00 AM of Resident #41's provider orders revealed an order for Oxycodone, 10 mg tablets, to be administered orally every 4 hours as needed for pain. This order started on [DATE] and stopped on [DATE]. A review of Resident #41's closed medical record on [DATE] at 9:30 AM revealed nursing pain assessments in the resident 's vitals section of the record revealed the following: a pain score of 5 on [DATE] at 9:02 PM, a pain score of 5 on [DATE] at 7:48 PM, and a pain score of 7 on [DATE] at 7:55 PM. Review of the [DATE] Medication Administration record (MAR) revealed the resident did not receive any Oxycodone from [DATE] to his/her [DATE] discharge from the facility. The nursing staff also failed to document any non pharmacological nursing interventions used to alleviate Resident #41's complaints of pain. Further review of Resident #41 ' s closed medical record on [DATE] at 10:00 AM revealed the resident was found unresponsive on [DATE] at approximately 3:00 PM. Progress notes revealed the resident was revived with Narcan. A progress note from Behavioral Staff #17 revealed Resident #41 was interviewed after the unresponsive episode and the resident stated he/she used illegal substances because the facility failed to give him/her pain medication to alleviate the pain from the knee joint surgery. On [DATE] at 8:06 AM, the survey team interviewed the facility pharmacy customer service #38 regarding Resident #41 's Oxycodone 10 mg orders. The facility pharmacy customer service #38 indicated the provider ordered Oxycodone on [DATE], but the pharmacy was never faxed or supplied the required C-II form from the provider. A C-II narcotic form is a form that the providers are required to complete before the pharmacy will dispense narcotic medications. The pharmacist stated that the pharmacy never authorized dispensing the medication to the facility for Resident #41. Interview with the Director of Nursing on [DATE] at 11:00 AM regarding the facility 's failure to provide pain medication to Resident #41 revealed the facility ordered other medications to assist in reducing pain from the knee joint surgery. The DON stated that the resident was ordered ibuprofen 800 mg, cyclobenzaprine (Flexeril) 10 mg, gabapentin 600 mg, and baclofen 5 mg as additional medication to reduce the pain from the knee joint surgery. The surveyor pointed out that the resident had breakthrough pain on three occasions and nursing progress notes revealed no evidence that the resident was offered any additional pain medication for his/her breakthrough pain. The DON restated that the provider ordered the flexeril, gabapentin and the baclofen to assist with the resident 's pain. The DON provided no further information to the surveyor. On [DATE] at 10:30 AM, the DON provided the survey team with evidence that the facility addressed the issue of pain management in their QAPI process on [DATE]. Review of the QAPI documents revealed the facility changed their medication ordering policy to include automatic prompts that ensure the proper authorization forms are included when providers sign their medication orders. Also, the facility conducted in-service education to all licensed nursing staff regarding the pain management process including the process of ordering medications that required a C-2 authorization form to be signed by the provider on [DATE]. A review of the QAPI process documents also revealed the facility placed the pain management process on their QAPI schedule as a continuous process to be monitored as of [DATE]. The continuous QAPI process includes continuous auditing of medication records, nursing progress notes and care plans of residents that are prescribed pain medications. After review of the QAPI documents provided by the DON on [DATE] at 10:30 AM, the survey team considered the deficient practice as past non-compliance with a correction date of [DATE].

Based on medical record review, interviews with facility staff and pharmacy and review of facility investigation, it was determined that the facility staff failed to obtain a [MEDICATION NAME] level and administer [MEDICATION NAME] as ordered by the physician for (resident #151). This was evident for 1 of 9 residents selected for review. The findings include: The facility failed to obtain a [MEDICATION NAME] level and administer the correct dosage of [MEDICATION NAME] for 22 days as ordered by the physician; resulting in the resident falling, becoming lethargic, confused and [MEDICATION NAME] toxic. The resident was transferred to the hospital via 911 on 7/18/17 with a toxic [MEDICATION NAME] level of 52.8. [MEDICATION NAME] ([MEDICATION NAME]) is an Anticonvulsant medication that can treat and prevent [MEDICAL CONDITION]. [MEDICATION NAME] ([MEDICATION NAME]) is an extended release [MEDICATION NAME] Anticonvulsant medication that can treat and prevent [MEDICAL CONDITION]. The [MEDICATION NAME] test is used to measure and monitor the amount of [MEDICATION NAME] in the blood and to determine whether drug concentration are in the therapeutic range. According to the lab the therapeutic range [MEDICATION NAME] is 10 -20 ug/ml. Review of the medical record on 10/4/17 at 10 am, revealed resident (#151) was admitted to the facility with [DIAGNOSES REDACTED]. According to the medical record the resident was ordered [MEDICATION NAME] 100 mg (milligrams) three times a day. On 6/21/17, the resident's [MEDICATION NAME] level was 8.5 (below normal range), the physician was made aware and a new order was obtained to draw a free [MEDICATION NAME] on 6/22/17. On 6/22/17, the free [MEDICATION NAME] was drawn. On 6/26/17, the free [MEDICATION NAME] result was .67mcg/ml (therapeutic range is 1.00-2.00). The physician was made aware. A new order to give 700 mg (milligrams) of [MEDICATION NAME] tonight and repeat [MEDICATION NAME] level on 7/3/17. Review of Medication Administration Record [REDACTED]. Review of the pharmacy manifest on 6/27/17 revealed 500 mg of [MEDICATION NAME] and 1400 mg of [MEDICATION NAME] was delivered to the facility. This is above the dosage ordered. On 7/3/17, the resident [MEDICATION NAME] level was 20.1. The physician ordered that the current dose on [MEDICATION NAME] 100 mg TID (three times a day) be continued. On 7/9/17, the resident experienced a change in condition, vomited times one and had confusion. Stat labs were ordered including a [MEDICATION NAME] level. Medical record revealed the staff failed to draw the stat [MEDICATION NAME] level. During interview with nurse #1 on 10/4/17 at 2 pm, s/he stated the [MEDICATION NAME] Level was discontinued by the physician. On 10/5/17 at 11 am, the physician who ordered the labs was interviewed. S/he stated the labs were not discontinued, s/he was waiting for the results, but never received them. On 7/12/17 according to the medical record, the resident was found on the floor in the room during medication pass. A new order was obtained for stat labs and Intravenous fluids; however, did not include a [MEDICATION NAME] level. According to the medical record on 7/14/17 at 3:44 pm, labs were ordered including a free [MEDICATION NAME] level. At 10 pm the resident was found on the floor with increased confusion and hallucinations. According to the medical record on 7/16/17 at 12:37am, the resident was transferred to the hospital via 911 for change in mental status, due to increased confusion, hallucinations, and a fall. At 7:14 am, the resident returned to the facility with no new orders. Lab work was drawn at the hospital; however, a [MEDICATION NAME] level was not obtained. Continued review of the medical record revealed at 6:45 pm the resident was confused and had a fall from the wheelchair. According to the medical record on 7/17/17 at 10:45 pm, lab results revealed a free [MEDICATION NAME] level of greater than 4. The normal therapeutic range is 1.00-2.00. The physician gave orders to repeat Free /Total [MEDICATION NAME] level and hold the am dose of [MEDICATION NAME]. According to the medical record on 7/18/17 at 7:08 pm, the Total/Free [MEDICATION NAME] level was drawn. At 8:30 pm, the resident was noted on the floor beside the bed sustaining a laceration to the middle of the forehead. The physician was made aware and gave an order to continue monitoring. At 10 pm, the resident had a change in mental status with increased confusion and incontinence. Lab called the facility with a critical High Total [MEDICATION NAME] level of 52.8. The Physician was made aware and ordered the resident to be transferred to the Emergency Department. According to the medical record, the resident was admitted to the hospital with [REDACTED]. The resident's [MEDICATION NAME] level was 51.3 at the hospital (per the hospital discharge summary). During interview with the DON (Director of Nursing) on 10/4/17 at 2 pm, it was revealed on 7/18/17, resident #151's Total [MEDICATION NAME] level showed a critical high level of 52.8 ug/ml. The DON stated on review of the medication cart, it was found that the pharmacy was sending (prepackaged) [MEDICATION NAME] 300 mg (milligrams) TID (three times a day), instead of the physician ordered [MEDICATION NAME] 100 mg three times a day. The MAR (Medication Administration Record) revealed the nurses were incorrectly signing off [MEDICATION NAME] 100 mg TID. A review of the facility medication Delivery Manifest on 10/5/17 at 1pm revealed the following [MEDICATION NAME] was delivered to the facility: Pheytoin Deliveries to facility based on Delivery Manifests: 6/26/2017 11:39 PM: [MEDICATION NAME] 100 mg ( 3 tablets)= 300 mg 6/27/2017 1:54 AM: [MEDICATION NAME] 100 mg (2 tablets) 200 mg , [MEDICATION NAME] 100 mg (3 tablets) (in two separate orders)= 300 mg 6/27/2017 6:05 PM: [MEDICATION NAME] 200 mg (7 tablets) =1400 mg 6/28/2017 6:10 PM: [MEDICATION NAME] 200 mg (3 tablets) =600 mg 6/29/2017 6:02 PM: [MEDICATION NAME] 200 mg (3 tablets) =600 mg 6/30/2017 6:22 PM: [MEDICATION NAME] 200 mg (3 tablets) =600 mg 7/1/2017 5:55 PM: [MEDICATION NAME] 200 mg (9 tablets) = 1800 mg 7/2/2017 5:12 PM: [MEDICATION NAME] 200 mg (3 tablets) = 600 mg 7/2/2017 5:12 PM: (different manifest #) [MEDICATION NAME] 100 mg (9 tablets) =900 mg 7/3/2017 6:12 PM: [MEDICATION NAME] 200 mg (3 tablets)=600 mg and [MEDICATION NAME] 100 mg (3 tablets)=300 mg 7/4/2017 4:46 PM: [MEDICATION NAME] 200 mg (3 tablets)= 600 mg and [MEDICATION NAME] 100 mg (3 tablets)= 300 mg 7/5/2017 6:14 PM: [MEDICATION NAME] 200 mg (3 tablets)= 600 mg and [MEDICATION NAME] 100 mg (3 tablets)= 300 mg 7/6/2017 6:40 PM: [MEDICATION NAME] 200 mg (3 tablets)= 600 mg and [MEDICATION NAME] 100 mg (3 tablets)= 300 mg 7/7/2017 6:15 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3tablets) = 300 mg 7/8/2017 3:53 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) = 300 mg 7/9/2017 4:21 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) = 300 mg 7/10/2017 6:05 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) = 300 mg 7/11/2017 6:05 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) = 300 mg 7/12/2017 8:43 PM: [MEDICATION NAME] 200 mg (3 tablets) )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) = 300 mg 7/13/2017 5:50 PM: [MEDICATION NAME] 200 mg (3 tablets)and [MEDICATION NAME] 100 mg (3 tablets) =300 mg 7/14/2017 6:05 PM: [MEDICATION NAME] 200 mg (3 tablets )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) =300 mg 7/15/2017 5:13 PM: [MEDICATION NAME] 200 mg (3 tablets )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) =300 mg 7/16/2017 4:38 pm: [MEDICATION NAME] 200 mg (3 tablets )= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) =300 mg 7/17/2017 6:20 PM: [MEDICATION NAME] 200 mg (3 Tablets)= 600 mg and [MEDICATION NAME] 100 mg (3 tablets) =300 mg 7/18/2017 6:29 PM: [MEDICATION NAME] 200 mg (3 tablets) = 600 mg and [MEDICATION NAME] 100 mg (3 tablets) =300 mg Review of the Pharmacy Delivery Manifest revealed the resident was sent the incorrect dose of [MEDICATION NAME] for 22 days. During interview with the pharmacy on 10/4/17 at 12:30 pm, it was revealed that the Pharmacy Representative (#7) stated too many [MEDICATION NAME] were prepackaged in the packages. This caused the error. Also, s/he stated the incident is being internally investigated. During interviews on 10/5/17 at 5 pm five of the 14 nurses involved in the medication error revealed the following: Interview with Nurse #1 revealed that a one-time order was turned into a recurring dose from the pharmacy. S/he stated double checking pharmacy orders with the MD order would have prevented it. Interview with Nurse #2 revealed s/he pulled the bag, matched it with the resident and administered whatever was in the bag. S/he stated s/he used poor judgment to administer the medication. Interview with Nurse #3 revealed the resident was given routine medications per MD order. On 6/26/17, s/he stated the resident's free [MEDICATION NAME] level was .67. A new order was given for one-time dose of 700 mg of [MEDICATION NAME] to be given the following shift. Interview with Nurse # 4 revealed s/he worked on 7/8/17 (3-11 shift) and emptied the medications on top of the cart and cross checked it to the resident. The nurse stated s/he does not remember if s/he gave all the medications to the resident. Interview with Nurse #5 revealed s/he worked on June 29th and July 6th, 2017 and administered medications to resident #151. S/he stated, s/he had the computer MAR indicated [REDACTED]. S/he stated The mistake I made, was not looking at the medication doses. Therefore, resident #151 received the wrong dose of [MEDICATION NAME]. I made an honest mistake and I am truly sorry. Following the incident, a review of the facility's investigation noted that the facility in-serviced 27 of 34 nurses. This included the 14 nurses that were involved in the medication error. The facility also did a medication check for all resident's receiving [MEDICATION NAME]. This was also ongoing. Seven of the 34 nurses, who were not inserviced, are no longer working at the facility. The facility's plan of correction included the following: Nurses directly involved in the incident received immediate education and corrective counseling. 100% medication cart audit was completed by nursing administration and, again by a pharmacy representative. AD-H(NAME) QAPI meeting was held to determine and review root cause, and evaluate facility's plan for corrective action Corrective action plan was developed and completed by contracted pharmacy. Joint QAPI meeting held with facility and pharmacy to review joint plan for corrective action. Family care conference was held to appraise responsible party of the medication error and discuss preventative measure implemented to avoid further incidents Nurse Managers completed 100% audit of residents ordered [MEDICATION NAME] levels were within therapeutic range, and correct medication dosages are administered. No other residents were identified. Nurse account manager and Pharmacy representative completed med pass observations and in servicing on 100% licensed staff (Note: 2567 references 7 nurses who failed to complete the required training. These individuals were removed from the schedule and subsequently prohibited from returning to work until mandatory training was successfully completed.). Med pass observations and in servicing is ongoing for all new hires, and nurses identified for additional training. All licensed nurses were in-serviced on safe medication administration practices. Pharmacy and facility clinical staff completed medication observations with 100% license nurses. Nurses who have not been in-serviced and received medication administration observations are not allowed to take a clinical assignment without completing training and assessment. Newly hired nurses will receive medication administration in-service and medication administration observation during their clinical onboarding and orientation. Pharmacy team completed 100% audit of PAXIT and pharmacy system orders against facility PCC orders to ensure accuracy. Pharmacy and facility clinical teams will provide on-going medication observation of nurses to improve practice standards with medication administration. Pharmacy team will complete a minimum of 30 resident's medications reviews monthly by reconciling physician orders [REDACTED]. The results of audit will be discussed in QAPI meetings monthly x 6. Nursing team to complete med pass observations of 25% of licensed nurses to assure medications are administered as ordered. The results of audit will be discussed in QAPI meetings monthly x 3 and then quarterly x 3. Facility was in compliance by 9/10/17

Based on medical record review and facility staff interview, it was determined that the facility failed to honor the advanced directives of a resident in regards to not having Cardiopulmonary Resuscitation performed upon arrest. This was evident for 1 of 34 (Resident #168) residents reviewed during stage 2 of the Quality indicator Survey. The findings include: During review of closed records that took place on [DATE] at 9:45 AM, Resident #168 was identified as having expired within the facility on [DATE]. A nurse's note, dated [DATE] at 8:46 AM, stated that Resident #168 was found unresponsive and that Cardiopulmonary Resuscitation (CPR) was initiated. The writer indicated that both 911 emergency services and Resident #168's attending physician were called once the code was initiated. The note stated, 911 arrived after few minutes later and took over CPR. At 3:47 the (patient) was pronounced dead. In closer review of the resident's closed record, the resident was noted to have a (NAME)land Orders for Life Sustaining Treatment (MOLST) form, dated [DATE], that specified NO CPR option A-2, Do not intubate. The MOLST form is a standard form used in (NAME)land for individuals or their surrogate decision makers to express their wishes at end-of-life or in the event of death. The status of NO CPR option A-2, Do not intubate, specifies not to perform CPR if a person dies and not to use artificial breathing machines if a person cannot breathe on their own prior to death. Nurse #11 was interviewed in person, on [DATE] at 9:05 AM. During the interview, Nurse #11 stated that one of the Geriatric Nursing Assistants (GNA) came and got me and told me (Resident #168) wasn't responsive. I checked on the resident, then looked at the Resident's MOLST and saw that the resident had (Option A-2) ' Do Not Intubate ' marked. I knew that we wouldn't need to intubate this resident, but saw no reason not to begin CPR, so I had the GNA start CPR immediately. Shift Supervisor #3 was interviewed in person on [DATE] at 10:20 AM. The Supervisor stated that, on the night in question, she/he saw the same MOLST form as Nurse #11 had, confirmed that the resident was only Do Not Intubate, and encouraged staff to continue CPR. During an interview that took place on [DATE] at 10:15 AM, the DON confirmed that Resident #168 did receive CPR, despite having orders that specified not to perform CPR in the event of Resident #168's arrest. When asked how staff determine whether a resident should receive CPR after an arrest, the DON stated that the expectation is for staff members to look at the MOLST sheet which is kept as the first page in the Physicians' Orders section of a resident's paper chart. The DON stated that, in the case of Resident #168, both the assigned Nurse of the 3rd floor unit (Nurse #11) and the overnight shift supervisor (Shift Supervisor #3) misinterpreted Resident #168's MOLST and instructed staff to perform CPR on Resident #168. The DON also clarified that Nurse #11 was the first staff member to make the decision to begin CPR. On [DATE], a list of residents who had died in the facility from [DATE] to [DATE] was obtained and reviewed, and all seven other residents' code status orders on their MOLST forms correctly corresponded with whether CPR was performed upon their arrest. The Facility's Plan of Correction included the following: Resident #168 no longer resides in the facility. Licensed Staff directly involved immediately received additional training on correctly interpreting the MOLST. An Ad-H(NAME) QAPI meeting was held to determine and review root cause and evaluate the facility's plan of corrective action. Facility submitted a request for onsite training on the MOLST (the MOLST form: learn what you need to know) by Asst. Attorney General . The interdisciplinary team audited 100% of resident's charts to ensure code status was accurate and nurses are able to correctly interpret MOLST forms. Licensed nurses received training on how to clearly interpret the MOLST form to assure the facility honors advanced directives of a resident. Newly hired nurses will be educated on interpreting the MOLST form during orientation to assure resident's advanced directives are honored. Social Service Director will audit 25% of residents' charts MOLST forms monthly for accuracy. 25% of licensed nursed will be assessed every month for 6 months to evaluate MOLST education and competency. The results of the audit findings will be discussed in the monthly QAPI meeting x 6 months. Facility was in compliance on [DATE].