Every finding on record at Fayetteville Center for Nursing & Healing LLC

Based on record reviews, family and staff interviews, and review of the facility policy titled Notification of Changes, the facility failed to notify the physician and Responsible Party (RP)/family of a fall of one of seven Residents (R) (R7) reviewed for notification of change.Findings include:Review of the facility policy titled Notification of Changes, reviewed/revised date of January 2024, revealed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative (consistent with their authority) when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents. Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] with diagnoses of, but not limited to, bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the admission Minimum Data Set (MDS) for R7, dated 6/24/2025, revealed a Brief Interview for Mental Status (BIMS) was not assessed. Review of the Employee Punch Report revealed LPN III worked the following hours on 7/14/2025 8:01 pm to 7/15/2025 7:24 am. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 7/15/2025, created on 7/16/2025 at 3:41 am, revealed that R7 had a fall. The SBAR documented that the family was notified on 7/15/2025 at 6:50 am, and the primary care physician was notified on 7/15/2025 at 11:00 am. A telephone interview on August 27, 2025, at 2:13 pm with R7's family member, who is the RP, revealed that the family stated they did not receive a call at 6:50 am on July 15, 2025, from the facility stating that R7 had a fall. A telephone interview on 9/3/2025 at 12:40 pm with Licensed Practical Nurse (LPN) III stated she did not call the family prior to leaving work regarding R7's fall on 7/15/2025. She stated she notified __ (the medical service that takes calls from the facility after 5 pm or weekends) of R7's fall prior to leaving work on the morning of 7/15/2025. An interview on 9/23/2025 at 1:44 pm with LPN JJJ stated she received report from LPN III on 7/15/2025. She stated LPN III never mentioned that R7 had a fall on the 7 pm to 7 am shift. LPN JJJ stated the family was visiting and asked if their dad had a fall last night. LPN JJJ immediately called LPN III and was initially told that R7 did not fall. LPN JJJ stated that after having a further conversation with LPN III, she admitted that R7 had a fall. Licensed Practical Nurse JJJ stated she assessed the resident and notified the Nurse Practitioner of the fall and received an order for x-rays. An interview on 9/24/2025 at 9:23 am with the Director of Nursing stated she was not able to verify that the physician/medical service was notified of R7's fall on the morning of 7/15/2025.

Based on staff interviews, record reviews, and review of the facility policies titled Resident and Family Grievances, and Resident Personal Belongings, the facility failed to make a prompt effort to file a grievance for one of nineteen sampled residents (R) (R8) who's family/responsible party (RP) reported both a written and verbal grievance. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner. Findings include: Review of the policy titled Resident and Family Grievances, with a reviewed/revised date of 12/2024, revealed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. 10. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Review of the policy titled Resident Personal Belongings, with a reviewed/revised date of 3/2024 revealed: Policy: It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility. Policy Explanation and Compliance Guidelines: 3. All resident personal items will be inventoried at the time of admission by the resident or their representative and then verified by social services designee, or another designated staff member and documentation shall be retained in the medical record. Review of the admission Record for R8 revealed he was admitted to the facility on [DATE] with diagnoses of, but not limited to, cerebrovascular disease, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed at 13, indicating cognitively intact. Review of the Skin Wound Note dated 7/17/2025 revealed: New admit resident wears glasses. Review of the __ admission Packet revealed it was signed by the family on 7/19/2025 and the facility representative on 7/21/2025. On page 31, titled Inventory of Personal Items, it was documented that R8 was admitted with a pair of eyeglasses. Review of the Grievance Reports from 6/13/2025 to 8/26/2025 revealed one documented grievance filed by the family for R8 on 8/11/2025. The grievance did not include missing items. Review of an email from R8's Family titled Second Formal Complaint Regarding Care of R8 dated 8/3/2025, and addressed to the Administrator, Assistant Director of Nursing (ADON), Director of Nursing (DON), Business Office Manager, Human Resources, and the wound care nurses. Four family members were carbon-copied on the email. The email revealed R8's glasses are missing, with no accountability. In an interview on 9/3/2025 at 11:35 am, the Social Service Director (SSD) stated the facility uses __ to report, log, and track the facility's grievances. She stated that any staff person can input the information into __. The SSD stated that if a resident/family/RP had a concern, it was entered into the grievance tracking system. The grievances were sent out to all departmental heads, including the department(s) that were required to address and investigate the grievance. She stated that grievances were discussed in the morning management meeting. The SSD stated that the Administrator and herself oversaw and ensured that the grievances were resolved in a timely manner and closed out. The SSD stated that no one reported or logged in the grievance tracking system that R8 lost his eyeglasses. In a telephone interview on 9/4/2025 at 2:45 pm, R8's family member, who is the RP, stated that on 8/1/2025, it was reported to the ADON and a Certified Nursing Assistant (CNA) that R8's shorts and eyeglasses were missing. The family member stated the CNA returned with R8's shorts, but the glasses could not be located. She stated she reported the missing items again in a formal email on 8/3/2025. In an interview on 9/9/2025 at 11:10 am, the ADON stated she never had any communication with the family of R8 regarding lost eyeglasses or clothes. She stated that if a resident or family reported lost items, she would report it to the Social Worker. The ADON stated the Social Worker was responsible for logging the resident/family grievances into the __ system. The ADON stated she would also report the lost items to the laundry department so that they could look for the missing items. In an interview on 9/16/2025 at 10:57 am, the ADON confirmed that she did receive an email from R8's family. She stated she does not remember reading the email. She stated, Those things are handled by the DON.

Based on family and staff interviews, record reviews, observations, and the facility policies titled Abuse, Neglect and Exploitation, and Safe Resident Handling/Transfer, the facility failed to protect two out of five Residents (R) (R7 and R16) by neglecting to use the designated mechanical lift to transfer the residents. Specifically, Licensed Practical Nurse (LPN) III and Certified Nursing Assistant (CNA) DDDD attempted to transfer R7 from the floor to the bed by his legs and his neck. During this improper transfer from the floor to the bed CNA DDDD lost control and dropped R7, causing his head to hit the floor. The facility allowed the LPN III and CNA DDDD to continue working with the vulnerable residents for an additional 15 days. CNA EEEE transferred R16 from the bed to the chair without using the required mechanical lift, causing a laceration to R16's right great toe. The neglect had the potential to affect fifty residents who require a mechanical lift for transfer. Findings include:A review of the policy titled Abuse, Neglect and Exploitation, reviewed/revised date of April 2024. Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. A review of the policy titled Safe Resident Handling/Transfer, reviewed/revised date of March 2025. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual Lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical Lifts are a safer alternative and should be used. Compliance Guidelines: 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. 1. A telephone interview on 8/27/2025 at 2:13 pm with R7's family member who is the Responsible Party (RP). The family stated that upon reviewing the camera located in R7's room on 7/15/2025 around 1:00 pm Central Standard Time (CST). The family stated that around 6:40 am Eastern Standard Time (EST), R7's legs were hanging over the side of the bed that was in a high position. The family stated R7 fell out of the bed and yelled out for about ten minutes before the nurse entered the room. The family stated the staff left the room and returned 4-5 minutes later with another nurse or CNA. The family stated, dad was picked up by the neck and legs and dropped on the floor. The family stated dad was picked up a second time and thrown in the bed, causing the mattress to move off the bed. The family stated the entire time dad was crying out. No one from the facility notified the family of the fall until after the family reached out to the Regional Director of Operations on 7/15/2025 at 2:20 pm CST. An interview on 8/29/2025 at 2:00 pm with R7 at __ Nursing Home with the Director of Nursing (DON) DDD, and Unit Manager (UM) BBBBBB. The interview took place in UM's office. The resident appropriately answered the screening questions. The resident answered yes when he was asked about being in a different place. He answered yes when asked if he had fallen at the previous home. The resident verbalized that he fell and lay on the floor. He was able to verbalize he was dropped and had hurt his head. He verbalized that he bumped his head on the headboard. The resident became tearful during the interview when talking about the previous facility. He verbalized he wanted to go home to Jesus. He (R7) expressed that he was in pain at the time of the interview. Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] and a diagnosis of, but not limited to bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed. Section GG revealed R7 is dependent on staff for transfers. Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated on 6/20/2025 revealed that R7 has a deficit in activities of daily living (ADL) self-care. Intervention to be implemented includes a mechanical lift with two staff assistants for transfers. A review of the video of R7 on the floor and transferred by two staff to the bed, provided to the surveyor by the family, revealed that on 7/15/2025 at 6:53 am, a person in a blue shirt was in R7's room. The resident was on the floor, lying on his right side, facing the door, and moaning. The bed was in a high position and lowered by the person in the room. The person was standing over the resident and pulled out a phone. The person left the room at 6:55 am and returned at 6:59 am with a person in a white lab jacket. The person in blue was positioned at R7's feet, and the person in the white lab jacket was positioned at the right side of R7's body. R7 was picked up by the legs and neck from the floor. The resident was lifted to the level of the bed. During this transfer from the floor to the bed, R7 was dropped with his head hitting the floor first, then his legs. The resident was picked up off the floor a second time by the same two people by the legs and neck and transferred to the bed. The resident was moaning and crying throughout the video, 6:53 am -7:01 am. This video was also viewed by the DON CC, who confirmed the person in the blue was LPN III and the person in the white was CNA DDDD. Review of a Nurses Note created on 7/15/2025 at 11:37 pm and dated 7/15/2025 at 6:50 am revealed that the writer went into the room when resident was yelling, then found resident almost on the floor, resting his back on the bed rails, resident was assisted to the floor, and writer called for her, resident was assessed, no bruises or injuries noted at this time. with 1-assist, resident was transferred to bed, well-position, telemeds were notified, orders said to initiate neuro-checks. vital signs within normal limits. resident in bed resting at this time. will continue to monitor for further changes in condition. There was no documentation in this nurse's note that the family was notified. Review of the document titled Mechanical Lift Transfer Resident List dated 9/15/2025 revealed that fifty residents require a mechanical lift for transfer. Review of the Employee Punch Report revealed LPN III worked the following shifts after 7/15/2025: 7/15/2025 6:44 pm to 7/16/2025 7:20 am 7/16/2025 6:46 pm to 7/17/2025 7:23 am7/17/2025 6:48 pm to 7/18/2025 6:57 am7/20/2025 6:48 pm to 7/21/2025 7:43 am7/21/2025 6:46 pm to 7/22/2025 7:37 am 7/22/2025 6:46 pm to 7/23/2025 7:30 am7/25/2025 6:47 pm to 7/26/2025 7:33 am7/26/2025 6:50 pm to 7/27/2025 6:59 am7/27/2025 6:50 pm to 7/28/2025 7:19 am 7/28/2025 6:45pm to 7/29/2025 7:11 am7/30/2025 6:51pm to 7/31/2025 7:14 am7/31/2025 6:42 pm to 8/1/2025 7:18 am8/2/2025 6:53 pm to 8/3/2025 7:30 am8/4/2025 6:50 pm to 8/5/2025 7:26 am8/5/2025 6:45 pm to 8/06/2025 7:23 am Review of the Employee Punch Report revealed CNA DDDD worked the following shifts after 7/15/202:7/18/2025 7:24 pm to 7/19/2025 8:02 am7/19/2025 7:01 pm to 7/20/2025 7:31 am7/20/2025 7:03 pm to 7/21/2025 7:44 am7/21/2025 7:00 pm to 7/22/2025 7:41am7/22/2025 7:01pm to 7/23/2025 7:26 am7/23/2025 7:09 pm to 7/23/2025 7:37 pm7/25/2025 6:49 pm to 7/26/2025 7:32 am7/26/2025 6:58pm to 7/27/2025 7:05 am7/27/2025 7:19 pm to 7/28/2025 7:25 am7/28/2025 7:11 pm to 7/29/2025 7:13 am7/31/2025 6:31 pm to 8/1/2025 7:14 am8/01/2025 7:04 pm to 8/2/2025 8:05 am8/02/2025 6:57 pm to 8/3/2025 7:01 am8/03/2025 7:10 pm to 8/4/2025 7:30 am8/4/2025 7:03pm to 8/05/2025 7:16 am8/08/2025 7:16 pm to 8/8/2025 7:36 pm Review of the LPN III employee file in the presence of the Human Resource Director revealed: Separation Notice, hire date of 3/28/2025, and a termination date of 8/21/2025 for gross misconduct, failed to do a proper assessment and care plan update signed by Human Resource on 8/22/2025. Review of CNA DDDD employee file in the presence of the Human Resource Director revealed: Separation Notice, hire date of 6/17/2025, and termination date on 8/21/2025 for gross misconduct, participated in an improper transfer of patient during an incident signed by Human Resource on 8/22/2025. An interview on 8/27/2025 at 10:04 am with DON CC stated R7 was admitted to a private room The DON stated that when R7 was admitted , the family requested to place a camera in the room. She stated the camera was there for a few weeks with signage alerting anyone who entered the room that there was a camera. She stated the upper management had the family remove the camera. She stated on 7/15/2025 LPN III was making rounds and found R7 sliding off the bed, and the resident was lowered to the floor. The LPN went to get help to assist with transferring R7 back to bed. The CNA DDDD assisted with transferring R7 back to bed. The LPN assessed the resident, and no injuries were identified. The DON stated the family was notified of R7's fall. The DON stated that when she spoke with the LPN on 7/15/2025, she did tell her that no fall documentation was located in R7's Electronic Medical Record (EMR). The DON stated she instructed the nurse to complete the required documentation. The DON stated on 8/1/2025 family arrived to the facility for an impromptu meeting to inform the facility that R7 was dropped on the floor during a transfer. The DON stated she reviewed the resident's EMR, and the only documented fall was 7/15/2025. She decided to reinvestigate the fall from 7/15/2025. The DON stated the family's allegation was reported to the State Survey Agency immediately, and the investigation was started. She stated she called the nurse and CNA who was involved and was told absolutely a mechanical lift was used to transfer R7 off the floor into the bed. The DON stated LPN III and CNA DDDD were terminated on 8/1/2025. A telephone interview on 9/3/2025 at 12:40 pm with LPN III stated on 7/15/2025 she worked on 800 halls. She stated that around 6:57 am, she could hear R7 yelling. She stated when she entered the room the bed was in low position and R7 had one leg on the floor and one leg in the bed on the body pillow. She stated R7 was assisted to the floor. The LPN stated she assessed and checked R7's vital signs and disconnected the feeding. She stated she checked the care plan and Kardex and R7 were care plan for transfer with a mechanical lift. The LPN stated she could not locate a sling for the mechanical lift on 800/900 linen closet or the linen closet on the other side of the facility. The LPN stated she went to the other side of the building to get help. The LPN stated that because R7 needed to get off the floor a two-person transfer was done. She stated during the transfer herself, and the CNA had to lay R7 back on the floor. She stated the second time doing the two-person assist transfer they were able to get R7 back into the bed and R7 was fine. The LPN stated during the interview she did not notify the family of the fall. She stated the family was called later that day. A telephone interview on 9/3/2025 at 1:05 pm with CNA DDDD stated on 7/15/2025, she was working on 400/500 hall. She stated around 6 something LPN III ask for assistants to get a resident off the floor. The CNA stated when she arrived in R7's room the resident was on the floor. The CNA stated she placed her hands under the resident's shoulders, no I mean arm pits to transfer the resident from the floor to the bed. She stated the mattress on the bed started sliding and the resident was lowered back to the floor. She stated the mattress was adjusted and R7 was transferred from the floor to the bed. After helping the nurse get R7 back in bed she left the room. An interview on 9/3/2025 at 2:15 pm with the Human Resource Director (HRD) JJ confirmed there was no documentation for a suspension or disciplinary action on or after 7/15/2025 in LPN III's file. An interview on 9/3/2025 at 2:16 pm with the HRD JJ confirmed there was no documentation for a suspension or disciplinary action on or after 7/15/2025 in CNA DDDD's file. An interview on 9/5/2025 at 2:00 pm with the Director of Clinical Operations stated the management team spent a weekend reeducating the staff on safe transfers. She stated that the management team reeducated the staff on the use of mechanical lifts during transfers. The staff was also required to complete the skills check-off for proper use of a mechanical lift. 2. An observation and interview on 9/16/2025 at 10:43 am of R16's skin along with UM LLL. The resident complained of right knee pain. The resident stated she did tell the nurse and was given a pill. The UM asked the resident for permission to look at her skin. An observation of the right and left legs elevated on a pillow. An observation of swelling in the right knee, laceration on the right great toe open to air with red drainage, and an observation of an open area on the left second toe. Review of the admission Record for R16 revealed she was admitted to the facility on [DATE] and a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy. Review of the resident's admission MDS dated [DATE] revealed a BIMS assessed at eight, indicating moderately impaired. Section GG revealed that R16 requires partial/moderate assistance with transfer. Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS. Review of the care plan initiated 7/25/2025 revealed that R16 has an ADL self-care performance deficit related to limited mobility. Intervention to be implemented included a mechanical lift with two staff for assistance with transfers.Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred R16 from bed to wheelchair causing a laceration on right leg. The investigation revealed that as a result of CNA EEEE failure to follow the facility policy of using a mechanical lift when transferring R16 causing a small laceration to R16's great right toe. Review of the CNA EEEE employee file in the presence of the Human Resource Director revealed: a Disciplinary Action Form description of violation and events leading to personnel action: employee fail to use lift to transfer resident from bed to the wheelchair. Work improvement plan: Employee must perform all job duties outlined in the description as requested by manager/supervisor. Signed by the employee, UM, and the DON dated 9/8/2025. Further review revealed a Separation Notice with a hire date of 9/1/2019 and a termination date of 9/9/2025 for violating company policies; poor performance; transferred resident without using lift as educated, signed by Human Resources on 9/10/2025. A telephone interview on 9/17/2025 at 10:24 am with CNA EEEE stated she was educated on reviewing the kiosk for the residents' plan of care for transfers. The CNA stated R16 was assigned to her on 9/8/2025. She also stated she was aware that R16 required a transfer with two people using the mechanical lift. The CNA stated R16 had been crying and complained of general hurting and refused to get out of bed for the day. She stated R16 did not want to get up using the mechanical lift to be transferred from the bed to the chair. The CNA stated she asked R16 was it okay for her (CNA) to be transferred from the bed into the chair. The CNA stated the resident agreed and was transferred from the bed to the wheelchair. The CNA stated she did not report to the charge nurse or the UM that the resident was in pain and did not want to get up. The CNA stated she was not aware that R16 sustained an injury to the right knee and toe during the transfer. An interview on 9/17/2025 at 10:32 with UM LLL stated she has daily huddles with the staff on 100-700 hall. She stated that because of the incident with R7, she educates the staff to review the resident's plan of care. All mechanical lifts must be done with two staff; in the event there is not a second person available she (UM) will assist with the transfer. The UM stated on 9/8/2025, R16's family approached her and asked, Why was my mom transferred out of bed today without using the mechanical lift? The family went on to inform the UM that R16 was in pain, and her knee had been injured during the transfer. She stated the resident was assessed and sent to the hospital. The UM stated she asked the CNA assigned to R16 did you transfer R16 without using the mechanical lift. The CNA confirmed she had transferred the resident from the bed to the wheelchair alone without the lift. She stated she reported the incident to the Administrator immediately, and the CNA was sent home by the Assistant Director of Nursing.

Based on record reviews, family and staff interviews, text messages, and the facility policies titled Bed Hold Prior To Transfer, EXHIBIT B Bed Hold Policy, and the Immediate Discharge Notice the facility failed to permit one of three Residents (R) (R7) to return to the facility after being sent to the hospital emergency room. The facility also denied R7's family from entering the building to obtain the resident's personal belongings. This deficient practice had the potential to place the residents who are sent to the hospital in an unsafe and unsuitable situation and cause stress and harm to the residents.Findings include:Review of the policy titled Bed Hold Prior To Transfer, with a reviewed/revised date of March 2025, revealed: Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices at the time of a transfer for hospitalization. Policy Explanation and Compliance Guidelines: 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. Review of the admission Packet and an undated document titled EXHIBIT B Bed Hold Policy revealed that the Resident and Resident's Authorized Representative and/or Responsible Party shall receive a copy of the facility's bed hold policy within twenty-four (24) hours of hospitalization. Should the following restrictions (as allowed by state and federal guidelines) not be met and the Resident is discharged , it is the policy of this facility to offer the next available bed to the Resident. Private Pay Residents: If the resident chooses not to reserve the bed through payment, he/she will be readmitted to the Facility upon the first availability of a bed in a semi-private room. At the end of the admission packet, signed by the family, was a copy of R7's identification, social security card, and insurance information. Review of the facility's Midnight Census Report dated 7/31/2025 revealed there were twenty-four empty beds. Out of the twenty-four empty beds, fourteen were open for male admission. Review of the facility's Midnight Census Report dated 8/1/2025 revealed there were twenty-five empty beds. Out of the twenty-five empty beds, twelve were open for male admission. Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] with diagnoses of, but not limited to, bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed. Review of the Document titled Memorandum for Record Subject: Representatives of the Resident (R7) The following are appointed resident representatives by R7. All parties of [facility name] and all affiliates, to include (owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others working for [facility name]), agree to contact the primary representative prior to any medication orders or administering of medication to a resident not already known. This document had four individuals listed as contacts. There was no indication that only the primary contact could be contacted about any other matters regarding R7. Review of the Care Plan Participation Record dated 7/21/2025, provided to the surveyor revealed: signatures by six interdisciplinary team members; Social Service Director (SSD), Director of Rehab, Nurse Practitioner (NP), Business Office Manager (BOM), Unit Manager, Clinical Marketing Director, and one family member via telephone participated in R7's care plan development. The document is unclear whether R7 attended his care plan meeting. There was no documentation that the family was informed that if R7 went out to the hospital, he would not be allowed to return to the facility. Review of the Immediate Discharge Notice dated 7/28/2025, addressed to R7, and the representative revealed: Effective Date of discharge: The discharge will take place effective immediately on the date of this notice, on 8/28/2025. The resident will not be discharged before this date. Review of [hospital name] emergency room (ER) documentation revealed R7 arrived at the ER on [DATE] at 11:16 am, with a diagnosis of a urinary tract infection without hematuria (blood in urine). The resident was treated with antibiotic intravenous. At 4:18 pm, the emergency department case manager attempted to contact the facility's liaison but was unable to reach or leave a voicemail. Contacted the facility, spoke with [facility staff name], who confirmed that R7 was a resident at the facility. At 6:00 pm, the nurse attempted four times to call in a report to the facility, and no one picked up the call. At 6:02 pm, the nurse called the facility and notified them that R7 will be transported by [transport name] at 10:00 pm. Case Management note on 8/1/2025 at 12:53 am: R7 was discharged back to the facility after being cleared by the provider. When emergency medical service (EMS) arrived at the facility, staff stated, the resident is banned from the facility and not allowed back. Per EMS, staff would not give a reason. The resident was brought back to the hospital ER, and case management will be consulted. The resident is tube-fed dependent with a [urinary catheter]. Resident (R7) blood pressure 149/84, heart rate 115. Per ER physician, unclear etiology (cause) of tachycardia (elevated heart rate), though improving as R7 rests in the emergency department. Case Manager note on 8/1/2025 at 3:47 pm: R7 was sent back to the emergency department by the facility, stating that R7 cannot return to the facility. Per the facility, they cannot manage R7's needs. After several lengthy discussions with the hospital leadership and the facility leadership, the facility still would not accept R7. Referral was sent to several other long-term care facilities. Review of a telephone text message from the Director of Nursing (DON) sent to Licensed Practical Nurse (LPN) NNN dated 7/31/2025 at 5:18 pm revealed: R7 is not to be taken back. Do not take report. Do not allow them to bring him. Refer them to __. An interview on 8/27/2025 at 10:40 am with the DON, who explained the facilities policy and procedure for residents returning from the hospital. The DON verbalized that the nurses are required to review __ (a digital dashboard) to confirm if a resident is cleared for admission. If a resident's name does not appear on the digital dashboard, they are not permitted to be admitted . The DON stated it is the responsibility of the marketing liaison (Clinical Marketing Director) to update the dashboard for all admissions. The DON stated this holds true for residents who have been sent out to the hospital by the Physician/Physician Assistant/Nurse Practitioner (NP). The DON stated that on 7/31/2025, R7 complained of suprapubic pain. The NP assessed the resident and gave an order to send the resident to the local hospital emergency room for further evaluation. She stated the supervisor on duty called around 11:30 pm on 7/31/2025, stating that R7 was not on the dashboard. The DON instructed the supervisor to reach out to the marketing liaison (Clinical Marketing Director) to get permission for the resident to return to the facility. She stated that, as the DON of the facility, she could not give permission for R7 to return because he was not listed on the dashboard. The DON stated she was not part of a meeting that discussed that the resident could not return to the facility after being sent out to the hospital on 7/31/2025. She stated she had no knowledge of the resident not being able to return. An interview on 8/27/2025 at 3:43 pm with the Clinical Marketing Director stated that the decision was made by her not to allow R7 to return after being sent out to the hospital. She stated the facility had a care plan meeting with the family discussing the resident's discharge. The Clinical Marketing Director stated she was clear in the meetings that if R7 was sent out to the hospital and we do not have a payment your dad will not be allowed to return to the facility. She assured the surveyor that the information was documented in the care plan meeting notes on 7/21/2025. She stated the bed hold policy was sent with the hospital paperwork when the resident was transferred to the hospital on 7/31/2025. The Clinical Marketing Director stated that not taking R7 back worked because the family is cooperating with the Medicaid process at the new facility. A phone interview on 9/2/2025 at 12:36 pm with the facility's Ombudsman stated she received the 30-day discharge letter for R7 on 7/29/2025. She stated she did not reach out to the resident or the family until returning to work (no date given). She stated that when she spoke with the family, she was informed that the resident was no longer at the facility. She stated she spoke with the staff at the facility regarding R7's discharge. She attempted to explain to the facility that when given the 30-day discharge letter, the resident goes back to square one and should have an opportunity to decide regarding the stay. She stated the facility did not allow R7 or the family of R7 to comply with or appeal the discharge. She stated the leadership at the facility needs more education regarding resident discharges. An interview on 9/3/2025 at 10:37 am with LPN JJJ stated she assisted with sending R7 out to the hospital on 7/31/2025. She stated the only paperwork that was sent with R7 was a face sheet and an order summary. The LPN stated she has never sent a copy of the residents' bed hold. The LPN stated she does not know where to get a copy of a bed hold policy. An interview on 9/3/2025 at 11:35 am with the SSD stated that one of her responsibilities includes resident discharge plans. The SSD stated she was not aware that R7 was not allowed back into the facility after being sent to the emergency room. She stated that had she been aware, she would have assisted R7 and the family in finding placement and ensuring that the discharge/transfer was safe. An interview on 9/3/2025 at 6:48 pm with LPN NNN stated she worked 7:00 pm to 7:00 am on 7/31/2025. She stated the DON had texted her around 5:18 pm that day and told her not to take R7 back. She stated transportation arrived around 11:30 pm with R7. She stated that transportation called from the front entrance, to be let in, to return R7. The LPN stated that as she arrived at the door, LPN III was also walking towards the door. She stated LPN III informed her she had received a text from the DON not to allow R7 back inside the facility. She stated there was a CNA in the lobby who was concerned that she was not allowing R7 back inside the facility. She stated that herself, LPN III, and the CNA went to the door. She told the drivers, I have been instructed not to allow Mr. __ (R7) back inside the facility. She stated she did not realize the family was also at the door. The LPN stated the family was not aggressive, but had a look of shock on their face. She stated the family did ask, What should we do? The LPN stated she encouraged them to take R7 home. She stated the family asked if they could come inside to get his belongings. She stated she told the family she could not allow them inside. An interview on 9/4/2025 at 9:23 am with the BOM stated that she never communicated with the resident or the family about the bed hold policy on 8/1/2025. The BOM stated that upon her return to work, the resident had been discharged . She stated she only communicated with one family member regarding establishing a payor source or carrying out the Medicaid and Medicare process. The BOM stated she never communicated with the resident or any other family member regarding establishing a payor source or the Medicare Medicaid process. A phone interview on 9/19/25 at 2:58 pm with the facility's Medical Director stated he was aware that R7 was sent out to the hospital and was not allowed to return. The Medical Director stated his understanding was that R7 was at the end of the 30-day discharge notice. He stated he did not realize the notice was issued on 7/28/2025. The Surveyor confirmed on 9/26/2025 with the regional staff that the Clinical Marketing Director was not an LPN or a Registered Nurse. A post survey interview on 10/5/2025 at 3:21 pm with R7's family, and his emergency contact number two, stated that he visited with R7 every week. The family stated no one from the facility ever contacted them with any issues regarding R7's stay at the facility. The family stated that they would have assisted if they had known. The family stated they were shocked when R7 was not allowed to return on 7/31/2025. He stated the nurse informed the family R7 no longer had a bed and was not allowed to obtain R7's belongings. The family did meet with the Administrator, DON, and the Clinical Marketing Director on 8/1/2025. The family stated that the Clinical Marketing Director informed the family that it was her decision that R7 was not allowed to return.

Based on staff interviews, record reviews, the facility policy titled Comprehensive Care Plans, and the Charge Nurse Job Description, the facility failed to implement the care plan interventions for mechanical lift with two staff assistants for transfers for two Residents (R) (R7 and R16). In addition, the facility failed to implement fall mats and update R7's care plan after an incident and an accident.Findings include: A review of the policy titled Comprehensive Care Plans, reviewed/revised date of March 2025. Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Review of the undated document titled Charge Nurse Job Description, revealed: Required Qualifications: A Nursing Degree from an accredited college or university or a graduate of an approved Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) program. Major Duties and Responsibilities: Initiates, reviews, and updates care plans as required. 1. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed. Section GG revealed R7 is dependent on staff for transfers. Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated on 6/20/2025 revealed that R7 has a deficit in activities of daily living (ADL) self-care. The intervention to be implemented includes a mechanical lift with two staff for assisted transfers. Review of the care plan initiated 6/20/2025 revealed that R7 is at risk for a fall. Intervention to be implemented fall mats. A telephone interview on 9/15/2025 at 1:12 pm with LPN III stated that on 7/15/2025 she worked on 800 hall. The LPN confirmed that R7 was care planned to transfer with two people using a mechanical lift and fall mats on the floor. She stated the resident did not have fall mats on the floor at the time of the transfer. The LPN stated R7 was transferred from the floor to the bed with the assistance of a Certified Nursing Assistant (CNA) without using a mechanical lift. The LPN confirmed that R7's care plan was not updated. The LPN stated updating a resident's care plan is not part of her job description. She stated the facility never educated her on updating care plans or the use of a mechanical lift. 2. Review of the resident's admission MDS dated [DATE] revealed a BIMS assessed at eight, indicating moderately impaired. Section GG revealed R16 is partial/moderate assistance with transfer. Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS. Review of the care plan initiated 7/25/2025 revealed that R16 has an ADL self-care performance deficit related to limited mobility. Intervention to be implemented included a mechanical lift with two staff for assistance with transfers. Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred R16 from bed to wheelchair, causing a laceration to the right leg. The investigation revealed that as a result of CNA EEEE failure to follow the facility policy of using a mechanical lift when transferring R16 causing a small laceration to R16's great right toe. A telephone interview on 9/17/2025 at 10:24 am with CNA EEEE stated she was educated on reviewing the kiosk for the residents' plan of care for transfers. The CNA stated she was aware that R16 required a transfer with two people using the mechanical lift. The CNA stated she asked R16 was it okay to be transferred from the bed into the chair. The resident agreed and was transferred from the bed to the wheelchair. The CNA stated she was not aware R16 sustained an injury to the right toe due to the transfer. An interview on 9/9/2025 at 9:30 am with the Administrator stated his expectations that all documentation is completed after a fall and or incident. He stated that documentation includes updating the residents' care plan. Cross reference F689

Based on family and staff interviews, record reviews, observations, and the facility policy titled Safe Resident Handling/Transfer, the facility failed to provide appropriate interventions while transferring two of five residents (R) (R7 and R16), reviewed for mechanical lift transfers. Findings include:A review of the policy titled Safe Resident Handling/Transfer, reviewed/revised date of March 2025. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual Lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical Lifts are a safer alternative and should be used. Compliance Guidelines: 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. 1. Review of the admission Record for R7 revealed a diagnosis of, but not limited to bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed. Section GG revealed R7 is dependent on staff for transfers. Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 6/20/2025 revealed that R7 has an activity of daily living (ADL) self-care performance deficit. Intervention to be implemented includes a mechanical lift with two staff assistants for transfers. Review of the video of R7 on the floor and transferred by two staff without a mechanical lift. The video was also viewed by the Director of Nursing (DON) CC who confirmed the person in the blue was Licensed Practical Nurse (LPN) III and the person in the white was Certified Nursing Assistant (CNA) DDDD. On 7/15/2025 at 6:53 am LPN III was in R7's room the resident was on the floor lying on his right side facing the door and moaning. The bed was in a high position the LPN lowered the bed. The LPN left the room at 6:55 and R7 remained on the floor. The LPN returned at 6:59 am with CNA DDDD. The LPN was positioned at R7's feet. The resident's right leg was at a 90-degree angle. The LPN placed her left hand on R7's right calf and her (LPN) right hand was under the resident's left knee. The CNA's body was positioned on the right side of the resident. The CNA held the resident with her right hand under R7's right knee. The CNA's left hand grasped the left underside neck of the resident with four fingers while the thumb grasped the resident's throat. During this transfer from the floor to the bed the CNA let go of R7 and his head hit the floor first followed by his legs. An interview on 9/10/2025 at 11:55 am with Nurse Practitioner (NP) BBB stated that R7 was physically assessed on 7/16/2025, and that she issued an order based on information provided by the nursing staff. NP BBB stated that an order for x-rays of the right shoulder, left shoulder, and cervical spine was given. The NP BBB revealed that had she known the R7 had been dropped and hit his head, the orders would have been different. A telephone interview on 9/15/2025 at 1:12 pm with LPN III stated that on 7/15/2025, around 6:57 am, she could hear R7 yelling. She stated that when she entered the room, the bed was in a low position, and R7 had one leg on the floor and one leg on the body pillow. LPN III stated R7 was assisted to the floor. The LPN III stated that R7 did not have fall mats on the floor and that the mechanical lift sling was not located. LPN III stated that R7 was transferred from the floor to bed with assistance from a CNA. The LPN III stated that she reported to the oncoming nurse that R7 had a fall and to follow up with the family. An interview on 9/23/2025 at 1:20 pm with LPN RRR stated she was the oncoming nurse on 7/15/2025. She stated LPN III gave a verbal report to her (LPN RRR) and the other nurse working on the 800 hall. She stated there was no report about any residents falling on the 7 pm-7 am shift. LPN RRR stated there was no discussion about following up with R7's family regarding a fall. 2. Review of the admission Record for R16 revealed a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy. Review of the resident's admission MDS dated [DATE] revealed a BIMS assessed at eight, indicating moderately impaired. Section GG revealed R16 is partial/moderate assistance with transfer. Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS. Review of the care plan initiated 7/25/2025 revealed that R16 has an ADL self-care performance deficit related to limited mobility. Intervention to be implemented included a mechanical lift with two staff assistance for transfers. Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred R16 from bed to wheelchair causing laceration on the right leg. The investigation revealed that as a result of CNA EEEE's failure to follow the facility policy of using a mechanical lift when transferring R16, a small laceration to R16's great right toe. A telephone interview on 9/21/2025 at 4:37 pm with R16's family stated that on 9/8/2025, while visiting mom, she (R16) verbalized that her knee was hurting. She stated she was informed by B that a CNA had transferred mom without using the mechanical lift. She stated she was told that her mom's right leg/foot was injured. She stated she immediately reported the incident to the Unit Manager. A phone interview on 9/19/2025 at 2:58 pm with the facility's Medical Director (MD) stated he was part of the Quality Assurance and Performance Improvement Meeting and discussed and reviewed the safe transfers policies. He stated that during the meeting, the team discussed educating the staff to report incidents as they happen and accurately. The MD stated he was not aware that another incident with failing to use the mechanical lift had occurred. The MD was informed on 9/8/2025 that R16 was transferred without the mechanical lift and sustained an injury to her right great toe. The MD stated he would follow up with the Administrator and the other Health Care Providers regarding R16's unsafe transfer on 9/8/2025. Cross-reference to F600

Based on record review, staff interviews, and review of the facility policy titled Oxygen Administration, the facility failed to obtain a physician's order for oxygen use, including the frequency of use and flow rate, and an order for a continuous positive airway pressure (CPAP) for one of four sampled resident (R) (R8) of four sampled residents. This deficient practice had the potential to place R8 at increased risk for respiratory complications.Findings include:Review of the policy titled Oxygen Administration reviewed/revised date 12/2025. Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. Types of delivery systems include: a. Nasal Cannula. d. CPAP Mask - This mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Review of the admission Record for R8 revealed an admission date of 7/16/2025 with diagnoses of, but not limited to, asthma, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA).Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessed as 13, which indicated cognitively intact. Section O revealed oxygen and a non-invasive mechanical ventilator while a resident. Review of the care plan initiated 7/17/2025 revealed that R8 has CPAP related to COPD. Interventions included implementing CPAP as ordered by the physician. Review of the admission summary dated [DATE] revealed: Addendum. Resident's daughter brought in CPAP machine from home. Oncoming nurse alerted. CPAP is set up and resident's bedside. He has oxygen place and functioning properly per ordered liter.Review of the Encounter Note dated 7/20/2025 revealed: Physician admission History and Physical. History of Present Illness: Right frontal hemorrhagic stroke, left side weakness. COPD with baseline 2 liters nasal cannula requirement, obstructive sleep apnea on CPAP. Maintain spot oxygen 88-92 percent. Supplement oxygen as needed. CPAP on at night.Review of the Encounter note dated 8/3/2025 by the Physician Assistant revealed: History of Present Illness: Right frontal hemorrhagic stroke left side weakness. COPD with baseline 2 liters nasal cannula requirement, obstructive sleep apnea on CPAP.Review of the electronic medical record (EMR) oxygen concentration log revealed R8 received oxygen on the following days: 7/16/2025, 7/17/2025, 7/29/2025, 8/5/2025, 8/9/2025, and 8/10/2025.Review of R8's physician order summary report revealed that there was no order written for the resident to receive oxygen or a CPAP at night.In an interview on 9/4/2025 at 2:54 pm, R8's family member, who was the responsible party (RP), stated that R8 lived at home prior to his admission to the facility. The family stated R8 was dependent on oxygen and slept with a CPAP every night. The family stated that before R8 was admitted to the facility, they received a call from the marketing liaison, and the family was told R8 could not be admitted if he did not have the CPAP machine. In an interview on 9/8/2025 at 9:09 pm, Licensed Practical Nurse (LPN) CCCC stated her regular assignment was the 500 Hall, where R8 resided. She stated R8 used oxygen and was consistent with sleeping with his CPAP machine at night. In an interview on 9/10/2025 at 8:59 am, Certified Nursing Assistant (CNA) MMMM stated R8 always had his oxygen on when in bed. In an interview on 9/10/2025 at 9:18 am, the Director of Nursing (DON) explained the admission process. The DON stated that when a resident was admitted from the hospital, the nurse was responsible for reviewing the hospital discharge orders and entering the orders into the resident's EMR. She stated on the following day, during the clinical meeting, the hospital physician's orders were reviewed, and the team ensured the orders were correctly entered into the resident's EMR. She stated there was always a Nurse Practitioner (NP) in the clinical meeting as the orders were reviewed and adjustments could be made by the NP at that time. She stated that after hours and on weekends, the nurse reviewed the hospital orders with the after-hours medical service. The DON stated she was not aware that R8's CPAP and oxygen were not part of the order summary. The DON stated she would review the resident's chart.In an interview on 9/10/2025 at 9:50 am, the DON stated R8 did use oxygen and had a CPAP machine, and there was no order. She stated that the nurses would be educated to ensure that the hospital orders were accurately transcribed.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled Medication Administration, the facility failed to assess three of 73 sampled residents (R) (R51, R482, and R456) for self-administration of medication. This deficient practice had the potential to place R51, R482, and R456 at risk of unsafe medication use and unauthorized medication access by other residents. Findings include: Review of facility's policy titled Medication Administration indicated under Practice Standards: . 8. Medication Administration. 8.1 Assist patient as needed. 8.2 Remain with patient until administration is complete. Do not leave medication at the patient's bedside. 1. Review of the electronic health record (EHR) for R51 revealed the resident was admitted to the facility with diagnoses including but not limited to cerebral infarction, type 2 diabetes mellitus without complications, chronic diastolic congestive heart failure, bronchiectasis (uncomplicated), generalized muscle weakness, dysphagia (oropharyngeal phase), and paraplegia. Review of R51's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Additional MDS findings revealed in section GG (Functional Abilities and Goals) dependency with multiple activities of daily living (ADLs), including bathing, dressing, and personal hygiene. Section H (Bladder and Bowel) documented bowel and urinary incontinence. Section M (Skin Conditions) indicated Moisture Associated Skin Damage (MASD). Review of a physician's order dated 2/27/2025 stated R51 was not capable of self-administering medications with approval and review by the Interdisciplinary Team. Review of the EHR revealed no documentation of a self-administration assessment. Observation on 6/10/2025 at 11:27 am and 12:29 pm revealed a white powdery substance on the bedside table of R51. An interview conducted at the time of the observation with R51 revealed the powder was for use down in her vaginal area. R51 stated the nurse placed the powder there in the morning so the Certified Nursing Assistants (CNAs) could apply it during care. She reported this was a common occurrence. Interview on 6/10/2025 at 12:38 am with Medication Technician (MT) LL revealed that staff were expected to remain at the bedside while residents took their medications. She explained that medications should not be left unattended. MT LL stated that if a resident refused medication, she took the medication with her and informed the nurse. She emphasized that residents were not allowed to keep medications at their bedside due to the risk of unauthorized access. Interview on 6/9/2025 at 12:41 pm with CNA/MT QQ confirmed the powder was Nystatin (an antifungal medication) and was left by the previous night shift. CNA/MT QQ stated she had not initially noticed the powder but later removed it from the bedside. She stated she had been trained to observe for unsecured medications and acknowledged that leaving medications at the bedside could result in a medication error or unauthorized access. 2. Review of the EHR for R48 revealed the resident was admitted with diagnoses including but not limited to end-stage renal disease, dependence on renal dialysis, hypertensive chronic kidney disease with stage 5 chronic kidney disease, anemia, generalized muscle weakness, and difficulty walking. Review of R48's quarterly MDS dated [DATE] documented a BIMS score of 10, indicating moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed functional limitations with ADLs, including substantial/maximal assistance required for bathing, toileting, dressing, and personal hygiene. Record review revealed no documentation of a self-administration assessment for R53. Observation on 6/10/2025 at 11:40 am revealed two pills in a clear container on the bedside table of R48. Interview at that time with R48 revealed that the medication was for her digestive system, and she did not know what the other pill was for. R48 stated the MT just set it there and left. Interview on 6/10/2025 at 12:38 am with MT LL revealed that staff were expected to remain at the bedside while residents took their medications. She explained that medications should not be left unattended. MT LL stated that if a resident refused medication, she took the medication with her and informed the nurse. She emphasized that residents were not allowed to keep medications at their bedside due to the risk of unauthorized access. Interview on 6/9/2025 at 12:41 pm with CNA/MT QQ revealed she was assigned to R48's room and recalled giving her medications. CNA/MT QQ confirmed she did not verify that R48 took the medications before she left the room. She explained she was busy, shaking, and stressed. She stated people were calling for her assistance, so she walked out. She acknowledged that it did not happen all the time but admitted this was a lapse in protocol. She confirmed that a negative outcome of leaving medication at the bedside could include a medication error or another individual accessing the medication. 3. Review of the EHR for R456 revealed the resident was admitted to the facility with diagnoses including but not limited to end-stage renal disease, osteomyelitis, type 2 diabetes mellitus without complications, peripheral vascular disease, generalized muscle weakness, and hyperkalemia. Review of a Physician Order dated 6/06/2025 stated that R456 was not capable of self-administering medications with approval and review by the Interdisciplinary Team. Review of the EHR for R456 revealed no documentation of a self-administration assessment. Observation on 6/10/2025 at 11:02 am revealed a clear medication cup containing a red liquid on the bedside table of R456. An antidiarrheal medication was also observed sitting on the resident's dresser. Interview conducted at the time of observation with R456 revealed he had refused the medication because he felt he was receiving too much, and that he had recently begun experiencing jerking movements. He stated the nurse just dropped it off and said here is your medication and left. He confirmed the antidiarrheal was his and stated his family had brought him the medication. Observation on 6/10/2025 at 11:10 am, CNA/MT QQ was observed entering R456's room and proceeded to ask R456 if he was going to take his medication. R456 told her he did not want the red liquid medication and requested that she discard it. She threw the medication away as requested. Interview on 6/10/2025 at 12:38 am, MT LL revealed that staff were expected to remain at the bedside while residents took their medications. She explained that medications should not be left unattended. Med Tech LL stated that if a resident refused medication, she took the medication with her and informed the nurse. She emphasized that residents were not allowed to keep medications at their bedside due to the risk of unauthorized access. Interview and observation on 6/9/2025 at 12:41 pm with CNA/MT QQ confirmed she had given R456 a liquid protein supplement (a wound care vitamin), and he stated he would take it right away. CNA/MT QQ stated she walked out of the room when called for assistance by another CNA and did not verify that R456 took the medication. She confirmed that when she later returned, the medication was still present and was discarded due to the resident's refusal. CNA/MT QQ acknowledged the antidiarrheal medication on R456's dresser and reported the resident's family had likely brought it in. She stated she was unaware that prescription verification was required for over-the-counter medications kept at the bedside. She added that residents sometimes tell her not to touch their belongings and expressed hesitation about removing any medications without specific instructions. Interview on 6/13/2025 at 9:50 am with the Director of Nursing (DON) revealed the facility encouraged residents not to self-administer medications unless they have a BIMS score above 12 with no signs of intermittent confusion. She stated that if a resident qualified, they were assessed for self-administration, and medications were kept in a secure, locked location at the bedside. She stated staff were expected to observe the resident taking the medication and provide hydration. She acknowledged possible negative outcomes of leaving medications at the bedside included unmonitored administration, incorrect dosage, and access by other individuals. Interview on 6/13/2025 at 9:25 am with Nurse Practitioner (NP) revealed that self-administration assessments were conducted by the clinical team to determine resident competence. She was unsure if medications were kept at the bedside or on the cart. She identified that negative outcomes from unmonitored medication access could include missed doses or unintended ingestion by residents with dementia. Interview on 6/13/2025 at 10:30 am with the Administrator revealed that residents should not have medications at the bedside. She stated the facility had experienced ongoing issues with family members bringing in medications, and staff were expected to monitor and collect such items when observed. The Administrator stated that MTs were not to leave the room before confirming that the resident had taken the medication. She further explained that all staff were expected to remain observant and report any medications found at the bedside.

Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive, person-centered care plan for one of 73 sampled residents (R) (R101). The deficient practice had the potential to place R101 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated October 2022, revealed under Policy Statement: The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered be considered in developing the care plan. Review of R101's admission record from 9/17/2024 revealed the resident had diagnoses including, but not limited to, bipolar disorder, post-traumatic stress disorder (PTSD), and hyperlipidemia. Review of R101's Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 01 (indicating the resident had severe cognitive impairment). Section E (Behaviors) documented the resident does not have any behaviors. Review of R101's care plan dated 9/19/2024 revealed no mental health diagnoses of PTSD and bipolar disorder. In an interview on 6/13/2025 at 9:20 am, the Director of Nursing (DON) verified that R101's care plan did not include the bipolar disorder or PTSD diagnoses, and stated it should. She stated her expectations were to have these diagnoses in R101's care plan. Interview with the MDS Coordinator on 6/13/2025 at 10:33 am confirmed that the care plan should have included R101's diagnoses of bipolar disorder and PTSD. She stated that it was a collaborative effort for management and staff to update all of the residents' care plans.

Based on observation, staff interviews, record review, and review of the facility's policies titled Medication Administration and Unavailable Medications, the facility failed to ensure that two of five residents (R) (R452 and R580) reviewed for medication administration received medications as ordered by the physician. Specifically, the facility failed to ensure R452 received ordered intravenous (I.V.) antibiotics, oral antibiotics, insulin injections, and oral diabetic medications after admission to the facility, and failed to ensure that R580's anti-hypertensive medications were administered as ordered by the physician. Findings include: Review of the facility's undated policy titled Medication Administration revealed under the Purpose of the Policy To provide a safe, effective medication administration process 4. Medications will be administered as soon as possible, but no more than two hours after doses are prepared. 5. Doses will be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. 5.1. If medication(s) is not available, the nurse will: 5.1.1. Coordinate with pharmacy to procure the medication(s) as soon as possible and discuss possible substitution options with the pharmacist, if applicable; 5.1.2. Notify the physician/APP of the unavailability of the medication(s); 5.1.3. Discuss substitution options for ordered medication(s) or substitutions within one hour of the prescribed time; consider medication error situation. 6. If discrepancies occur, notify physician/APP and/or pharmacy as indicated. 7. Administer medication. 8. Document: .11.1. Administration of medication on Medication Administration Record (MAR); 11.2. Patient's response to medication; 11.2.1. Notification of physician/APP, if applicable. Review of the facility's policy titled Unavailable Medications, updated June 2024, revealed the Policy included 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, PRN (as needed), and emergency medications. 2. A STAT (immediate) supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and /or specific orders for monitoring resident while medication is on hold. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. 1. A review of R452's electronic health record (EHR) revealed diagnoses including, but not limited to, bladder cancer, bladder mass, hematuria, (blood in the urine), encephalopathy (group of conditions that cause brain dysfunction), chronic kidney disease, dementia, depression, and shortness of breath. Review of R452's Entry Tracking Minimum Data Set (MDS) assessment, dated 12/20/2024, revealed the resident was admitted to the facility from a short-term general hospital on [DATE]. Review of R452's Discharge MDS Assessment, dated 12/23/2024, revealed the resident was discharged on 12/23/2024 to a short-term general hospital. Review of the hospital Discharge summary, dated [DATE], revealed that, prior to admission to the facility, R452 was hospitalized with hematuria (blood in the urine), sepsis (a life-threatening illness caused by infection), bacteremia (bacteria in the bloodstream), and hydronephrosis (a buildup of urine in the kidney). Further review of the hospital discharge summary revealed that the resident was to continue medications including, but not limited to, ceftriaxone 2 grams (gm) intravenous (IV) push every 12 hours, ampicillin 2 gm IV in 100 milliliters (ml) of 0.9 percent sodium chloride to be administered every 8 hours, insulin lispro 100 units/ml, inject five units subcutaneously three times daily before meals, empagliflozin 10 mg by mouth every morning, and Lantus Solostar U-100 insulin glargine 35 units subcutaneously in the abdomen nightly. Review of R452's medication administration record (MAR) dated 12/1/2024 to 12/31/2024 revealed the following medication orders: Dapagliflozin Propanediol 5 mg tablet, give one tablet by mouth one time a day for DM [diabetes mellitus] starting 12/21/2024 at 9:00 am. There was no documentation of the medication being administered or a reason for omission on the MAR on 12/21/2024 or 12/22/2024. Novolog FlexPen100 unit/ml solution pen-injector, inject five units before meals subcutaneously starting 12/21/2024 at 8:00 am. There was no documentation of the medication being administered or a reason for omission on the MAR on 12/21/2024 or 12/22/2024. Ampicillin sodium intravenous solution reconstituted 2 gm (grams) (Ampicillin Sodium), use 2 GM intravenously three times a day for infection, starting 12/21/2024 at 9:00 am. The MAR was coded as a 9 on 12/21/2024 and 12/22/2024 for all six scheduled doses, and one dose was administered on 12/23/2024 at 9:00 am. Review of the Chart Codes on the MAR revealed 9 indicated Other/See Progress Notes. Review of the Progress Notes revealed no documentation of a reason for medication omission. Ceftriaxone sodium injection solution reconstituted 2 gm (Ceftriaxone Sodium), use 2 gm intravenously two times a day for infection starting 12/21/2025 at 9 pm. The MAR was coded as 9 on the 12/21/2024 9:00 pm, 12/22/2024 9:00 am, and 9:00 pm dates, and one dose was administered on 12/23/2024 at 9:00 am. Review of the Chart Codes on the MAR revealed 9 indicated Other/See Progress Notes. Review of the Progress Notes revealed no documentation of a reason for medication omission. Doxycycline Hyclate oral tablet 100 mg, give one tablet by mouth one time only for infection starting 12/21/2024 at 9:00 am. There was no documentation of the medication being administered or a reason for omission on the MAR on 12/21/2024. Doxycycline Monohydrate 100 MG capsule, give one capsule by mouth one time a day for UTI (urinary tract infection) starting 12/21/2024. There was no documentation of the medication being administered or a reason for omission on the MAR on 12/21/2024 or 12/22/2024. Review of R452's Blood Sugar Summary revealed the resident's blood sugar was checked on 12/21/2024 at 4:21 am, with results of 208. There were no other blood sugar checks for R452 documented. Review of the Progress Notes revealed an entry dated 12/20/2024 at 8:10 pm of At approximately 7:10 pm, resident arrived at the facility via stretcher, accompanied by EMS (emergency medical services) and his wife. Further review revealed an entry dated 12/23/2024 at 12:15 pm documenting the resident had an elevated temperature of 101.4 [degrees Fahrenheit] and acetaminophen tablet 325 mg, two tablets were administered. An entry dated 12/23/2024 at 1:12 pm documented that the resident had a change in condition, the resident's temperature was 101.6 [F], and the primary care provider recommended that the resident go to the emergency room (ER). Continued review revealed entry dated 12/23/2024 at 1:30 pm documented Patient transferred [local hospital] at 13:30 for elevated temperature R/T [related to] sepsis. Patient assessed by NP [Nurse Practitioner] and order given to sent patient to ER. Patient seems lethargic and not at baseline. No complaints of pain at this time. Review of the EHR revealed R452 did not return to the facility. In an interview on 6/12/2025 at 8:15 am, the Director of Nursing (DON) stated that when a resident was admitted after hours, daily medications were normally delivered the following day. She stated that antibiotics were available in the facility in the automated medication storage/administration system, allowing treatment to begin without delay. The DON further revealed that if there was a concern regarding a possible allergy to the ordered antibiotics, the nurse was expected to contact the provider for directions to prevent a delay in treatment. If the ordered antibiotics were not available, the nurse may request that the hospital send the next dose of IV antibiotics with the resident. If that was not an option, the nurse was expected to contact the provider for guidance on how to proceed until the medication was delivered. The DON added that ceftriaxone and ampicillin were medications usually available at the facility. The DON was unable to explain why R452 did not receive doxycycline until 12/23/2024 or why the nurse did not contact the provider to clarify the ceftriaxone order. Review of the automated medication storage/administration system's emergency medication list with the DON confirmed that the medications were available at the facility. The DON was unable to explain why the resident's blood glucose was only checked once during the three-day stay or why the diabetic medications were not administered. She stated that if a resident was diabetic, their blood sugar was expected to be checked. She further confirmed that nurses were not permitted to leave blanks in the MAR and could not explain why the antibiotics and diabetic medications were neither given nor documented. If a medication was not administered, staff were required to document the reason, whether the medication was unavailable, refused by the resident, or for any other reason. The DON further revealed that her expectation was for all staff to follow the physician's orders and administer medications as ordered. In an interview on 6/13/2025 at 11:00 am, the Assistant Director of Nursing (ADON) provided a list of medications stored in the automated medication system, and ampicillin, doxycycline, and ceftriaxone were all listed as available medications in the automated medication system. In an interview on 6/12/2024 at 10:00 am, the Administrator stated that the facility investigated R452's medication administration. Review of the investigation revealed documentation that the resident's medications had been delivered to the facility the day after his arrival. The Administrator noted that one of R452's medications was held due to a possible allergy to penicillin, and staff were in the process of clarifying this information. However, the resident was transferred out before clarification was obtained. The report also stated, All other medications were delivered and given as prescribed. When the surveyor asked the Administrator how she knew that medications were given as prescribed and whether she reviewed the MAR, she responded that she was not clinical and had asked a nurse to provide a report of what had happened. In that report, written by Registered Nurse (RN) NN on 1/3/2025, RN NN documented, Ampicillin was charted as not given r/r allergy to clin. [sic] In an interview on 6/12/2025 at 2:45 pm, Nurse Practitioner (NP) GG stated that she remembered R452 well. When asked whether it was standard nursing practice in the facility not to notify the provider if an ordered antibiotic was unavailable or if a resident was allergic to a prescribed medication, the NP responded that it was not, and that she expected staff to notify her. She added that she was not in the facility on weekends and did not see the resident until Monday. She reported that when she saw the resident for the first time on 12/23/2024, he was febrile (an elevated temperature) and lethargic. She noted that the resident's most recent hospital discharge diagnosis included sepsis and that he was supposed to be receiving IV antibiotics, and due to his condition, NP GG transferred the resident back to the ER for evaluation and treatment. 2. Review of R580's EHR revealed diagnoses including, but not limited to, acute or chronic diastolic (congestive) heart failure (CHF), paroxysmal atrial fibrillation, essential hypertension, and chronic kidney disease. Review of R580's Physician's Orders revealed the following orders: 5/29/2025: Losartan potassium oral tablet 100 mg, give one tablet by mouth in the morning for CHF. 5/28/2025: Hydralazine HCL [hydrochloride] oral tablet, give one tablet by mouth three times a day for HTN [hypertension]. 5/29/2025: Furosemide oral tablet 20 mg, give one tablet by mouth in the morning for CHF. 5/28/2025: Carvedilol oral tablet 25 mg, give one tablet by mouth twice a day for HTN; take with meals. 5/28/2025: Amiodarone HCL oral tablet 200 mg, give one tablet by mouth every morning and at bedtime for atrial fibrillation. Observations during observation of a medication pass on 6/11/2025 at 8:45 am by Licensed Practical Nurse (LPN) BB revealed LPN BB checked R580's blood pressure (BP) and heart rate (HR) prior to administering medications. The readings were BP 136/61 and HR 63. LPN BB administered the losartan potassium but did not administer the hydralazine HCL and carvedilol. She documented both medications as not given on the MAR. Review of the MAR revealed that the blood pressure medications did not include parameters to hold. When asked why she chose which medication to give and which to hold, LPN BB was not able to explain how she selected those two medications among the three and stated she was afraid the resident's blood pressure might drop and that she would recheck it later. In an interview on 6/11/2025 at 2:00 pm, NP GG revealed that she did not always include specific parameters for holding blood pressure medications, as it depended on the individual resident's condition. She explained that if a nurse encountered a borderline BP reading, they were expected to consult with her before making a decision. NP GG reported that she was in the facility five days a week, and between her and the Physician Assistant (PA), there was always a provider on-site. She emphasized that nursing staff were expected to notify the provider if they encountered abnormal vital signs, and the decision to hold or administer BP medications would be made by the provider. When asked if R580's carvedilol and hydralazine HCL should have been administered or held with a BP reading of 136/61 and HR of 63, she stated that the medications should have been administered. In an interview on 6/11/2025 at 4:00 pm, the DON stated that her expectations for nurses were to follow the provider's orders and, if in question, contact the provider for guidance.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure medications were not available for use past their expiration date and were stored in the original container on two of seven medication carts (Hall 900 and Hall 800). These deficient practices created the potential for residents to receive medications with altered effectiveness. Findings include: Review of the facility's policy titled Medication Storage, revised December 2022, revealed under Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments) i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. b. Temperatures are maintained within 36-46 degrees F (Fahrenheit). Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee. c. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such finding to the Maintenance Department for emergency repair .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. 1. Observation on 6/11/2025 at 8:30 am of the medication cart on 900 Hall with Licensed Practical Nurse (LPN) AA revealed one bottle of folic acid 1000 micrograms (mcg) with an expiration date of 1/2025. LPN AA removed the expired medication from the cart and stated that both day and night shift nurses were responsible for checking medications for expiration dates as part of their routine. 2. Observation on 6/11/2025 at 9:04 am of the medication cart on 800 Hall with LPN BB revealed the top drawer contained a medication cup full of pink capsules. When asked what medication it was, LPN BB stated it was Benadryl. When asked how she knew it was Benadryl, she said she recognized the capsules by appearance. When asked whether storing the medication out of the original package was acceptable nursing practice, LPN BB confirmed that it was not. In an interview with the Director of Nursing (DON) on 6/11/2025 at 4:00 pm, she stated that she expected staff to follow the facility's medication storage policy. The DON stated that when a new medication container was opened, staff were required to label the box with the date of opening using a marker. Expired medications must be discarded. She stated that it was not allowed to keep unlabeled medications in a medication cup and that medications must remain in their original containers, and nurses were not permitted to identify medications by appearance. In an interview with the ADON on 6/12/2025 at 9:00 am, she stated that medications were routinely checked for expiration dates and discarded before they expired. She also confirmed that all medications must remain in their original containers and may not be stored in open medication cups.

Based on observations, staff interviews, record review, and review of the facility's policies titled Handwashing/Hand Hygiene and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently perform hand hygiene during two of four medication pass observations and failed to sanitize shared medical equipment between residents during one of four medication pass observations. This failure had the potential to increase the risk of infection transmission among staff and residents. Findings include: Review of the undated facility policy titled, Handwashing/Hand Hygiene revealed the Policy Interpretation and Implementation section included . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap(antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . l. After contact with objects (eg., medical equipment) in the immediate vicinity of the resident . Review of the undated facility policy titled Cleaning and Disinfection of Resident-Care Equipment revealed the Policy Interpretation and Implementation section included . 3. b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident d. Multiple-resident use equipment shall be cleaned and disinfected after each use. Observation of a medication pass on 6/11/2025 at 8:10 am with Licensed Practical Nurse (LPN) AA revealed there was no alcohol-based hand rub (ABHR) located on the medication cart. LPN AA prepared and administered medication to R592 without performing hand hygiene with ABHR or soap and water before or after administering the medications. Observation revealed ABHR was available from a dispenser in the hallway. LPN AA then obtained ABHR from the nurses' unit, placed it on the medication cart, and performed hand hygiene. When questioned by the surveyor immediately following the observation about whether hand hygiene should have been performed, the nurse acknowledged that yes, hand hygiene should have been performed before and after contact with residents, and admitted that she had not done so. Observation of a medication pass on 6/11/2025 at 9:30 am with LPN CC revealed LPN CC prepared and administered medications to R57 without performing hand hygiene before or after administering the medications. Further observation revealed LPN CC used a shared blood pressure cuff to check R57's blood pressure and did not sanitize the cuff before or after checking the resident's blood pressure. When questioned by the surveyor immediately following the observation about whether hand hygiene and cleaning of shared equipment should have been performed, the nurse acknowledged that she should have sanitized her hands but did not, and stated she was unsure about cleaning the blood pressure cuff. In an interview on 6/11/2025 at 4:00 pm, the Director of Nursing (DON) stated that she expected staff to perform hand hygiene before and after any contact with each resident and before and after administering medications. She further stated that shared medical equipment should be cleaned and sanitized between each resident.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to assess for the ability to self-administer medications prior to leaving medications at the bedside for one of 42 sampled residents (R) (R118). The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility's policy titled Medication Administration revised January 2023 indicated the following: Policy Explanation and Compliance Guidelines: 15. Observe resident consumption of medication if resident requests meds to be left at bedside, confirm cognition prior to. Review of the medical record for R118 revealed diagnoses including but not limited to secondary malignant neoplasm of bone cancer, spinal stenosis thoracic region, other hydronephrosis, hypercalcemia, personal history of other disease of the digestive system, long-term use of opiate analgesic, essential hypertension, hypokalemia, personal history of healed traumatic fracture. Review of R118's Physician orders revealed an order on 1/27/2024 for oxycodone extended-release tablet 20 milligrams (mg), 10/19/2023 for losartan potassium tablet 50 mg, 10/19/2024 for prednisone tablet 5 mg, 10/19/2024 for bisacodyl tablet delayed release 5 mg, 11/10/2023 for Tylenol extra strength 500 mg, 11/8/2023 for Colace capsule 100 mg, 11/15/2023 for metoprolol succinate tablet extended release 24-hour 25 mg, 11/6/2023 for tamsulosin capsule 0.4 mg, 10/25/2023 for levothyroxine sodium 88 microgram, 12/24/2023 for sennosides tablet 8.6 mg, and 1/20/2024 for Pepcid tablet 20 mg. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R118 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Review of the clinical record revealed there was no assessment for medication self-administration. Observation/Interview on 1/30/2024 at 12:10 pm revealed a small cup of approximately eight pills, cough syrup, two boxes of holistic medications, and one box of pain pads sitting on a bedside table. R118 revealed he forgot to take his medications left at his bedside and took his oxycodone earlier because of the pain from his cancer. R118 further revealed the nurse waited for him to take his narcotics medication before they left him, but the medical assistant leaves his regular medications at bedside. Interview on 1/31/2024 at 11:00 am with Certified Medical Assistant (CMA) AA stated she had been trained properly on how to administer medications. She stated that she had received several in-services/educations on administering medications and observances of medications at resident's bedside. She stated she cannot walk away until the resident takes their medications and then she removes the medication cup from the room. She mentioned that none of the CMAs are required/allowed to administer narcotics to residents. CMA AA stated she was out for two days, and CMA BB was assigned to her hall and assisted R118 for administering all his medications but excluding oxycodone. CMA AA further revealed R118 only liked taking his pain medication of oxycodone due to the discomfort from his progressing cancer. Interview on 1/31/2024 at 11:30 am with Licensed Practical Nurse Unit Manager (LPN/UM) CC confirmed and verified the medications were in R118's room. LPN/UM CC began to remove medications from R118 bedside table and explained to R118 she needed to check with the physician to make sure the other holistic medications do not interfere with his other medications. Interview on 1/31/2024 at 11:35 am with Nurse Practitioner (NP) DD confirmed R118 had not been assessed or deemed appropriate to self-administer his medications. NP DD mentioned R118 had an upcoming meeting with the physician on Friday to discuss R118 being placed on hospice care due to his progressing cancer and cognitive health decline. NP DD stated she doubted if the physician would create an order for self-administering of the medications that were located at R118's bedside. Interview on 2/1/2024 at 3:00 pm with the Director of Nursing (DON), she stated that currently there was not a resident residing in the facility who had been assessed and deemed appropriate to self-administer medications. The DON confirmed R118 did not have a physician order for the medications that were located at the resident's bedside on his meal tray. The DON further stated that there should not be any medications left at the resident's bedside, and she expected the residents to take their medication, and if not, the nurse should educate the resident. The DON stated if a resident does not take their medications, the nurse and/or CMA should call the doctor.

Based on staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the Medication Administration Record (MAR) documentation was completed for one of 42 sampled residents (R) (R31). Findings include: Review of the policy titled Medication Administration dated January 2023 revealed the policy was: Medication is administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section revealed: 17. Sign MAR after administered. For those meds requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign the narcotic book. Review of diagnoses for R31 included, but not limited to, chronic pain syndrome. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C-Cognition, Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment; section GG-Functional Abilities and Goals, required partial/moderate toilet assistance, and maximum assistance to bathe/shower and set up with personal hygiene; required an assistive device for mobility; section O-Special Treatments, no special procedures, treatments, nor programs. Review of the care plan revealed a focus area for chronic pain related to a history of cerebral vascular accident [CVA (stroke)]. Review of the physician's orders for R31 revealed an order dated 1/8/2024 for Lyrica oral capsule 75 milligrams mg (a medication used to treat pain) give 1 capsule by mouth two times a day for chronic pain. Review of the January 2024 MAR revealed there were 62 opportunities for Lyrica 75 mg with 21 missed episodes of documentation. Interview on 2/1/2024 at 11:44 am with Unit Manager (UM) EE, UM EE verified the missing documentation for the administration of Lyrica on R31's January 2024 MAR. UM EE and UM CC stated they didn't think the missing documentation could be possible. Interview on 2/1/2024 at 3:00 pm with the Infection Preventionist Nurse (IP) revealed that licensed nurses only sign out narcotics, and they sign the blue control substance book when they take the medication. She stated the MAR is to be initialed when the medication is given. She stated the night shift staff are supposed to go back and check the MAR every day. She said the Electronic Medical Record (EMR) system should turn red when a medication is given and there is no initial documented on the MAR for giving that medication. Interview on 2/1/2024 at 3:10 pm with the Director of Nurses (DON) revealed that routine medications are given by the Certified Medication Tech (CMA) and the narcotics are given by the licensed nurse. She said that each CMA is assigned to a nurse and the CMA informs the nurse when it is time for the narcotic to be given. She stated the CMA does not have keys to the narcotic drawer even though it is on the same cart. She said the problem is the nurse must access the same MAR as the CMA and that causes a problem for documentation because only one can be in the cart at the same time. The DON stated that it must be done because the MAR and the narcotic book must match. She stated when the nurse pulls the medication from the narcotic drawer, it is to be signed out immediately, and the MAR should be initialed when the narcotic is given to the resident.

AMENDED 11/30/2023 Based on staff interviews, record review, and review of the facility policy titled, Pressure Injury Prevention and Management the facility failed to identify and treat a pressure wound for one of five sampled residents (R) (R1) reviewed for pressure ulcer prevention and treatment. Harm was identified to occur on 7/29/2023 when the facility failed to identify and treat the wound resulting in the resident being sent out to the hospital for diagnosis of septic shock due to an infected sacral decubitus wound with bacteremia and requiring surgical debridement of the wound. Findings included: A review of the facility's policy titled, Pressure Injury Prevention and Management with a revision dated of February 2023, indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. A review of the Admission Record for R1 revealed admission diagnoses that included acute chronic systolic congestive heart failure, chronic kidney disease, and protein-calorie malnutrition. A review of R1's care plan, dated 7/12/2023, revealed the resident was at risk for skin impairment due to decreased mobility and incontinence issues. There was no documentation that the resident had a pressure ulcer. A review of the quarterly Minimum Data Set (MDS) assessment, dated 7/17/2023, indicated R1 had a Brief Interview of Mental Status (BIMS) score of 11, indicating mild cognitive impairment for daily decision making; that R1 was at risk for developing pressure ulcers; and no pressure ulcers documented on admission. A review of R1's physician orders revealed no treatments for a pressure wound. A review of R1's Behavior Note, dated 7/28/2023, revealed a family member had concerns with foul smelling urine, and increased confusion. The family asked staff to continue to turn and repositioned the resident every two hours due to the resident having some skin breakdown to the sacrum. This was documented by Licensed Practical Nurse (LPN) CC. A review of R1's shower sheet, dated 7/29/2023, revealed no skin conditions documented for the resident during the residents bathing time. A review of R1's skin checks, dated 7/29/2023 at 6:54 pm, revealed R1 had blister to right front upper hip. There was no documentation of the sacral pressure wound. A review of R1's hospital discharge summary, dated 8/7/2023, revealed the resident presented to the emergency department (ED) on 7/29/2023 at 5:49 pm. The patient was noted to have a foul-smelling sacral wound. The physician ordered a wound culture on 7/30/2023 at 12:57 am. The resident was treated during the stay for septic shock due to an infected sacral decubitus wound with bacteremia and the wound was present on admission. R1 had surgical debridement on 8/1/2023 and a wound vac was placed on 8/2/2023. During an interview on 10/18/2023 at 12:08 pm, LPN CC stated if a wound was identified she would dress the wound and leave it for the wound care nurse to pick up. She stated she would put a notification of the wound on the 24-hour report and pass it on to the next nurse. She stated she could not really remember the resident and could not remember if they had a wound. She stated she was not aware of the process for this facility once a wound was identified. During an interview on 10/19/2023 at 9:09 am with LPN FF, she stated she remembers R1, but she did not recall them having a wound to their sacral region. The LPN stated she was not aware the resident had a sacral wound on admission to the hospital. During an interview on 10/19/2023 at 10:37 am with the Director of Nursing (DON), she stated the facility does admission overall skin assessments. The DON stated she did not see where R1 was being treated for a sacral wound. She stated she feels like her team would have found the wound if R1 had a wound while in the facility. During an interview on 10/24/2023 at 12:55 pm, Nurse Practitioner (NP) GG stated he had seen this resident one or two times. He stated R1 had abnormal labs which contributed to them going to the hospital. He stated the nursing staff sent R1 to the hospital for a change of condition. He stated if the resident had a wound, the wound should have been in the wound notes. He stated he expected the staff to follow their wound assessment schedule. During an interview on 10/25/2023 at 10:26 am, Certified Nursing Assistant (CNA) DD stated when she gives a bath/shower she does a full skin check and if there were any changes in the skin, she would report it to the nurse. She stated R1was a total assist and she gave her a bed bath. She stated R1 had not had a wound that she remembered. During an interview on 11/9/2023 at 9:13 am with NP HH, she stated she admitted R1. She stated she was on leave when R1 went out to the hospital. She stated breakdown could happen in a week if the resident was laying and urinating on themselves. She stated R1 to her knowledge did not have a wound. She stated she could not speak to R1's wound because the resident did not have it on admission. She stated a wound could not get an infection and develop within seven hours on admission to the hospital. During an interview on 11/9/2023 at 10:40 am, the Administrator stated the facility staff will identify and treat wounds on admission and any wound identified inhouse will be treated as soon as identified. She was made aware of the findings during the survey.

Based on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to complete a thorough investigation for one of three sampled residents (R) (R25) reviewed for misappropriation of personal property. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, revision date 9/8/2022, revealed An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse neglect or exploitation occur . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. A review of R25's Admission Record revealed a diagnosis that included chronic pain syndrome. A review of R25's Order Summary Report, dated 5/11/2023, revealed an order for Fentanyl Transdermal Patch 72 hour 25 micrograms (MCG)/ hour (HR) (Fentanyl) apply one packet transdermal every 72 hours for chronic pain. A review of a facility report dated 6/22/2023 revealed R25's fentanyl patches were never delivered to the facility for the resident. A review of R25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R125 had a Brief Interview of Mental Status (BIMS) of 15 indicating the resident was cognitively intact for daily decision making. The MDS indicated the resident had received Opioid's four out of the seven days on the look back. A review of R25's care plan, with revision date of 9/27/2023, revealed the resident had complaints of acute and chronic pain. Interventions in place were to administer pain management as ordered. A review of the facility's investigation revealed there was one statement obtained or signed by staff on duty the night of the incident. There were multiple nurses and Certified Nursing Assistants (CNAs) on duty the night the medications were delivered. During an interview on 10/30/2023 at 9:32 am, the Director of Nursing (DON) stated the process would be to interview everyone who was there when the medication was delivered. She stated there were a couple of nurses sitting at the nurse's station on the film. She stated she questioned them. She was asked if there were statements from the nurses at the nurse's station that witnessed the incident. She stated she did not have statements from the nurses at the nurses' station. She stated she would need to ask the Administrator if there were statements. There were no statements provided. She stated the nurses were questioned and educated on the proper procedure to receive medications from the courier. During an interview on 10/30/2023 at 3:06 pm the Administrator stated she spoke with other staff members. She stated she would need to ask the DON if there were statements from those staff members. She stated they made verbal statements but may not have signed statements. She stated written statements were something that was usually obtained during an investigation.

Based on staff interviews, record review, and review of the facility policy titled, Notification of Changes the facility failed to provide care and treatment according to professional standards for two of 33 sampled residents related to (1) failing to notify the physician when a resident's blood pressure was out of range for R10; and (2) failing to follow physician's orders to obtain a urinalysis for R32. Findings included: A review of the facility's policy titled, Notification of Changes, revision date of January 2023, indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident' s physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. 1. A review of Resident (R) 10's Admission Record revealed admission diagnoses that included chronic kidney disease and type two diabetes without complications. A review of R10's care plan, revision date 4/11/2023, revealed R1 has a history of urinary tract infections (UTI). A review of R10's Order Summary Repot, dated 7/19/2022, revealed a laboratory order for a urinary analysis (UA) with culture and sensitivity (C&S). A review of R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R10 had a Brief Interview of Mental Status (BIMS) of 14 indicating the resident was cognitively intact for daily decision making. R10 required extensive assistance with toileting. R10 was always incontinent of bladder. A review of R10's nurses notes, dated 7/19/2023 through 8/3/2023, had no documentation as to why the UA was not obtained. There was no physician notification the UA was not obtained. During an interview on 10/23/2023 at 11:41 am with Licensed Practical Nurse (LPN) II she was asked for the laboratory results for the UA ordered on 7/19/2022. During a follow up interview on 10/23/2023 at 1:00 pm LPN II stated she could not find the UA results for 7/19/2022. She stated she looked in both systems because they had changed systems and could not find where the urine was tested . During an interview on 10/24/2023 at 9:14 am with the Director of Nursing (DON) she stated the physician had discontinued the order in July because the resident had just been in the hospital and had a UA in June. She was asked when it was discontinued and if there was a note to show why it was discontinued and was it prior to the resident going to the hospital on 8/3/2023 because according to documentation the order was discontinued on 8/11/2023 which was after the resident went to the hospital. She stated she would need to look to see if anyone documented they obtained a physician order to discontinue the UA. The DON did not provide any further documentation. During a follow up interview on 10/30/2023 at 9:49 am the DON stated if the physician put the UA order in today it should be collected that day. If attempts were made but not collected, try again the next day. The results should take three days at the lab. During an interview on 10/24/2023 at 1:05 pm with Physician JJ he observed the order and the discontinued date in the medical record. He stated he could not answer why the UA was not obtained. He stated if he signed the order, he expected the UA to be obtained. 2. A review of R32's Admission Record revealed admission diagnoses which included chronic kidney disease and hypertensive heart disease. A review of R32's care plan, revision date 10/22/2023, revealed R32 was at risk for complications related to hypertension. A review of R32's annual MDS assessment dated [DATE], revealed R32 had a BIMS score of 00, indicating the resident had severe cognitive impairment for daily decision making. A review of R32's Order Summary Report, revealed lisinopril tablet 2.5 milligrams (mg) given by moth one time a day for kidney protection. There was no indication of when to notify the physician if blood pressure was high. A review of the Medication Administration Record, dated October 2023, revealed Lisinopril tab 2.5 mg had not been given on 10/17/2023, 10/18/2023, and 10/19/2023. There was a nine above the initial on the MAR which indicated the resident did not get the medication. A review of R32's vital signs, dated 10/19/2023, revealed the resident had a blood pressure of 192/116 millimeters of mercury (mmHG). Staff interviews and record review revealed no negative outcome to the resident. A review of R32's nurses notes, dated 10/19/2023, was reviewed and no physician notification was documented for the BP of 192/116. During an interview on 10/23/2023 at 4:01 pm with LPN LL she stated the nine above the initial on the MAR means the resident did not get the medication and the medication was not on the cart. During an interview on 10/23/2023 at 4:36 pm with DON she stated she was not aware the resident had missed their lisinopril three days in a row. She stated if the resident has more than one blood pressure (BP) medication, the physician will hold the BP medication until received from the pharmacy and require staff to monitor the resident to ensure there are no issues with the resident and their BP. The physician should be notified if the resident has a BP 130/90 or higher. During an interview on 10/23/2023 at 5:32 pm with Certified Medication Aide (CMA) MM she stated she recalled taking the BP. She stated a BP too high would be 155/90 and she should tell the nurse. She stated It was her first day for orientation by herself and she did not notify the nurse of the BP she obtained of 192/116. During an interview on 10/23/2023 at 5:09 pm with Physician JJ he stated he did recall that there were some issues with pharmacy sending the medication. He stated if the resident had more than one BP medication, he would give them an order to hold the medication until it arrives from the pharmacy, and he should be notified if the resident's BP was not controlled. He stated with a BP of 192/116 the physician should have been notified. He stated this BP should have prompted a repeat BP and a call to the physician.

Based on staff interviews, record review and review of the facility pharmacy manual titled, Medication Ordering and Receiving from Pharmacy the facility failed to follow the procedure for medications received from the pharmacy for one of three residents (R) (R25) reviewed for misappropriation of personal property. Findings included: A review of the facility pharmacy manual titled, Medication Ordering and Receiving from Pharmacy, revision date January 2018, revealed Upon arrival at the facility, the [courier/driver] delivers the medication directly to a licensed nurse, facility representative or to an Automated Dispensing System (ADS). The pharmacy provides a method such as a manifest, for both parties to confirm delivery and receipt of all items. The nurse receiving the delivery provides a written or electronic signature to the [courier/driver] as proof of delivery, or in the case of delivery to and ADS, an electronic receipt is generated. A review of R25's Admission Record revealed a diagnosis that included chronic pain syndrome. A review of R25's Order Summary Report, dated 5/11/2023, revealed an order for Fentanyl Transdermal Patch 72 hour 25 micrograms (MCG)/ hour (HR) (Fentanyl) apply one packet transdermal every 72 hours for chronic pain. A review of R25's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R10 had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact for daily decision making. The MDS indicated the resident had received Opioid's four out of the seven days on the look back. A review of R25's care plan, revision date 9/27/2023, revealed the resident has complained of acute/chronic pain. Intervention was to administer pain management as ordered. A review of the pharmacy list of medications delivered, dated 6/12/2023, revealed three Fentanyl patches were delivered. The list of medications delivered was signed by Licensed Practical Nurse (LPN) II with no date or time. LPN II stated she did not sign for those medications and the fentanyl patches were not in the delivery. A review of the electronic printed signature, dated 6/12/2023, revealed LPN II printed her name on the electronic record. LPN II verified the printed name on the electronic record was her handwriting, but stated she never received the hard copy with the listed medications from the courier the night the medications were delivered. A review of a Facility Incident Report Form, dated 6/22/2023, revealed R25's fentanyl patches were never delivered to the facility for the resident. A review of a statement, dated 6/22/2023, revealed LPN NN stated she did not sign for the medications on 6/12/2023. A review of an email sent to the pharmacy, dated 6/22/2023, revealed LPN NN admitted to signing the electronic tablet for the medications, but did not sign the pharmacy hard copy because it was not presented at the time of the delivery. During an interview on 10/25/2023 at 1:59 pm with pharmacist 00 she stated there were two methods of signatures to receive medications. She stated one was an electronic handheld and the other one was a paper delivery which itemized everything sent. She stated the paper delivery sheet was not dated the night of the delivery, but it was signed by LPN PP. She stated the electronic signature was signed by LPN PP on June 12th at 7:25 pm. She stated three patches were sent. She stated the order was dated 6/8/2023 and it was not sent to us until 6/12/2023 at 7:21 am when the fax hit our system. She stated if the facility has signed for the medication, they are supposed to be verifying what was in their delivery. If they sign the electronic or the paper copy, they own it. During an interview on 10/25/2023 at 2:27 pm LPN PP stated the pharmacy brings narcotics in a red bag. She stated the nurse opens the bag and checks off all the medication against a medication list to make sure what the pharmacy sent matched the list. She stated she did not remember signing for the narcotics that night. She stated she received the medications for that night but does not remember the Fentanyl patches being in the delivery. She stated she did not remember if the patch was listed on the medications that had come in that night. She stated that was not her signature on the hard copy with the listing of the medications. She stated the courier did not require an electronic signature at that time. She stated she was suspended for three days because she was the one who checked in the medications. A follow-up interview on 10/25/2023 at 3:57 pm with LPN II was conducted. She observed the signature to verify if she signed the sheets. She stated the print on the electronic record was her printed wiring, but the signature on the hard copy with all the medications listed was not her signature. During an observation on 10/25/2023 at 4:44 pm, was made of a drug delivery by the pharmacy. LPN II was observed receiving the delivery of the medications. She stated the red bag comes inside the blue bag and the courier brings two slips to verify the medications delivered. She stated one hard copy was for the pharmacy and one hard copy was for our records. She stated each sheet was signed as the medications are verified. She stated staff verify the medications then sign the hard copies then sign the electronic record. During an interview on 10/30/2023 at 8:46 am LPN II stated the courier would not leave the medications without someone checking the medications into a nurse. She stated if that was to happen, and she had never heard of it happening, she would immediately notify the DON and the Administrator. During an interview on 10/30/2023 at 9:32 am the Director of Nursing (DON) stated if the courier left the medications and there were no sheets to check in the medications the staff should have called the courier back to verify the medications. She stated the staff should have called the pharmacy and let them know the courier left the medications and the courier needed to return to the facility to verify the medications. She stated no one contacted the pharmacy the night the courier left the medications. During an interview on 11/1/2023 at 9:33 am the Administrator stated the facility staff had no idea a staff member had not signed for the medications that were delivered. She was made aware that the staff was not checking off the medications per protocol and not calling the pharmacy that night to verify the medications which were delivered by the pharmacy was her staff not following facility protocol. She stated she understood.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Errors the facility failed to maintain a medication error rate of less than five percent (%). There were three errors made in 25 opportunities, resulting in a medication error rate of 12.0 %. These errors affected three out of four residents (Resident 31, Resident 32, and Resident 33) observed during medications pass. Findings included: A review of the facility's policy titled, Medication Errors, with a revision date of February 2023, indicated, The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. 1. A review of the Admission Record for R31 revealed admission diagnoses that included acute respiratory failure, and chronic obstructive pulmonary disease. A review of the quarterly Minimum Data Set (MDS) assessment, dated 9/19/2023, indicated R31 had a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairment for daily decision making. A review of R31's Order Summary Report, revealed Flonase suspension 50 micrograms/actuation (MCG/ACT) (Fluticasone Propionate) one spray in both nostrils one time a day for cough. During an observation made on 10/17/2023 at 8:43 am of Licensed Practical Nurse (LPN) AA during morning medication pass, she was observed to administer R31's nose spray and administered two sprays in both nostrils. During an interview on 10/17/2023 at 8:48 am with LPN AA, she stated she gave two sprays in each nostril. She was asked to review the physician's orders for the nose spray, and she stated the medication should have only been one spray in each nostril. 2. A review of the Admission Record for R32 revealed admission diagnosis that included hypertensive heart disease without heart failure. A review of the quarterly MDS assessment dated [DATE] indicated R32 had a BIMS score of 00, which indicated the resident was severely cognitively impaired for daily decision making. Active diagnosis included hypertension. A review of R32's care plan, with revision dated 10/22/2023, revealed the resident was at risk for complications related to hypertension. Interventions were to give medications as ordered. A review of R32's Order Summary Report, revealed lisinopril tablet 2.5 milligram (mg) by mouth one time a day for kidney protection. During an observation made on 10/17/2023 at 8:14 am of LPN AA during the morning medication pass, she was documenting lisinopril 2.5 mg not given in the computer. She stated when the medication had not come in from pharmacy, but was reordered, and she was required to document the medication as not given. She stated she would notify the physician the medication was not given. 3. A review of the Admission Record for R33 revealed admission diagnoses that included cholecystitis and acute pancreatitis. A review of the quarterly MDS assessment, dated 10/19/2023, indicated R33 had a BIMS score of 12, indicating mild cognitive impairment for daily decision making. A review of R33's care plan, dated 10/16/2023, revealed the resident was at nutritional risk related to multiple medical problems and nutrition/hydration via percutaneous endoscopic gastrostomy (peg) tube. A review of R33's Order Summary Report, revealed Metoclopramide HCL oral solution 10 milligrams (mg)/10 milliliter (ml) (metoclopramide HCL) give 5ml via peg tube every 8 hours for nausea and vomiting. During an observation on 10/17/2023 at 9:19 am of LPN BB during the morning medication pass, she administered Metoclopramide tablet 5mg via peg tube. The order on the bubble pack read give 15 mg via peg tube every 8 hours as needed. This order was discontinued and a new order for an oral solution was in place. During an interview on 10/17/2023 at 9:29 am with LPN BB, she stated the order for the tablet was discontinued and the oral solution was supposed to be administered. She stated she had not followed the physician's orders. During an interview on 10/17/2023 at 9:29 am with the Director of Nursing (DON), she stated the staff member gave a pill order that was discontinued and should have given an oral solution via peg tube. She stated the staff member should have looked at the current orders and not followed a discontinued order. During an interview on 11/9/2023 at 10:40 am with the Administrator, she stated her expectation for the medication error rate was for the rate to be as low as possible. She was made aware of the observations and the 12% medication error rate.

Based on interview, record review, and review of the facility policy Change in a Resident's Condition or Status, the facility failed to notify the physician of an accident sustained by one resident (R) (R#78) of three residents investigated for accidents. Findings include: A review of facility policy titled, Change in a Resident's Condition or Status, revised June 2013, revealed, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: 1. An accident or incident involving the resident. A review of R#78's Admission Record revealed the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record revealed R#78 was their own responsible party (RP). A review of R#78's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS revealed the resident required extensive one-person physical assistance with bed mobility, locomotion, toileting, dressing, personal hygiene, and bathing, required supervision and set-up help with eating, and was totally dependent on two-person physical assistance with transfers. The MDS revealed the resident displayed no behaviors during the assessment period. A review of R#78's Care Plan, dated 3/25/22, revealed the resident was resistive to care and refused wound care, skin assessments, and antibiotic therapy. A review of a Care Plan, dated 6/18/21, revealed the resident was resistant to care at times and non-compliant related to adjustment to nursing home. An interview with R#78 on 3/28/22 at 2:56 p.m. revealed a certified nursing assistant (CNA) had spilled hot ravioli on their chest on 3/7/22 and sustained a burn from the food. They stated the burn was being treated in house, and they received no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated the treatment nurse had been helping treat the burn since. A review of R#78's Progress Notes revealed there was no documentation of the resident sustaining a burn from 3/7/22 (date of accident) until 3/20/22. On 3/20/22, the nurse observed the resident's chest and the nurse practitioner was notified. That was 13 days after the accident occurred. An interview with the Administrator, on 3/30/22 at 5:17 p.m., revealed she spoke with R#78 about the burn incident. She stated telehealth was contacted, the treatment nurse and physician saw the resident, and treatment and medications were ordered. An interview with Licensed Practical Nurse (LPN) TT, on 3/31/22 at 12:31 p.m., revealed if something hot spilled on a resident she would do a skin assessment, assess for injuries and the well-being of the resident, and check back with the resident periodically throughout the rest of their shift to inquire about pain or discomfort. She stated the nurse, physician, and responsible party would be informed of the spill and any injuries. If the resident was their own responsible party, the nurse and physician were notified. She stated she saw the wound on 3/20/22 and the wound was crusted over. The resident told her they had not told anyone about the wound and did not know the date of the incident. A telephone interview with LPN GGG on 3/31/22 at 2:55 p.m. revealed she was working on 3/7/22 and was the nurse assigned to R#78. She stated she recalled the CNA reporting the accidental spill of hot food onto the resident's chest. She stated she assessed the resident, and the resident had a red area to their chest where the food had spilled. She stated normally she documented those kinds of accidents. She stated she did not inform anyone of the accident after it happened because she got busy and forgot. An interview with the Director of Nursing (DON) on 4/1/22 at 12:18 p.m. revealed she was made aware of the accident with R#78 on 3/20/22. She stated in the event of a hot spill staff were to address any environment concerns, clean the resident, notify the nurse, provide first aid, notify the physician, complete a head-to-toe skin assessment, notify the RP or resident, and if needed, the resident would be sent out. She stated everything should be documented in the electronic chart.

Based on clinical record review and attending physician interview, the facility failed to ensure that the drug regimen of one (1) resident (#1), on the total survey sample of sixteen (16) residents, was free of an unnecessary drug. Specifically, Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq.), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician, and thus administering the drug for excessive duration, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: Please cross refer to F333 for more information regarding Resident #1. Record review for Resident #1 revealed a Progress Notes entry dated [DATE] at 1:30 p.m. which documented that Resident #1 arrived at the nursing facility. This Note documented that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Resident Progress Notes entry of [DATE] at 11:00 p.m. for Resident #1 documented that physician's orders [REDACTED]. [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed documentation indicating that Resident #1 actually received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received an excessive dose consisting of six (6) 40 mEq. doses of KCL, instead of two (2) doses as ordered by the physician. A Laboratory Report for Resident #1, with a draw date and time of [DATE] at 4:30 a.m., documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 mmol/L (Reference Range, 3.5 - 5 mmol/L). Subsequently, a Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 and that the resident was observed by the nurse to be unresponsive to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. During an interview with the Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. Based on the above, the facility failed to administer KCL 40 mEq every 4 hours for 2 doses to Resident #1 as ordered by the physician, but rather administered an excessive dose of KCL 40 mEq every 4 hours for a total of six (6) doses, in error. The resident was subsequently determined to have a critically elevated potassium level of 8.2 mmol/L, became unresponsive and died . It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of an investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outlined by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as described above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.

Based on clinical record review, hospital Discharge Summary review, review of the facility's Policy/Procedure for Verbal/Telephone Orders, National Library of Medicine reference information review, facility staff interview, attending physician interview, and physical therapist interview, the facility failed to ensure that each resident was free of any significant medication errors by failing to administer potassium chloride (KCL) in accordance with the physician's orders [REDACTED]. [REDACTED]. Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Review of the facility's Policy/Procedure for Verbal/Telephone Orders, dated as having been last revised on [DATE], revealed a heading which read "Caution: Following the procedure below is very important to prevent confusion, medication errors and maintain communication between the disciplines." Part 2 of the Procedure specified to record the physician's orders [REDACTED]. Record review for Resident #1 revealed a hospital Discharge Summary dated [DATE] which documented that Resident #1 had been admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital physician documented that the resident was sitting up in a chair, followed commands, and moved all extremities. The hospital physician also documented that the resident had worked with physical therapy (PT) and occupational therapy (OT) and would be discharged to the nursing facility for rehabilitation. A Resident Progress Notes entry dated [DATE] at 1:30 p.m. documented Resident #1 arrived at the nursing facility, and that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Physical Therapy Evaluation dated [DATE] documented that the resident had resided in a personal care home prior to hospitalization . The physical therapist documented that the resident needed stand-by assistance with ambulation, and presented with generalized weakness following hospitalization . The therapist further documented that the resident presented for skilled physical therapy to address the generalized weakness and balance deficits for return to the prior living situation, and with the patient/family goal of returning home. A Daily Patient Services Record documented that on [DATE], the resident began receiving skilled physical therapy services. During an interview with the physical therapist on [DATE] at 1:10 p.m., who had provided physical therapy services to Resident #1, this physical therapist stated that although the resident was weak from dehydration and being in the hospital, once admitted to the nursing facility the resident was ambulating and had made significant progress toward the goal to return to the assisted living setting. The physical therapist stated that it was the plan for the resident to return to the prior living setting. A Resident Progress Notes entry dated [DATE] at 9:00 a.m. documented that the resident had ambulated to the bathroom with assistance of one, responded well to all verbal stimuli, and had attended the facility church services that morning. Review of a Laboratory Report, with a draw date and time of [DATE] at 3:25 a.m., revealed a Basic Metabolic Profile (BMP) which documented Resident #1 to have a low potassium level of 3.3 millimoles per liter (mmol/L), with a reference range listed as 3.5 - 5.0 mmol/L. A Resident Progress Notes entry of [DATE] at 11:00 p.m. documented that physician's orders [REDACTED].#1, signed by Licensed Practical Nurse (LPN) "DD", specified an order to administer KCL forty (40) mEq by mouth every four (4) hours times two (2) doses, and also specified a BMP laboratory test to be done on [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received a total of six (6) 40 mEq doses of KCL, instead of two (2) doses as ordered by the physician. Resident Progress Notes entries of [DATE] at 9:00 a.m. and 9:00 p.m., and [DATE] at 9:00 a.m., documented that Resident #1 had remained alert during this period of time while she had been receiving, in error, these excess doses of KCL 40 mEq. However, a Laboratory Report for Resident #1, with a draw date and time of [DATE] at 4:30 a.m., which was approximately the same time the resident received the final dose of KCL, documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 mmol/L (Reference Range, 3.5 - 5 mmol/L). A notation on this Laboratory Report documented that this "Critical Value" had been called to a nursing facility nurse on [DATE] at 12:30 p.m.. A subsequent Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 by a certified nursing assistant, and that the resident was observed by the nurse to be non-responding to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. A Resident Progress Notes entry of [DATE] at 7:20 p.m. documented that the body of Resident #1 had been released to the funeral home. During an interview conducted on [DATE] at 9:00 a.m. with the Director of Nursing (DON), the DON acknowledged the medication error involving potassium drug therapy for Resident #1. During an interview with Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that she had actually been present in the facility when the critical potassium laboratory value report was called to the facility. The physician stated she had then gone to examine the resident and had assessed the resident to be unresponsive. The physician stated she had called the resident's family to notify them of the resident's high potassium level, at which time the family member stated she would call the physician back. The physician stated that before the family member returned the call, the resident had expired. The physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. Based on the above, the facility failed to administer KCL 40 mEq every 4 hours for 2 doses to Resident #1 as ordered by the physician, but rather administered KCL 40 mEq every 4 hours for a total of six (6) doses, in error. The resident was subsequently determined to have a critically elevated potassium level of 8.2 mmol/L, became unresponsive and died . 2. Record review of Resident #2 revealed an entry on the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Resident Progress Notes entry of [DATE] at 10:30 a.m. documented that the resident's [MEDICATION NAME] was supplied by the family. Review of the National Library of Medicine, National Institutes of Health reference for [MEDICATION NAME] revealed that the medication is used to treat certain types of [MEDICAL CONDITION] by blocking [MEDICAL CONDITION] cells from multiplying. The [DATE] MR for Resident #2 indicated that the resident was to receive a [MEDICATION NAME] 150 mg. capsule twice a day via gastrostomy tube at 10:00 a.m. and 10:00 p.m. for the [DIAGNOSES REDACTED]. A [DATE] entry by the evening nurse in the Nurse's Medication Notes Section of this MR documented that this medication was not available at that time, and that the family would bring the medication in the following day. However, further record review conducted on [DATE] revealed no evidence to indicate that the resident had received additional doses of [MEDICATION NAME] at that time, even though the order specifying administration of the drug remained current. There was also no evidence to indicate that the facility had made additional efforts to obtain the resident's [MEDICATION NAME] for administration, nor was there evidence to indicate the attending physician had been notified that the resident had missed multiple doses of [MEDICAL CONDITION] medication. During an interview on [DATE] at 11:20 a.m., the DON stated she had no knowledge that the resident's [MEDICATION NAME] had not been administered as the physician ordered. The DON reviewed the MR at that time and acknowledged that the medication had not been given as ordered. The DON obtained the package container for the resident's [MEDICATION NAME], and confirmed that it was empty and that there was no medication available. During an interview conducted on [DATE] at at 9:40 a.m. with the attending physician, the physician indicated she had no knowledge that Resident #2 was not receiving the ordered medication [MEDICATION NAME]. The physician stated that the medication should be given as ordered, and if unavailable, the physician should be notified. Record review revealed that after the physician's interview referenced above, an order was written to hold Resident #2's [MEDICATION NAME] until available. Evidence thus indicated that Resident #2 missed a minimum of five (5) doses of [MEDICATION NAME], ordered to be given twice daily, due to the medication not being available, during which time the facility failed to notify the physician for further instructions. It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the DON, Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outlined by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as described above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.

Based on observation, clinical record review, hospital Medication Profile review, facility staff interview, and attending physician interview, the facility failed to ensure that the clinical records of four (4) residents (#s 1, 2, 6, and 7), on the total survey sample of sixteen (16) residents, were accurate, related to the transcription of a physician's orders [REDACTED]. This resulted in the resident receiving four (4) additional doses of the drug in error, and the resident subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to accurately transcribe the order, and failure to thus administer KCL as ordered by the physician, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Cross refer to F329 and F333, example 1, for more information regarding Resident #1. Record review for Resident #1 revealed a Physician's Telephone Orders sheet dated [DATE] which specified an order to administer KCL forty (40) mEq. by mouth every four (4) hours times two (2) doses. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received a total of six (6) 40 mEq. doses of KCL, instead of two (2) doses as ordered by the physician. A Laboratory Report for Resident #1 of [DATE] at 4:30 a.m. documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 millimoles per liter (mmol/L) (Reference Range, 3.5 - 5 mmol/L). A subsequent Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 and that the resident was observed not to respond to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. During an interview with the Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. 2. Record review of Resident #2 revealed Physician's Telephone Orders sheet dated [DATE] with an order for [REDACTED]. However, during observations of Resident #2 conducted on [DATE] at 9:40 a.m., 10:15 a.m., 11:25 a.m. and 3:15 p.m., and on [DATE] at 9:00 a.m. and 10:55 a.m., the oxygen concentrator flow meter was set on four (4) LPM. Review of the [DATE] MR revealed that nursing staff had initialed, in error, that Resident #2's oxygen concentrator was flowing at two (2) LPM during the 7:00 a.m.-3:00 p.m. shift of [DATE], even though during the observations referenced above the resident's oxygen was observed to be at four (4) LPM. 3. Record review for Resident #7 revealed a hospital Medication Profile sheet dated [DATE] which documented that the resident was transferred to the nursing facility with admission orders [REDACTED]. However, review of a nursing facility Physician's Telephone Orders sheet for Resident #7 dated [DATE], and signed by Registered Nurse "HH", revealed that the transfer order specifying that a [MEDICATION NAME] be completed on [DATE] had been transcribed to specify only that a [MEDICATION NAME] be done, but did not specify the date the laboratory test was to be completed. This physician's orders [REDACTED]. During an interview conducted on [DATE] at 2:55 p.m. with Licensed Practical Nurses "AA" and "BB", these nurses acknowledged that the order written by Nurse "HH" should have been clarified. 4. Record review for Resident #6 revealed a Physician's Telephone Orders sheet dated [DATE] indicating to discontinue [MEDICATION NAME], and to continue [MEDICATION NAME] sulfate. However, there was no indication in this order of the dose, frequency of administration, or route of administration for [MEDICATION NAME] sulfate. It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the Director Of Nursing (DON), Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outline by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until on [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.