Every finding on record at Fountains Rehabilitation at Mill Cove

Based on observations, interviews and record review, the facility failed to store and label food items in a manner to prevent foodborne illness and maintain sanitary conditions, by failing to appropriately date mark food items in the dry storage area and nourishment rooms. This deficient practice had the potential to affect all residents who receive food and nourishment items prepared and/or stored by the facility.The findings include:During the initial kitchen tour on 2/8/26 at 11:30 AM, the following was observed: A dessert was plated on the walk-in refrigerator's shelving unit, which was wrapped but was not date marked. (Photographic evidence obtained)An observation of the 800 Wing nourishment room on 2/9/26 at 8:44 AM revealed that seven of 13 sandwiches in the refrigerator were not date-marked, and foods brought in from outside the facility were without dates. (Photographic evidence obtained)On 2/9/26 at 8:44 AM, a follow-up observation was conducted with the Certified Dietary Manager (CDM), in which he confirmed that there were seven sandwiches without date markings. In an interview at the time of the observation, the CDM stated the sandwiches were from the kitchen and should have been dated. He removed the sandwiches and discarded the items that were not labeled. He explained that the kitchen staff were responsible for date marking items from the kitchen and removing items from the kitchen that were older than three days and not labeled in the nourishment rooms.During a second kitchen observation on 2/10/26 at 11:04 AM, the following was observed in the dry storage room: An opened half full container of peanut butter without date marking. (Photographic evidence obtained) Lead [NAME] I observed the surveyor obtain a photograph of the peanut butter jar, then she removed the item from the shelf and was overheard asking the kitchen staff who put this in there without a date. During an interview on 2/10/26 at 11:35 AM, Lead [NAME] I stated whoever opened the items in the dry storage room was responsible for dating them. During an interview on 2/11/26 at 9:27 AM with Dietary Aide G, he stated certified nursing assistants (CNAs) were responsible for cleaning nourishment rooms and discarding food. He further stated everyone was responsible for date marking in the kitchen.A review of the facility's policy titled Food Storage - Dry Goods (dated 1/27/26), revealed:The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate.

Based on interview and record review, the facility failed to provide documentation to confirm that each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for three (Residents #49, #998 and #999) of three residents whose Beneficiary Notices were reviewed. The findings include:On [DATE] at 11:57 AM, an entrance conference was conducted with the Administrator. At this time, he was given the Beneficiary Notice form and asked to provide a list of residents discharged within the last six months.On [DATE] at 3:40 PM, the survey team was provided with the completed Beneficiary Notice forms. The Administrator was advised that the Beneficiary Notice forms contained inaccurate information. He was advised that the list contained residents who were discharged to the hospital, other skilled nursing facilities and/or who had expired. He was referred to the instructions on the form which instructed to exclude beneficiaries who received Medicare Part B benefits only, were covered under Medicare Advantage insurance, expired, or were transferred to an acute care facility or another SNF (skilled nursing facility) during the sample date range. The form's instructions were highlighted for easy visibility.On [DATE] at 8:40 AM, the survey team received what the facility presented as the corrected Beneficiary Notice forms. The documentation remained inaccurate. At 10:05 AM, the survey team advised the Administrator of the inaccuracies. Again, the forms and instructions were reviewed. The instructions were highlighted on the new forms for easy visibility, and the Administrator was asked to provide accurate information based on the instructions that were highlighted. On [DATE] at 12:58 PM, the facility provided the Beneficiary Notice forms. The information provided by the facility was incomplete. Residents who remained in the facility during the designated period were not listed on the forms.On [DATE] at 4:04 PM, the Administrator was advised that the forms provided this day at 12:58 PM were also inaccurate. He was shown that there were no residents listed as remained in facility. He replied, and there definitely should be. He stated he would have the information corrected and would return it to the survey team on the following day ([DATE]).During an interview on [DATE] at 9:41AM, the Administrator was asked whether or not the Beneficiary Notice Review forms were available for review. He stated the facility was unable to access the information electronically; it would have to be done manually. He did not provide any further explanation.An interview was conducted on [DATE] at 10:23 AM with the Director of Nursing (DON). He provided all of the previous lists along with a separate list for residents who remained in the facility. Three residents were randomly selected from the lists provided, one resident who went home and two residents who remained in the facility. The names of the selected residents were written on three separate Beneficiary Notice Review forms and given to the DON. He was asked to have the forms completed and returned to the survey team. On [DATE] at 3:28 PM, the Administrator was asked to provide the three selected resident Beneficiary Notice Review forms. He stated he did not know what the surveyor was referring to but would check on the request.On [DATE] at 3:41PM, the Business Office Manager (BOM) approached the survey team. She did not have the three selected resident Beneficiary Notice Review forms. She stated she was given the forms and was told to file them. When asked about her tenure with the facility, she stated she had been employed as the BOM for 3.5 years. She was asked if she had knowledge of the Beneficiary Notice requirement for the facility's annual survey. She stated she did not recall completing this task on the last annual survey. She stated she was responsible for the Advance Beneficiary Notice (ABN) forms and that it was the responsibility of the Social Services Director to complete the Notice of Medicare Non-coverage (NOMNC). She stated she would consult with the SSD for more information. She asked if the forms needed to be completed, adding that she did not know if she should write on them.On [DATE] at 10:47AM, the facility provided the three selected resident Beneficiary Notice Review forms to the survey team. A review of the information revealed that the forms still contained inaccurate information. One of the three residents, who the facility stated remained in the facility, had been discharged . Only one of the residents requested remained in the facility, Resident #49. No additional attempts were made after the survey team identified that inaccuracies remained in the documentation.

Based on record review, interviews and a review of facility policies and procedures, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, by failing to monitor and track infections properly between August 2025 and February 2026. This failure can contribute to preventable diseases spreading rapidly, resulting in widespread resident illness with potentially fatal outcomes.The findings include:A review of the facility's infection control tracking information on 2/11/26 with the Director of Nursing (DON) revealed that no tracking was available for August 2025 through November 2025 or for January 2026. During an interview on 2/11/26 at 2:30 PM, the DON stated, Since [previous Infection Preventionist] left, I've been keeping up with it. When asked where the missing data was, the DON replied, I have like four binders; I just have to find it.A review of the facility's infection control tracking information on 2/12/26 at 9:30 AM revealed that antibiotic records generated from the electronic health record for August 2025 to present (2/12/26) revealed that they were generated on 2/8/26 and 2/11/26 during the time of the survey. (Photographic evidence obtained)During an interview on 2/12/26 at 10:00 AM regarding the infection control tracking information, the DON stated, I thought people were keeping track of it and I just ended up with all these papers. A review of the facility's policy titled Infection Prevention Control Program - Core Practices (reviewed 5/2025), revealed: C. Surveillance: a. Routine monitoring through use of audits and surveillance will be conducted to determine compliance with infection prevention and control policies and procedures. Surveillance tools will be used for recognizing the occurrence of infections, recording the number of infections and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens (e.g., C difficile, MDROs) with infection control implications. Surveillance is designed to identify possible communicable diseases and infections before they can be spread to other residents in the facility and procedures for reporting possible incidents of communicable diseases or infections.

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #10) of 2 residents reviewed for vision abilities/status from a total survey sample of 21 residents, received proper treatment and assistance in making appointments and arranging for transportation to and from the office of a practitioner specializing in the treatment of vision impairment or the office of a professional specializing in the provision of vision assistive devices to maintain vision abilities. The findings include:An interview was conducted on 2/09/2026 at 11:23 AM with Resident #10. During the interview the resident became visibly upset and in a raised voice stated he was blind and they (facility staff) were not helping him. He further stated he had cataracts and was supposed to have surgery a year ago and still had not had that. He stated he had insurance and other funds to pay for the surgery, but the facility was not assisting him with arranging for it. He said his loss of vision impacted his mood and made him feel trapped. He did not feel that the facility staff cared about his wellbeing; they only wanted his money.A review of the resident's medical record revealed an admission date of 10/23/2023. His diagnoses included cerebral infarction (stroke), AFIB (Atrial Fibrillation - rapid, irregular heartbeat), urinary retention, hypertension (HTN - high blood pressure) and morbid obesity. His active physician's orders included: May have podiatry, dental, audiology, ophthalmology and psychiatric/psychology services as needed (10/24/2023).A review of the resident's Annual minimum data set (MDS) assessment, dated 9/25/2024, revealed that Resident #10 scored 15 out of 15 possible points on his Brief Interview for Mental Status (BIMS), indicating intact cognition. His vision was noted as severely impaired. He displayed little interest or pleasure in doing things and felt down, depressed, or hopeless 7-11 days of the assessment reference period. He required supervision/touch assistance with tub/shower transfers and was independent with all other Activities of Daily Living (ADLs). A review of his most recent Quarterly MDS assessment, dated 11/24/2025, revealed a BIMS score of 13/15, indicating intact cognition. His vision was noted as impaired. He had no recorded mood/behavior issues and was independent with all ADLs. Resident #10's active care plan was reviewed. Focus Areas included: I have mood and behavior changes. My behaviors include refusal of the following: showering/assistance with ADLs/fingernail cutting/toenails [Resident #10] is on antiplatelet/anticoagulant therapy related to AFIB, anticoagulant and history of CVA (cerebrovascular accident - stroke) and his health status [Resident #10] is at risk for falls related to the use of medication, pain, cardiac disease and his health status.The Care Plan did not address the resident's impaired vision.Further review of the resident's record revealed that he had been seen by a vision service provider multiple times in the facility. Per the provider's consultation forms:1/31/24 - Referred to ophthalmologist for cataract surgery; visit Dx H25.13 age related nuclear cataract bilateral. 5/21/24 - Referred to ophthalmologist for cataract surgery additional note: Referred last visit and nothing has been done, no glasses ordered; no readers assigned; visit Dx H25.13 age related nuclear cataract bilateral. Exam 5/22/24: Chief complaint decreased vision; orientation to time and place: WNL (within normal limits); Mood and Affect: WNL; visit Dx H25.13 age related nuclear cataract bilateral. 2/20/25 - Referred to ophthalmologist for cataract surgery visit Dx H25.13 age related nuclear cataract bilateral. A review of the resident's progress notes revealed:5/21/24 - Late Entry: Patient examined by Optometrist on 5/21/24. see uploaded exam by documents2/20/25 - Late Entry: Patient examined by Optometrist on 2/20/25. See uploaded exam by documents.An interview was conducted on 2/10/26 at 2:23 PM with Licensed Practical Nurse (LPN) D who stated he was familiar with Resident #10. He said he was unsure of whether or not the resident was legally blind, but he knew the resident could not see. LPN D stated the resident was moved from the rehabilitation side of the facility to the long-term care unit. He stated the resident could manage and did not ask for a lot. His biggest complaint is that he can't see. He said the staff kept the resident's room dark because he couldn't tolerate too much brightness, and during medication administration, the resident requested that the pill cup be placed on his table within his reach so that he could pick it up. The resident would then shake the cup to determine whether or not he was receiving the correct amount of medication.An interview was conducted on 2/10/26 at 3:17 PM with Certified Nursing Assistant (CNA) B who stated she had been employed by the facility for more than 15 years and she was familiar with Resident #10. She stated he complained about pain and that he could not see well; he was supposed to have cataract surgery.An interview was conducted on 2/11/26 at 11:23 Am with Unit Clerk K who stated she had been employed by the facility for four years. Initially, she was CNA who worked as needed and after a year she transitioned to the Unit Clerk position. She was asked to describe her role as it related to resident care. She stated when the resident was admitted from the hospital, she introduced herself. She checked the hospital transfer form, what the form documented as having been done while the resident was hospitalized and the next steps to take while at the skilled nursing facility. She stated if the resident was alert and oriented, she asked them about any follow-up appointments they may have. She did a follow-up with the provider to schedule any appointments and transportation required. She was responsible for scheduling the dental and vision appointments with third-party providers. She said she was notified of needed appointments by residents, providers and at times, by the resident's family. Unit Clerk K said she was familiar with Resident #10. He had not had any appointments scheduled within the last two months. She said that a couple of months ago, he had an appointment to check his eyes, but he decided that he wasn't going. She stated she kept an email for the residents who went out for appointments. She was asked to provide documentation of the scheduled appointment and the resident's refusal to go. She stated she was not sure if there was any documentation of this, adding that the nurse should be documenting that information. She stated Resident #10 was declining and he had been asking to go to the eye doctor but then refused to go. Again, she could not provide documentation verifying this.An interview was conducted on 2/11/26 at 1:27 PM with the Social Services Director (SSD). She stated she had been employed by the facility for four years. She worked as the Social Services Assistant for two years and had been the SSD for two years. She stated the Unit Manager was responsible for setting up transportation when residents were scheduled for appointments outside of the facility. She was shown the documentation for the three visits referring Resident #10 for cataract surgery. She stated she was not sure why an appointment was not set up. She stated for the 5/21/24 visit, she believed there may have been a payer source change; however, she could not verify this. She stated she uploaded the visit notes and nursing, and everyone, should be viewing them. She stated the vision service provider came in quarterly and if a resident was referred out, the Unit Clerk was responsible for scheduling the appointment.

Based on interview and record review, the facility failed to implement its admissions policy for one (Resident #5) of six residents reviewed for admission agreements.The findings include:A review of Resident #5's record revealed no admission agreement present for his admission on [DATE] or his readmission following hospitalization on 11/21/25.Further review of the record verified an initial admission date of 9/26/25 with the most recent admission on [DATE]. During an interview on 2/11/26 at 9:10 AM, the Admissions Director (AD) stated, I didn't start until November [2025], but I did talk to him [Resident #5] one time about it. When the AD was asked where she documented her conversation with the resident, she stated, I didn't document it anywhere.A review of the facility's policy titled Admissions Process - IDT (Interdisciplinary Team) (revised 1/27/26, previously revised 7/1/23 and 3/1/22) revealed:It is the policy of this facility to follow a consistent and complete process for admission of a resident into the facility.Procedure:4. The facility will follow policies for the admission process for residents, and through the administrator, will be responsible for the development of and adherence to procedures implementing the policies.5. The facility may choose to develop an orientation packet specific to their facility to assist with some of the aspects of the resident's orientation to the facility.7. The full admission assessment process will be completed within five (5) days.The policy did not specify who was responsible for reviewing the admission agreement with the residents. The policy did not specifically address the admission agreement. A review of the Facility Admissions Director Position Description (effective 10/3/2018), revealed:Duties and Responsibilities: Administrative Functions: Provide, review, and explain to the resident and/or guardian admission paperwork and policies.

Based on observations, interviews and a review if facility policies and procedures, the facility failed to maintain its equipment in safe operating condition, by failing to ensure lint was promptly removed from facility dryers. Leaving lint in a dryer trap creates a severe fire hazard, as accumulated lint easily ignites from the heating element, potentially causing a fire that can place staff, residents and other facility occupants in danger. It also restricts airflow, which can lead to overheating. The findings include:An observation in the laundry room on 2/11/26 at 9:30 AM revealed that the lint removal log had not been completed for 7:00 AM or 9:00 AM.An observation in the laundry room on 2/11/26 at 9:35 AM revealed that the lint trap in the first dryer was covered with a thick layer of white fluffy material.During an interview with Laundry Assistant A on 2/11/26 at 9:40 AM, she stated, We clean it [lint trap] out after every load. When asked if it had been cleaned this morning, she nodded her head yes. When asked why there was a layer of what appeared to be lint in the trap of the dryer, she replied, I don't know how to answer that.During an interview on 2/11/26 at 9:45 AM regarding the laundry room's lint removal log and lint trap concerns, the interim Housekeeping Director stated, I don't know, I'm the Maintenance Director.During an interview on 2/12/26 at 9:30 AM regarding the laundry room's lint removal log and lint trap concerns, the Administrator stated, I'd have to look at the policy, but if it says after every load, then I expect them to do it after every load and document it.A review of the facility's policy titled Dryers/Lint Catcher (reviewed 1/2026), revealed: Lint Catch/Screens: Lint Catchers should be cleaned after each load.

Based on observations and interviews, the facility failed to ensure that 1) It posted daily, at the beginning of each shift, the facility name, current date, the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, as well as the resident census on two (2/8/26 and 2/9/26) of five days during the recertification survey.The findings include:During a tour of the facility conducted on 2/8/26 from 11:00 AM - 12:00 PM, no staffing information was posted. A clear frame with no staffing information was observed hanging on a wall next to the reception desk. A whiteboard near the south wing of the facility with staffing posted was dated 2/6/26. (Photographic evidence obtained) During the tour it was observed that all resident rooms had whiteboards next to each bed with spaces to list the current date, current shift and the assigned nurse and certified nursing assistant (CNA) for that shift. Seven of the boards observed had not been updated with the current date. One was dated 1/18/26(room [ROOM NUMBER]), three were dated 1/28/26 (room [ROOM NUMBER]), one was dated 2/2/26, one was dated 2/6/26 (room [ROOM NUMBER]), and another was undated and did not list the name of the assigned nurse or CAN (room [ROOM NUMBER]). (Photographic evidence obtained)During a tour of the facility on 2/9/26 at 9:01 AM, the Daily Staffing posted at the entrance of the facility near the nurses' station was dated Sunday, 2/8/26. An interview was conducted with the Director of Nursing (DON) on 2/11/26 at 4:21PM. He was asked who was responsible for posting the facility's daily staffing. He stated previously the staffing coordinator was responsible for this task; however, that individual was no longer employed with the facility and that as of 2/6/26, the task had become his responsibility. He stated he should not have been assigned this task and was only filling in until they hired another staffing coordinator. He was made aware of the concerns with the posted staffing and was shown the photographic evidence. He acknowledged that the staffing had not been posted, and he acknowledged the incorrect/missing dates on the boards in the residents' rooms. He stated the nurses were responsible for updating the staffing on the unit and the CNAs were responsible for updating the boards in the residents' rooms. This should be done at the beginning of each shift. The Administrator was present during the interview. He stated the information should have been corrected by the nurses and/or the CNAs.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that reflected the resident's individualized needs for one of (Resident #10) of 21 residents whose care plans were reviewed. Resident #10 had no care plan addressing his vision problems and although he had been referred to an ophthalmologist more than once in 2024 (January and May) for cataract surgery, the facility did not follow through until February of 2025. An interview with the resident revealed this negatively affected his mood and he felt trapped. The findings include: An interview was conducted on 2/09/2026 at 11:23 AM with Resident #10. During the interview the resident became visibly upset and in a raised voice stated he was blind and they (facility staff) were not helping him. He further stated he had cataracts and was supposed to have surgery a year ago and still had not had that. He stated he had insurance and other funds to pay for the surgery, but the facility was not assisting him with arranging for it. He said his loss of vision impacted his mood and made him feel trapped. He did not feel that the facility staff cared about his wellbeing; they only wanted his money. A review of the resident's medical record revealed an admission date of 10/23/2023. His diagnoses included cerebral infarction (stroke), AFIB (Atrial Fibrillation – rapid, irregular heartbeat), urinary retention, hypertension (HTN – high blood pressure) and morbid obesity. His active physician's orders included: May have podiatry, dental, audiology, ophthalmology and psychiatric/psychology services as needed (10/24/2023). A review of the resident's Annual minimum data set (MDS) assessment, dated 9/25/2024, revealed that Resident #10 scored 15 out of 15 possible points on his Brief Interview for Mental Status (BIMS), indicating intact cognition. His vision was noted as severely impaired. He displayed little interest or pleasure in doing things and felt down, depressed, or hopeless 7-11 days of the assessment reference period. He required supervision/touch assistance with tub/shower transfers and was independent with all other Activities of Daily Living (ADLs). Per his most recent Quarterly MDS assessment, dated 11/24/2025, revealed a BIMS score of 13/15, indicating intact cognition. His vision was noted as impaired. He had no recorded mood/behavior issues and was independent with all ADLs. Resident #10's active care plan was reviewed. Focus Areas included: I have mood and behavior changes. My behaviors include refusal of the following: showering/assistance with ADLs/fingernail cutting/toenails [Resident #10] is on antiplatelet/anticoagulant therapy related to AFIB, anticoagulant and history of CVA (cerebrovascular accident – stroke) and his health status [Resident #10] is at risk for falls related to the use of medication, pain, cardiac disease and his health status. The Care Plan did not address the resident's impaired vision. Further review of the resident's record revealed that he had been seen by a vision service provider multiple times in the facility. Per the provider's consultation forms: 1/31/24 - Referred to ophthalmologist for cataract surgery; visit Dx H25.13 age related nuclear cataract bilateral. 5/21/24 - Referred to ophthalmologist for cataract surgery additional note: Referred last visit and nothing has been done, no glasses ordered; no readers assigned; visit Dx H25.13 age related nuclear cataract bilateral. Exam 5/22/24: Chief complaint decreased vision; orientation to time and place: WNL (within normal limits); Mood and Affect: WNL; visit Dx H25.13 age related nuclear cataract bilateral. 2/20/25 - Referred to ophthalmologist for cataract surgery visit Dx H25.13 age related nuclear cataract bilateral. A review of the resident's progress notes revealed: 5/21/24 - Late Entry: Patient examined by Optometrist on 5/21/24. see uploaded exam by documents 2/20/25 - Late Entry: Patient examined by Optometrist on 2/20/25. See uploaded exam by documents. An interview was conducted on 2/10/26 at 2:23 PM with Licensed Practical Nurse (LPN) D who stated he was familiar with Resident #10. He said he was unsure of whether or not the resident was legally blind, but he knew the resident could not see. LPN D stated the resident was moved from the rehabilitation side of the facility to the long-term care unit. He stated the resident could manage and did not ask for a lot. His biggest complaint is that he can't see. He said the staff kept the resident's room dark because he couldn't tolerate too much brightness, and during medication administration, the resident requested that the pill cup be placed on his table within his reach so that he could pick it up. The resident would then shake the cup to determine whether or not he was receiving the correct amount of medication. An interview was conducted on 2/10/26 at 3:17 PM with Certified Nursing Assistant (CNA) B who stated she had been employed by the facility for more than 15 years and she was familiar with Resident #10. She stated he complained about pain and that he could not see well; he was supposed to have cataract surgery. An interview was conducted on 2/11/26 at 11:23 Am with Unit Clerk K who stated she had been employed by the facility for four years. Initially, she was CNA who worked as needed and after a year she transitioned to the Unit Clerk position. She was asked to describe her role as it related to resident care. She stated when the resident was admitted from the hospital, she introduced herself. She checked the hospital transfer form, what the form documented as having been done while the resident was hospitalized and the next steps to take while at the skilled nursing facility. She stated if the resident was alert and oriented, she asked them about any follow-up appointments they may have. She did a follow-up with the provider to schedule any appointments and transportation required. She was responsible for scheduling the dental and vision appointments with third-party providers. She said she was notified of needed appointments by residents, providers and at times, by the resident's family. Unit Clerk K said she was familiar with Resident #10. He had not had any appointments scheduled within the last two months. She said that a couple of months ago, he had an appointment to check his eyes but he decided that he wasn't going. She stated she kept an email for the residents who went out for appointments. She was asked to provide documentation of the scheduled appointment and the resident's refusal to go. She stated she was not sure if there was any documentation of this, adding that the nurse should be documenting that information. She stated Resident #10 was declining and he had been asking to go to the eye doctor but then refused to go. Again, she could not provide documentation verifying this. An interview was conducted on 2/11/26 at 1:27 PM with the Social Services Director (SSD). She stated she had been employed by the facility for four years. She worked as the Social Services Assistant for two years and had been the SSD for two years. She stated the Unit Manager was responsible for setting up transportation when residents were scheduled for appointments outside of the facility. She was shown the documentation for the three visits referring Resident #10 for cataract surgery. She stated she was not sure why an appointment was not set up. She stated for the 5/21/24 visit, she believed there may have been a payer source change; however, she could not verify this. She stated she uploaded the visit notes and nursing, and everyone, should be viewing them. She stated the vision service provider came in quarterly and if a resident was referred out, the Unit Clerk was responsible for scheduling the appointment.

Based on observations, staff interviews, and medical record review, the facility failed to ensure that a resident in a long term care nursing facility, who was identified with a MD/ID (Mental Disorder/Intellectual Disability) and/or other related conditions was re-evaluated to determine if specialized care and services were required, in the most integrated setting appropriate to their needs, for one resident (Resident #29) in a total sample of 20. The findings include: On 04/09/24 at 10:45 AM, a record review revealed that Resident #29 had a Level 1 PASRR (Preadmission Screening and Resident Review) that indicated she had a serious MI (Mental Illness) and that a Level 2 PASRR evaluation was indicated. The PASRR was signed on 6/10/2020 from an acute-care hospital. There was no Level 2 evaluation available in the electronic medical record (EMR) or in the resident's paper chart. On 04/10/24 at 1:55 PM, an interview was conducted with Social Services Director (SSD) B, who stated she had been employed at the facility since 01/09/2024. She was asked what the facility's process was for identifying residents with a possible MD/ID or related condition prior to admission to the facility. SSD B stated, Admissions receives the PASRR prior to the resident coming into the facility. The PASRR is uploaded into [the EMR] under the miscellaneous tab. The interdisciplinary team (IDT), including the Director of Nursing (DON), Assistant Director of Nursing (ADON), SSD, Administrator, and Therapy, reviews the PASRR to make sure the resident is appropriate for admission. When she was asked how the facility identified residents with newly evident or possible serious MD/ID or a related condition after admission to the facilitym SSD B replied, The staff observe the residents for any changes in mental status, behaviors, or depression. I am not qualified to complete a PASRR screening, but we have [physician's name], who is employed here at the facility and is qualified to do the Level 1 PASRR screening. When she was asked who was responsible for making the referral when a Level 2 PASRR was triggered, SSD B stated, I can make the referral or [physician's name] can make the referral. A review was conducted with SSD B of Resident #29's Level 1 PASRR screening in the EMR. It indicated the resident had a serious mental Illness and individual may not be admitted to an Nursing Facility. SSD B was asked who made the decision to re-admit the resident to the facility, in spite of the indication on the Level 1 PASRR. SSD B stated, It was the IDT's decision. When asked whether Resident #29's Level 1 PASRR should have triggered a Level 2 PASRR referral, SSD B stated, In my opinion, a Level 2 PASRR should have been triggered for this resident. When she was asked to explain why the referral was not made, she replied, To be honest with you, I can't answer that question. I don't know why. A record review revealed that Resident #29 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including cognitive/communication deficit, epilepsy, schizophrenia, Todd's paralysis, major depression and delusions (as documented per the Behavioral Health Progress Note, date of service 10/05/2022), history of suicidal ideations (as documented on hospital discharge, 7/27/2023). A review of the care plan revealed the following Focus Areas: FOCUS: Tactile Hallucinations at times as evidenced by feeling bugs crawling on her skin, responds to internal stimuli as evidenced by looking for others that are not there, packs items in her wheelchair and looks for people that are not present. Goals/Interventions reviewed (initiated 10/14/2021, revised 03/09/2022). FOCUS: Elopement Risk due to exit-seeking behavior. Goals/Interventions reviewed. (initiated 02/06/2024, reviewed 02/062024) FOCUS: Resident uses Psychotropic Medications related to diagnosis of nerve pain, history of schizophrenia and her health status. Goals/Interventions reviewed. (Initiated 09/23/2022, revised 02/01/2024)

Based on observations, interviews, record review, and facility policy review, the facility failed to provide one (Resident #25) of a total sample of 20 residents, with necessary services to maintain appropriate grooming and personal hygiene, by failing to provide timely nail care per the resident's comprehensive care plan. The findings include: On 04/08/24 at 12:41 PM, Resident #25 was observed with elongated fingernails with brown matter underneath. His mustache was long with the hair covering his top and bottom lips. Resident # 25 stated, They just asked me yesterday if I wanted my nails trimmed and I said yes. He was alert and oriented during the interview. (Photographic evidence obtained) On 04/09/24 at 9:17 AM, Resident #25 was observed unshaven with a long mustache covering his top and bottom lips. His fingernails were elongated with brown matter underneath and some with jagged edges. (Photographic evidence obtained) On 04/10/24 at 12:22 PM, an interview was conducted with Registered Nurse A, who reported the CNAs (certified nursing assistants) were primarily responsible for assisting residents with ADL (activities of daily living) care, but it is everyone's responsibility to see that they are taken care of. She stated the residents had their hair washed, were shaven, and received nail care on the days they received showers or bed baths. When she was asked who provided nail care, she replied, The CNAs give nail care on the resident's shower days; the activities staff does the nail polish; and the CNAs cut the fingernails unless the resident is diabetic. She further stated the nurses cut/trimmed the fingernails for diabetic residents, and the podiatrist took care of trimming toenails. RN A was accompanied to Resident #25's room. The resident stated, [Employee name] came this morning and asked me about a shave, but I can shave myself. Resident #25 had a long mustache that had grown past his bottom lip. He stated, She asked me if I wanted my fingernails cut and I said yes. She said she would come back later on and cut them, but if you want to cut them now let's go ahead and get it over with. RN A was asked if the resident was receiving anticoagulant/antiplatelet medication, and she stated yes. She was asked if she thought Resident #25 was in need of nailcare due to the implications of side effects of antiplatelet therapy and she stated, Yes he does need some nail care, especially on his left hand. A record review revealed that Resident #25 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic pulmonary edema, respiratory failure, cerebral infarction (stroke), anemia, chronic kidney disease, and adult failure to thrive. Review of a quarterly MDS (Minimum Data Set) assessment, dated 01/21/2024, revealed that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. He required supervision or touching assistance with transfers, partial/moderate assistance with personal hygiene, and partial/moderate assistance with toileting. There were no behaviors identified and the resident participated in the assessment. A review of the physician's orders revealed the resident was receiving Clopidogrel Bisulfate (Plavix - antiplatelet - keeps blood platelets from attaching to one another and making clots) 75 mg (milligrams) by mouth daily. A review of the resident's active care plan revealed the following Focus Areas: ADL/Self-Care Performance Deficit related health status. Goals: Resident will maintain current level of function through the review date. Interventions included but were not limited to: Bathing/Showering, Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. (initiated 10/30/2023). FOCUS: Anticoagulant/Antiplatelet Therapy related to blood clot prevention. (Initiated 11/03/23, revised 11/03/2023). FOCUS: Risk for Skin Impairment and/or Pressure Ulcers related to health status. Goal: Resident will have no untreated signs or symptoms of skin impairment or pressure ulcers through review date. Interventions included but were not limited to: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. (Initiated 10/30/2023, revised 01/22/0224). A review of the facility's policy titled ADL Care-Supporting Resident-General, Dept: Nursing, C-ADL-1, Manual: Clinical Manual, New Revised (Creation date: 6/2026, reviewed: 3/2024, last revision date: 3/12/24), revealed: Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Personal Care/Grooming: oral care/shaving/hair care/nail care C-ADL-1d-C-ADL-1g;.

Based on interviews and record reviews, the facility failed to ensure that two (Residents #227 and #31) of 30 sampled residents, were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Resident #227, who was continent of bowel per interview with nursing management, was told to soil her brief and the CNA would clean her up afterward. Resident #31's CNA turned off his call light and did not return to provide care until prompted by his nurse, approximately three hours later. At that time the CNA told the resident he lied about her and she was not going to speak to him. The findings include: 1. On 04/25/22 at 2:40 PM, Resident #227 stated during the morning shift on 04/25/22, she requested to use the bathroom, and the certified nursing assistant (CNA) that answered her call light said, Go ahead and use your diaper. I will clean you up. The resident stated she was shocked and felt embarrassed, as she was continent and did not want to soil her clothes. She added that she could not remember the CNA's name. Resident #227 stated she was assisted to the bathroom by a different staff member, and she told her what the other staff member had said to her. The resident could not identify the staff member that assisted her to the bathroom. Resident #227 concluded by stating that she felt as though the staff member who told her to use her brief did not want to help her. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Her care plan indicated an ADL/Self-Care Deficit related to health status requiring assistance from staff for transfers. Her Admission minimum data set (MDS) assessment, dated 4/22/22 (still in progress), indicated she had a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating she was cognitively intact. In an interview on 04/26/22 at 11:00 AM, Licensed Practical Nurse (LPN) L/Unit Manager and the Assistant Director of Nursing (ADON) confirmed that Resident #227 was continent of bowel and had an indwelling urinary catheter. They stated the resident required assistance to the bathroom. They were then notified of the resident's concern regarding her incontinence care, and they stated they would follow up with staff. During another interview on 04/27/22 at 3:41 PM, LPN L/Unit Manager, confirmed that Resident #227 had repeated the same concerns whe she spoke with her. She stated since the resident could not identify the staff involved, the facility would conduct an in-service for all CNAs regarding dignity, respect, and personal hygiene for residents. (Copy of grievance form obtained) In an interview on 04/28/22 at 5:30 PM, the Administrator confirmed that there had been incidents when staff had failed to show respect and were not compassionate. He added that there was an incident that was brought to his attention about staff who were unpleasant to each other during the survey. He added that there had been multiple in-services about customer service, and moving forward, staff who did not adhere facility policy would be terminated. A review of the facility's policy and procedure titled Dignity (CD-17), created on 3/8/21, revealed that each resident shall be cared for in a manner that promotes and enhances quality of life and dignity, respect and individuality. The policy interpretation and implementation read: 1. Resident shall be treated with dignity and respect at all times. 2. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. 2. On 04/26/22 at 1:16 PM, Resident #31 stated he had been sitting in his soiled brief since before lunch. He notified his assigned CNA (Employee H) at approximately 10:30 AM that he needed assistance with incontinence care. CNA H turned the call light off and did not return to change his brief. Registered Nurse (RN) I, standing at the medication cart outside of the resident's room, was notified at 1:20 PM that the resident stated he had been waiting for assistance with incontinence care since approximately 10:30 AM. RN I stated she was not aware that the resident needed incontinence care. She verified with the resident that he needed to be changed and then went and to find CNA H. At approximately 1:23 PM, CNA H was observed walking up the hallway stating the resident was telling a story. CNA H stated she went in the resident's room to change the resident in bed A, and she asked Resident #31 if he needed changing. He said no, he was dry. CNA H then went into the room to assist the resident with incontinence care. During a follow-up interview with Resident #31 on 04/28/22 at 11:37 AM, he stated CNA H became upset with him and told him that he lied on her and she wasn't speaking to him now. When asked how it made him feel, the resident stated, It hurt. I just want her to like me again. The resident stated he feared being discharged because he spoke up about what happened, and he didn't want to lose his home because he had nowhere else to go. The resident's Quarterly MDS assessment, dated 3/18/22, indicated he had a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating minimal cognitive impairment. A review of the facility's policy and procedure titled Dignity (CD-17), created on 3/8/21, revealed that each resident shall be cared for in a manner that promotes and enhances quality of life and dignity, respect and individuality. The policy interpretation and implementation read: 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 9. Staff shall maintain an environment in which confidential clinical information is protected, for example: a. Verbal staff-to-staff communication (e.g. change of shift reports) shall be conducted outside the hearing range of residents and the public. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: b. Promptly responding to the resident's request for toileting assistance.

Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure one (Resident #74) of four residents reviewed, from a total sample of 30 residents, received medication as ordered by the physician. On 4/25/22 at 12:06 p.m., Resident #74 stated she took [MEDICATION(S)] daily and had not received the medication for the last five days. A review of Resident #74's medical record revealed that she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS) assessment, dated 4/13/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required limited assistance for bed mobility, transfers, eating and toilet use. She received hypnotic and anxiolytic medications. A nursing note dated 4/18/22, indicated that the resident appeared anxious throughout the shift. A review of the resident's active physician's orders revealed a 4/7/22 order for [MEDICATION(S)] [MEDICATION(S)] ER (extended release) 300 mg (milligrams) daily at bedtime (9:00 p.m.) for [CONDITION(S)] disorder. A review of the current care plan revealed that Resident #74 received [CONDITION(S)] and anticonvulsant medications, and herbal supplements related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the administration of medications as ordered by the physician. Staff were to monitor for side effects and effectiveness every shift. A review of the pharmacy delivery receipt revealed that a 7-day supply of [MEDICATION(S)] [MEDICATION(S)] was delivered to the facility on [DATE] at 6:09 p.m. (Copy Obtained) In an interview on 4/26/22 at 3:45 p.m., Licensed Practical Nurse (LPN) D was asked if Resident #74 had [MEDICATION(S)] [MEDICATION(S)] in the medication cart. LPN D opened the cart and obtained a blister pack for a 30-day supply with a refill date of 4/22/22. Only one dose was removed. (Photographic Evidence Obtained) LPN D stated the resident took the medication at night and therefore, she did not know if the resident had been receiving it. When asked for the pharmacy delivery manifest, LPN D stated she did not think the facility had a system for keeping the manifests. She added that she would ask the Assistant Director of Nursing (ADON). In an interview on 4/26/22 at 3:50 p.m., the ADON confirmed that there was no process for maintaining the pharmacy delivery manifests. When asked how she would identify how many refills were made for Resident #74's [MEDICATION(S)] [MEDICATION(S)], she stated she had contacted the pharmacy about the medication and was notified that it was delivered on 4/22/22. She added that she had contacted the pharmacy since the family had contacted the facility to ensure that the resident had enough medication before her discharge on 4/27/22. The ADON stated she was not sure whether there was another delivery made before 4/22/22. During a telephone interview on 4/26/22 at 3:55 p.m., the pharmacy representative stated Resident #74's [MEDICATION(S)] [MEDICATION(S)] was dispensed as follows: A 7-day supply was sent on 4/11/22, and a 30-day supply was sent on 4/22/22. A review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (A 7-day supply sent on 4/11/22 would have made the medication available to the resident from 4/11 through 4/17/22. There was no explanation for how the facility administered the medication prior to 4/11/22. A 30-day supply sent on 4/22/22 would have made the medication available to the resident from 4/22/22 through her discharge on 4/27/22. There was no explanation for how the facility administered the medication from 4/18 through 4/21/22, and there was no explanation for why the 30-day supply delivered on 4/22/22 was only missing one pill as of 4/27/22 when the medication was ordered routinely every night.) In an interview on 4/27/22 at 3:11 p.m., the Director of Nursing (DON) stated he was not sure where the nurses obtained the [MEDICATION(S)] [MEDICATION(S)] for Resident #74 from 4/7/22 through 4/10/22, and from 4/18/22 through 4/21/22, since the April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy and procedure titled Medication Administration Created 6/2018 and reviewed on 1/2022 indicated that medications shall be administered in a safe and timely manner, and as prescribed. Procedure revealed that: 1. The director of nursing services will supervise and direct all nursing personnel who administer medications and /or have related functions. 2. Medications must be administered in accordance with the orders, including any required time frame. .

Based on observations, interviews, and record reviews, the facility failed to adminster tube feedings as ordered by the physician for one (Resident #44) of one resident reviewed for compliance with enteral nutrition from a total of 30 sampled residents. The findings include: A review of Resident #44's medical record revealed an admitted [DATE]. His primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A five-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 out of a possible 15 points, indicating moderately impaired cognition. Resident #44 required extensive to total assistance with activities of daily living (ADLs) and received his nutrition via enteral feeding (liquid nutrition delivered through a feeding tube). On 4/25/2022 at 1:35 p.m., Resident #44 was observed lying in his bed. His tube feeding was not connected. On 4/26/2022 at 2:19 p.m., Resident #44 was observed sitting in his wheelchair at his bedside. His tube feeding was not connected. On 4/28/2022 at 2:05 p.m., Resident #44 was observed sitting up in his wheelchair at his bedside with a visitor. His tube feeding was not connected. A review of Resident #44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) A review of Resident #44's progress notes revealed an entry by the dietician dated 3/31/2022 at 1:32 p.m., which indicated the resident's tube feeding was adjusted to promote participation in therapy. Resident is more alert and oriented in the AM and fatigued by lunch time per therapy. (Photographic Evidence Obtained) On 4/28/2022 at 2:15 p.m., an interview was conducted with Licensed Practical Nurse (LPN) A. He confirmed he was familiar with Resident #44 and that he was assigned to care for Resident #44 today. When asked what time Resident #44's tube feeding was due to be connected, LPN A stated, I think it is supposed to be connected at 3 o'clock. LPN A was asked to review Resident #44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/28/2022 at 2:26 p.m., LPN A returned and explained that the enteral feeding should be connected at 12:00 p.m. He stated he thought the order had changed. LPN A stated he was going to connect the enteral feeding immediately. A review of Resident #44's comprehensive care plan revealed a focus area for nutritional risk. Interventions included administration of tube feedings as ordered. (Photographic Evidence Obtained) .

Based on observations, record reviews, and interviews, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #31) of 19 residents receiving respiratory treatments from a total of 30 residents in the sample. The findings include: A review of Resident #31's medical record revealed his most recent admitted was 12/28/2021. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plans revealed a focus area for [CONDITION(S)] with an intervention that read, Give oxygen therapy as ordered by the physician. Resident #31 was observed on 4/26/2022 at approximately 11:11 AM. He was wearing his oxygen cannula and the concentrator was dispensing oxygen at a flow rate of 4 liters per minute (LPM). On 4/27/2022 at 1:16 PM, the flow rate for Resident #31's oxygen was set between 3.5 and 4 LPM. (Photographic Evidence Obtained) On 4/28/2022 at 11:37 AM, the oxygen concentrator's flow rate was set between 3.5 and 4 LPM. (Photographic Evidence Obtained) Registered Nurse (RN) F was interviewed at 11:45 AM on 4/28/2022. When asked about the resident's oxygen order, RN F confirmed that the resident was to receive oxygen at 3 LPM. When asked about the protocol for checking residents' oxygen concentrators, the nurse stated they were to be checked once per shift and documented on the Medication Administration Record (MAR). RN F checked Resident #31's oxygen concentrator flow rate and verified it was set at 4 LPM. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/28/22 at 12:26 PM. The ADON stated all orders were checked on admission. The nurses assigned to the unit were expected to check residents' flow rates every shift and sign off on the Treatment Administration Record (TAR), verifying the oxygen flow rate settings.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on four errors out of 30 opportunities for error, resulting in a facility error rate of 13.33%, and involving Residents #59, #6, #23, and #228. The findings include: 1. During medication administration on 4/26/22 at 11:30 a.m., Licensed Practical Nurse (LPN) A reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . He explained the process to the resident and obtained a blood glucose reading of 194 milligrams per deciliter (mg/dl). He then obtained the resident's [MEDICATION(S)] flex pen (insulin) and administered 5 units in the resident's left upper arm. He performed hand hygiene and documented in the MAR. (Copy obtained) In an interview on 4/26/22 at 11:40 a.m., LPN A confirmed that he had administered 5 units of [MEDICATION(S)] insulin. He added that the resident had a standard order for 5 units before meals. When asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If blood sugar is 181-220, give 2 units. LPN A confirmed that he should have given 7 units in total instead of 5 units. He added that he was not sure if he should give the other 2 units since the resident had a low blood sugar of 60 earlier this morning. After pausing momentarily, LPN A proceeded to the resident's room and administered the remaining 2 units of insulin. He initially checked off both orders on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) 2. On 4/26/22 at 12:06 p.m., Registered Nurse (RN) B was observed preparing to perform blood sugar monitoring for Resident #6. RN B performed hand hygiene with hand sanitizer donned clean gloves and obtained the glucometer, lancet, alcohol wipe and test strip. She entered Resident #6's room, cleansed the resident's right index finger with the alcohol wipe, pricked the resident's finger with the lancet, and obtained the blood sample. She obtained a blood sugar reading of 178 mg/dl. She cleansed the residents' finger used to obtain the blood sample with an alcohol wipe, collected the supplies and exited the resident's room. After appropriately discarding the lancet and test strip, she placed the glucometer on the medication cart, doffed her gloves and donned new gloves. She cleaned the glucometer with disinfecting wipes and placed it back on the medication cart. She doffed her gloves, performed hand hygiene, donned new gloves, obtained Resident #6's [MEDICATION(S)] insulin pen, and set it to 2.5 units. She proceeded to the resident's room and cleansed the resident's left upper arm. Just prior to administration of the insulin, RN B was asked to show the setting for the [MEDICATION(S)] pen and it revealed 2.5 units. She then adjusted the dosage to 2 units and administered the insulin. In an interview on 4/26/22 at 12:10 p.m., RN B confirmed that the insulin pen was at the wrong setting until she was prompted to adjust it. 3. On 4/27/22 at 10:19 a.m. LPN C was observed preparing medications for Resident #23. After performing hand hygiene, she obtained [MEDICATION(S)] tablet (Calcium Polycarbophil), 625 miligrams (mg), [MEDICATION(S)] 75 mg and probiotics (a lactobacillus capsule). The nurse crushed the medications separately and poured them into separate medication cups. She entered the resident's room, obtained water from the resident's bathroom sink and donned gloves. After donning gloves, the nurse proceeded to the resident's bedside table, opened the probiotic capsule and poured the contents into a separate cup. She obtained a disposable spoon, stirred the medication and began administering the medications one-at-a-time via the resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube). Medication was observed in the medication cups as the nurse completed administration of the medication. Before she could dispose of the cups, she was asked to look in the medication cups, which revealed approximately 50 % of the medications was not administered. (Photographic Evidence Obtained) In an interview on 4/27/22 at 10: 25 a.m., she confirmed that the medication was not completely dissolved and therefore not completely administered. She asked,Would you want to completely administer them? 4. On 4/27/22 at 10:30 a.m., the Assistant Director of Nursing (ADON) was observed preparing intravenous (IV) antibiotic medication for Resident #228. She obtained [MEDICATION(S)], 500 mg vial (Antibiotic) and reconstituted the powdered medication in a vial with 100 ml (milliliters) of normal saline. She primed the medication administration set, hung the medication on the IV pole, and connected the IV pump. There were visible bubbles still in the line. After cleaning the central line hub, she flushed it with 100 milliliters of normal saline, and connected the end of the IV medication administration set to the central line hub. As she was about to start the medication administration pump, she was stopped and notified of the air bubbles in the IV line. (Photographic evidence obtained). She disconnected the IV and started priming the line on a paper towel placed on the resident's bedside table. The paper towel did not absorb all of the medication; excess medication was running down the table. After she was finished reconnecting the IV, she dried the bedside table with a paper towel, doffed her gloves, performed hand hygiene and exited the resident's room. According to National library of medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 24/ (accessed on 4/28/22 at 1:17 p.m.), Air embolism is a rare but potentially fatal occurrence and may result from a variety of procedures and clinical scenarios. It can occur in either the venous or arterial system depending on where the air enters the systemic circulation. The effects will vary according to the vessels affected but cardiovascular, pulmonary, and neurological effects predominate the clinical picture. Occlusions of the cerebral and cardiac circulation are usually more clinically significant as these systems are highly vulnerable to [CONDITION(S)]. A review of the facility's policy and procedure titled Medication Administration (created 6/2018 and reviewed on 1/2022), revealed that Medications shall be administered in a safe and timely manner, and as prescribed. Procedure revealed that: 1. The director of nursing services will supervise and direct all nursing personnel who administer medications and /or have related functions. 2. Medications must be administered in accordance with the orders, including any required time frame. .

Based on observations, interviews and record reviews, the facility failed to ensure the residents' right to a dignified existence, by failing to ensure staff members knocked and announced themselves prior to entering resident rooms and by failing to ensure staff provided privacy to residents during personal care for two (Residents #609 and #610) of 34 residents sampled. The findings include: 1. During a tour of the facility on 10/4/2020 at 11:11 am, the rooms on the Pine Cove Unit were observed. There was a strong odor of bowel incontinence present on the North Hall of the unit where Resident #609's room was located. Upon exiting a room directly across the hall from Resident #609, the door leading to Resident #609's room was observed to be open and the call light above the room door was illuminated. Resident #609 was lying in bed uncovered from the waist down. His feet were resting on the mattress and his knees were raised. Resident #609 was observed wearing an adult incontinence brief with a clear catheter cord hanging from the side of the bed leading down to a covered bag. A thick, dark brown substance was observed on the back of the resident's right buttock and thigh. A review of the resident's clinical record revealed that Resident #609 was initially admitted into the facility on [DATE], with his most recent readmission on 9/30/2020. His [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment, completed on 8/26/2020, revealed that Resident #609 had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. No mood or behavior concerns were recorded. The resident required limited assistance with transfers, extensive assistance with personal hygiene, dressing, eating and bed mobility, and he was totally dependent for toileting. Resident #609 was documented as always incontinent of bowel and bladder. On 10/4/2020 at 11:29 am, Employee I, Certified Nursing Assistant (CNA), was observed entering Resident #609's room without knocking or introducing herself. She deactivated the resident's call light and promptly exited the room leaving the door ajar. No care or services were rendered. On 10/4/2020 at 11:31 am, while standing in the hall near the room directly across from Resident #609's room, the Executive Director (ED) approached. Upon making an observation of Resident #609, the ED asked whether anyone was in the resident's room with him. He was told No. He then exited toward the south end of the unit away from Resident #609's room. The door to the resident's room remained ajar. On 10/4/2020 at 11:32 am, Employee J, Licensed Practical Nurse (LPN), entered Resident #609's open door without knocking or identifying herself. She closed the door behind her. At this time, Employee I, CNA, also entered Resident #609's room without knocking or identifying herself. 2. On 10/7/2020 at 3:40 pm, while exiting the building from the Arbor Terrace Unit, two staff members (Employee E, LPN, and an unidentified staff member) were observed providing care inside of a resident room located on the south end of the 700 hall. The resident's room door was open and the privacy curtain was not pulled, revealing a clear view of the resident in the A bed and the two nurses providing care. From the hall leading to the resident's room, the resident observed and later identified as Resident #610, was fully unclothed. Upon discovering the presence of the survey team making observations from the hall, Employee E, LPN, immediately discontinued providing resident care and stated, I am sorry. This should be closed. She proceeded to close the door of the resident's room at that time. A review of Resident #610's clinical record revealed that the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. During an interview on 10/7/2020 at 11:42 am with the Assistant Director of Nursing (ADON), he stated call lights should remain lit until resident care has been completed. Staff should knock and introduce themselves prior to entering a resident's room, and when when providing care, the staff should close the privacy curtains and/or the resident's door to ensure the resident's privacy while providing care. During an interview on 10/07/2020 at 12:55 pm with Employee H, Certified Nursing Assistant (CNA), she stated she had been employed at the facility for approximately six years. She stated she knocked prior to entering a resident's room. She stated she informed the resident of the nature of her visit, and if the resident allowed her to enter, she closed the resident's door then pulled their privacy curtain to ensure the resident's privacy. During an interview on 10/07/2020 at 1:50 pm with Employee G, CNA, she stated she had been employed at the facility for approximately seven years. She further stated the care staff were to pull the curtains when doing patient care for privacy. The staff were to knock and explain to the residents the purpose of their visit, and when providing care, the staff were to cover the residents and change them when they were wet. During an interview on 10/7/2020 at 2:27 pm with Employee D, LPN/Clinical Services Manager, he stated all staff were responsible for responding to call lights. The staff were to turn off the call light after they had done what was needed. He also stated that to preserve the residents' dignity, staff should close the resident's room door when they were inside providing assistance. A review of the facility's policy titled: Quality of Life-Dignity-RR1. Policy Overview: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Detail: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 6. Residents' private space and property shall be respected at all times (a) Associates will knock and request permission prior to entering residents' room. 10. Associates shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Associates shall promote dignity and assist residents as needed by: (a) Helping the resident to keep urinary catheter bag covered (b) Promptly responding to the resident's request for toileting assistance. (Photographic evidence obtained)

Based on observations, interviews and record reviews, the facility failed to screen visitors for fever, known exposure to or symptoms of Novel Coronavirus (COVID-19) prior to allowing entry into the facility for five of five surveyors during four of five days of the facility's annual relicensure survey. Refer to https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The findings include: Upon arrival at the facility on 10/4/2020 at 11:00 a.m., five of five members of the survey team were not screened for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Upon arrival at the facility on 10/5/2020, Employee K, Site Security Supervisor, failed to screen four of five members of the survey team for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Upon arrival at the facility on 10/6/2020, Employee K, Site Security Supervisor, failed to screen four of five members of the survey team for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Upon arrival at the facility on 10/7/2020, Employee K, Site Security Supervisor, failed to screen five of five members of the survey team for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. During an interview with Employee K on 10/8/2020 at 1:23 p.m., he confirmed he was responsible for conducting the COVID screenings at the facility. He stated he had received training about how to properly perform the COVID screening. They have to have a mask. There is a series of yes and no questions they have to answer and I have to check their temperatures. He confirmed he did not conduct complete COVID screenings for four of five days for all members of the survey team. I didn't do the screening for the survey team. I should have. I am supposed to but I didn't. There is no reason I didn't. I don't know, we see so many people. On 10/8/2020 at 1:27 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). After reviewing the daily COVID screening sheets for 10/4, 10/5, 10/6, 10/7, and 10/8/2020 for five of five members of the survey team, he confirmed that complete COVID screenings were not conducted daily for each member of the team as they should have been. He stated security should have been asking visitors, staff and surveyors all of the screening questions. According to a review of Preparing for COVID-19 in Nursing Homes at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html: This guidance has been updated and reorganized according to core IPC practices that should remain in place even as nursing homes resume normal practices, plus additional strategies depending on the stages described in the CMS Reopening Guidance or at the direction of state and local officials. A review of the CMS (Centers for Medicare and Medicaid Services) Reopening Guidance for Visitation and Service Consideration revealed the need for: 100% screening of all persons entering the facility and all staff at the beginning of each shift to include: Temperature checks Ensure all outside persons entering building have cloth face covering or facemask. Questionnaire about symptoms and potential exposure Observation of any signs or symptoms .

Based on observations, record reviews and interviews, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice by failing to obtain laboratory reports as ordered by the physician; by failing to check glucometers for quality control; by failing to obtain an order to administer oxygen, and by failing to obtain and document an apical pulse before administering [MEDICATION NAME] for three (Residents #51, #31 and # 50) of 40 sampled residents. The findings include: 1. A record review was conducted for Resident #51 which revealed an admission date of [DATE] with a re-entry date of 10/25/18. [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME] - blood thinner), three milligrams (order dated 10/25/18) orally in the evening for prevention of blood clots. A physician's orders [REDACTED]. An 11/5/18 physician's orders [REDACTED]. Further review of the medical record revealed there was no documentation of the BMP ordered on 11/5 or the PT/INR ordered on [DATE]. (PT/INR's are required to monitor [MEDICATION NAME] so the dosage can be regulated accordingly.) An interview was conducted with Employee B, Registered Nurse (RN), on 11/28/18 at 2:35 PM. Employee B reviewed the computer and the laboratory book for the missing labs (BMP 11/5 and PT/INR 11/26/18). Employee B called the laboratory company the facility had a contract with, and the company confirmed there was no laboratory work obtained for a BMP on 11/5 or a PT/INR on 11/26/18. Employee B confirmed the lab work was not done. 2. Quality Control Records were reviewed for the Assure Platinum Blood Glucose Monitors at the facility. The documentation of testing the glucometers for the Pine Cove unit revealed there were two glucometers on each cart with documentation for only one glucometer with numerous days of missing documentation. Documentation for the cart for rooms 801-812 revealed that on (MONTH) 2, 15, 16, 18 and 21, documentation of the testing of the glucometer was missing. The second sheet of documentation for the rest of the rooms on the 800 unit revealed documentation for testing of one glucometer with the following missing dates: (MONTH) 2, 5, 6, 7, 8, 12, 14, 19, 20, 21, 22 and 26. (Glucometers are to be tested for accuracy, as improper blood sugar readings could result in a resident not receiving the correct insulin dosage.) An interview was conducted with the Director of Nursing (DON) on 11/28/18 at 2:12 PM. She was asked how often glucometers were checked for quality control, and she reported that staff checked the glucometers nightly on the 11:00 PM to 7:00 AM shift. The DON reviewed the two Pine Cove Quality Control Records, and confirmed the missing documentation over numerous days as stated above. She further stated that there should be two sheets for each cart, because there were two glucometers on each cart. There were two medication carts on the 800 hall unit. A review of the policy and procedure for Blood Glucose Management (revised 10/2016) noted to maintain blood glucose equipment per the manufacturer's instructions. 3. On 11/26/18 at 11:15 AM, Resident #31 was observed lying in bed with her eyes closed. She appeared asleep. An oxygen concentrator was on the floor next to the bed running at 2 liters per minute (LPM). A nasal cannula was observed lying on her chest, not placed in her nose. On 11/27/18 at 9:02 AM, Resident #31 was observed lying in bed with her breakfast tray on the tray table in front of her. She was eating her meal. Her nasal cannula was not properly placed on her face. Only one prong was in her nostril. The other prong was pressed against her face. Resident #31 did not appear to be in distress. The oxygen concentrator set at 2 LPM. A review of the physician's orders [REDACTED]. (Copy obtained) A review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed no administration of O2. A review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed an order to change, date & bag O2 tubing/nebulizer mask and tubing/rinse concentrator filter/clean oxygen filters on Friday if indicated. (Copy obtained) A review of the electronic clinical record for Resident #31 revealed she was admitted on [DATE]. Her date of birth was 03/11/1922, and her [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed: Section O: Oxygen (O2) treatments given while a resident. Hospice care while a resident. No respiratory therapy given in the last seven days. Three physician's orders [REDACTED]. Section C: Brief Interview of Mental Status (BIMS) score of 9 out of a possible 15. No [MEDICAL CONDITION], disorganized thinking, inattention or altered level of consciousness. Section J: No shortness of breath or trouble breathing while lying flat. (Copy obtained) A review of the resident's care plan dated 10/24/2018 revealed the following focus areas: [MEDICAL CONDITION]: Intervention: Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Monitor for SOB upon exertion. Resident has SOB related to anxiety, pain and allergies [REDACTED]. Monitor/document breathing patterns, nasal flaring, respiratory depth changes, altered chest excursion, use of accessory muscles, pursed-lip breathing or prolonged expiratory phase. Monitor/document/report breathing abnormalities to physician. Bradypnea, Tachypnea, Hyperventilation, Kussmaul's Respirations (deep respirations with any rate) Cheyne-Stokes, Apneusis (sustained maximal inhalation with pause) Biot's respiration, Ataxic patterns (irregular/unpredictable pattern with periods of apnea). Resident has a terminal prognosis related to [MEDICAL CONDITION]: O2 as needed for comfort. (Copy obtained) On 11/28/18 at 9:20 AM, Resident #31 was observed in bed with the head of her bed elevated to approximately 80 degrees. Her eyes were closed. Her nasal cannula was lying in her lap. The oxygen concentrator was running and was set at 2 LPM. When approached, she opened her eyes and said hello. She stated she was not feeling too good today. When asked whether she felt short of breath or if it was hard to breathe, she stated, sort of. When asked whether she was supposed to have the nasal cannula on her face, she said yes and asked for assistance applying it. The Unit Manager (UM), Employee D, came to the resident's room and attempted to obtain her blood oxygen saturation level using a pulse oximeter. The level obtained was 69. The UM rubbed her finger for a few minutes and tried again. The level did not change. At 9:29 AM, the UM stated that this resident would tell him if there was a problem. She talks to me and (Employee A). He told Employee A, Certified Nursing Assistant (CNA), to get the machine that the staff used to obtain vital signs. Employee A returned with the machine, and the UM attempted to obtain another blood oxygen level using it. The blood oxygen level he obtained was 79 and then decreased to 77. The nasal cannula was placed on the resident, and the staff was told by the Director of Nursing to attempt to get the blood oxygen saturation level again later. During an interview with the DON on 11/28/18 at 9:26 AM, she stated she would expect the resident's blood oxygen level to be above 91 while receiving oxygen. She was not sure what the order was for oxygen for this resident and she would go check. When she returned she stated that the order was part of the hospice care plan as a comfort measure only. When asked when the resident was supposed to have the nasal cannula on, she stated It's just for comfort, that's all. She did not know when the resident was supposed to have the nasal cannula on or off. She could not define comfort for this resident, or when she should have it. The DON told the UM to call the hospice provider and get a clarification order. She stated this resident could make her needs known and would tell the staff if she was not feeling well or was short of breath. She answered questions logically. During an interview with Employee A on 11/28/18 at 9:30 AM, she stated she thought the nasal cannula should be applied all the time, but the resident took it off sometimes. During an interview on 11/29/18 at 4:04 PM with the DON, she stated she did not know why the O2 level was set at 2 LPM. She thought it was in a policy and said she would check it. She provided the physician's orders [REDACTED]. A review of the hospice provider physician's orders [REDACTED]. Dyspnea related to [MEDICAL CONDITION] (diastolic): O2 as ordered. Head of bed elevated. (Copy obtained) A review of the policy and procedure entitled 6.0 General Dose Preparation and Medication Administration, effective 12/01/2007, revised last on 01/01/2013 ,revealed: 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 4.4.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. 4.1.2 Confirm that the MAR reflects the most recent medication order. 6.1 Document necessary medication administration/treatment information (i.e. when medications are given, as needed medications) on appropriate forms. (Copy obtained) 4. A review of the Order Summary Report for Resident #50 (admitted on [DATE]), showed a physician's orders [REDACTED]. The order had a start date of 11/18/18 and no discontinuation or change in the order was located. A review of the Medication Administration Record (MAR) for Resident #50 for 11/1/18 through 11/30/18 on page two (2) documented [MEDICATION NAME] tablet, 125 mcg signed off by nurses as having been given at 9:00 AM on 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18 and 11/29/18. No heart rate was documented on the MAR for any of the mentioned administration dates. A review of the Weight and Vitals Summary for Resident #50 revealed on pages four (4) and five (5) that no heart rate (pulse) was entered at 9:00 AM for 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18 or 11/29/18. The Director of Nursing (DON) was interviewed on 11/29/18 at 2:45 PM and stated, The pulses should be documented on the MAR. The nurses put in the orders and the unit manager checks behind them. On this one, which has parameters, the box is not there on the MAR for the pulse. The only other place to check is the vital signs page, but they aren't there either. The dates with a pulse documented in that timeframe are not at the right times. It doesn't look like the pulse is documented at all at the time the medication was given, so I don't know how you would know if it was greater than 60.

Based on resident interviews, observations, staff interviews, clinical record reviews and policy and procedure review, the facility failed to ensure sufficient and competent nursing staff to provide medication in a timely manner and as ordered by a physician for four (Residents #51, #26, #21 and #58) of five residents sampled for unnecessary medication review, and for three (Residents #45, #21 and #58) of 40 sampled residents who reported receiving their medications late. Residents who do not receive their medications according to physicians' orders are at risk for clinical complications. The findings include: 1. During an interview with Resident #45 on 11/28/18 at 9:16 AM, she stated she thought there were insufficient nursing staff in the building, because she received her medications late. She stated she received them at all times of the day and much later than the allowed hour beyond the time they were scheduled to be administered. She stated, I know the nursing staff have too much to do here and run late a lot! During an interview with Resident #45 on 11/29/2018 at 1:45 PM, she stated she was concerned that because the nurses did not hook her up to her IV (intravenous) antibiotic medication on time, she would not get well. Her disorder required that the medication be administered on time. You know, it can take hold if I don't get the antibiotic in a timely manner. She stated she felt the nurses were just too busy. One night recently they hooked her up to her IV line and then failed to turn the IV drip on. I went all night without getting it. When it was discovered, I received the medication, hours late. She stated that when the two medications she received intravenously were administered too closely together, it made her feel nauseated, and she then had to request [MEDICATION NAME] to make the nausea subside. A review of Resident #45's (MONTH) (YEAR) Medication Administration Record [REDACTED] [MEDICATION NAME] Solution intravenously (IV). Give 440 mg/NS (milligrams/normal saline) 100 @ 100 ml (milliliters) per hour. Give M-W-F (Mondays/Wednesdays/Fridays). Draw next trough 30-60 minutes prior to 11/09/18. Scheduled 11/16/18 at 9:00 AM. Administered on 11/16/18 at 3:58 PM by Employee W, Registered Nurse (RN). Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/01/2018 at 22:00 Administered 11/01/2018 at 04:47 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/02/2018 at 22:00 Administered 11/02/2018 at 23:31 by Employee V, Licensed Practical Nurse (LPN). Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/03/2018 at 14:00 Administered 11/03/2018 at 15:33 by Employee X, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/03/2018 at 22:00 Administered 11/03/2018 at 01:34 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/04/2018 at 14:00 Administered 11/04/2018 at 16:46 by Employee X, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/05/2018 at 14:00 Administered 11/05/2018 at 16:07 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/05/2018 at 22:00 Administered 11/06/2018 at 01:51 by Employee F, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/07/2018 at 14:00 Administered 11/07/2018 at 15:26 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/09/2018 at 22:00 Administered 11/09/2018 at 23:46 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/11/2018 at 22:00 Administered 11/12/2018 at 05:06 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/12/2018 at 14:00 Administered 11/12/2018 at 15:37 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/13/2018 at 14:00 Administered 11/13/2018 at 15:10 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/15/2018 at 14:00 Administered 11/15/2018 at 16:10 by Employee D, LPN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/16/2018 at 22:00 Administered 11/16/2018 at 23:34 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/17/2018 at 22:00 Administered 11/18/2018 at 03:11 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/20/2018 at 14:00 Administered 11/20/2018 at 15:45 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/21/2018 at 14:00 Administered 11/21/2018 at 15:35 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/21/2018 at 22:00 Administered 11/22/2018 at 00:23 by Employee G, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/22/2018 at 14:00 Administered 11/22/2018 at 15:13 by Employee X, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/22/2018 at 22:00 Administered 11/22/2018 at 00:08 by Employee F, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/23/2018 at 22:00 Administered 11/23/2018 at 23:34 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/24/2018 at 22:00 Administered 11/24/2018 at 23:42 by Employee N, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/25/2018 at 14:00 Administered 11/25/2018 at 15:28 by Employee C, LPN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/26/2018 at 14:00 Administered 11/26/2018 at 15:11 by Employee B, RN. Imipenem-Cilastatin Solution Reconstituted 500mg. Use 500mg intravenously every 8 hours. Scheduled 11/28/2018 at 14:00 Administered 11/28/2018 at 15:40 by Employee B, RN. [MEDICATION NAME] HCI Tablet ([MEDICATION NAME]) 4 mg. Give one tablet by mouth every eight hours as needed. Administered: 11/07/2018 at 15:30 11/12/2018 at 08:59 11/14/2018 at 09:21 11/21/2018 at 08:37 A review of the physician's orders [REDACTED].>[MEDICATION NAME] Solution intravenously (IV). Give 440 mg/NS 100 @ 100 ml per hour. Give M-W-F. Draw next trough 30-60 minutes prior to 11/09/18. Imipenem-Cilastatin Solution Reconstituted 500 mg. Use 500 mg intravenously every eight hours. [MEDICATION NAME] HCI ([MEDICATION NAME]) tablet ([MEDICATION NAME]) 4 mg. Give one tablet by mouth every eight hours as needed for nausea/vomiting. 2. Review of the electronic Medication Administration Record [REDACTED] Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/02/18 at 9:00 PM Administered 11/02/18 at 11:39 PM by Employee V, LPN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/02/18 at 9:00 PM. Administered 11/02/18 at 11:39 PM by Employee V, LPN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/02/18 at 9:00 PM. Administered 11/02/18 at 11:39 PM by Employee V, LPN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/02/18 at 9:00 PM. Administered 11/02/18 at 11:40 PM by Employee V, LPN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/05/18 at 9:00 PM Administered 11/05/18 at 10:45 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/05/18 at 9:00 PM. Administered 11/05/18 at 10:45 PM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/05/18 at 9:00 PM Administered 11/05/18 at 10:45 PM by Employee F, RN. [MEDICATION NAME] capsule 100mg. Give 1 capsule at bedtime - Scheduled 11/05/18 at 9:00 PM. Administered 11/05/18 at 10:45 PM by Employee F, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/07/18 at 9:00 PM. Administered 11/07/18 at 11:49 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/07/18 at 9:00 PM. Administered 11/07/18 at 11:49 PM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/07/18 at 9:00 PM. Administered 11/07/18 at 11:49 PM by Employee F, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/07/18 at 9:00 PM. Administered 11/07/18 at 11:49 PM by Employee F, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/12/18 at 9:00 PM. Administered 11/12/18 at 11:09 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/12/18 at 9:00 PM. Administered 11/12/18 at 11:17 PM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/12/18 at 9:00 PM. Administered 11/12/18 at 11:09 PM by Employee F, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/12/18 at 9:00 PM. Administered 11/12/18 at 11:09 PM by Employee F, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/14/18 at 9:00 PM. Administered 11/14/18 at 11:25 PM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/14/18 at 9:00 PM. Administered 11/14/18 at 11:25 PM by Employee F, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/14/18 at 9:00 PM. Administered 11/14/18 at 11:25 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/14/18 at 9:00 PM. Administered 11/14/18 at 11:31 PM by Employee F, RN. [MEDICATION NAME] Nebulizer Solution (2.5mg/3ml) 0.083% 3ml inhale orally via nebulizer two times a day - Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:46 AM by Employee B, RN. Magic cup bid two times a day - Scheduled 11/14/18 at 8:30 AM. Administered 11/14/18 at 9:35 AM by Employee B, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:46 AM by Employee B, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:45 AM by Employee B, RN. Salon Pas [MEDICATION NAME] Gel Patch 4%. One time a day. Leave on for eight hours, remove before applying new patch. Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:45 AM by Employee B, RN. [MEDICATION NAME] tablet 2.5 mg. Give 1 tablet by mouth one time a day. Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:46 AM by Employee B, RN. [MEDICATION NAME] Chloride tab 5 mg Give 1 tablet by mouth one time a day. Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:45 AM by Employee B, RN. [MEDICATION NAME] HCI 50 mg. Give 1 tablet by mouth one time a day. Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:46 AM by Employee B, RN. Senna Plus tablet. 8.6-50 mg. Give 2 tab by mouth one time a day. Scheduled 11/14/18 at 9:00 AM. Administered 11/14/18 at 10:45 AMby Employee B, RN. Magic cup bid (two times) a day - Scheduled 11/15/18 at 8:30 AM. Administered 11/15/18 at 11:58 PM by Employee D, LPN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 12:00 PM by Employee D, LPN. Salon Pas [MEDICATION NAME] Gel Patch 4%. One time a day. Leave on for 8 hours, remove before applying new patch. Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:58 AM by Employee D, LPN. Senna Plus tablet. 8.6-50 mg. Give 2 tab by mouth one time a day. Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 12:00 PM by Employee D, LPN. [MEDICATION NAME] HCI 50 mg. Give 1 tablet by mouth one time a day. Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:59 PM by Employee D, LPN. [MEDICATION NAME] tablet 2.5 mg. Give 1 tablet by mouth one time a day. Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:58 PM by Employee D, LPN. [MEDICATION NAME] Chloride tab 5 mg Give 1 tablet by mouth one time a day. Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:58 PM by Employee D, LPN. [MEDICATION NAME] Nebulizer Solution (2.5mg/3ml) 0.083% 3ml inhale orally via nebulizer two times a day - Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:58 PM by Employee D, LPN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/15/18 at 9:00 AM. Administered 11/15/18 at 11:58 PM by Employee D, LPN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/18/18 at 9:00 PM. Administered 11/18/18 at 10:06 PM by Employee N, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/18/18 at 9:00 PM. Administered 11/18/18 at 10:06 PM by Employee N, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/18/18 at 9:00 PM. Administered 11/18/18 at 10:06 PM by Employee N, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/18/18 at 9:00 PM. Administered 11/18/18 at 10:45 PM by Employee N, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/19/18 at 9:00 PM. Administered 11/19/18 at 11:44 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/19/18 at 9:00 PM. Administered 11/19/18 at 11:44 PM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/19/18 at 9:00 PM. Administered 11/19/18 at 11:45 PM by Employee F, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/19/18 at 9:00 PM. Administered 11/19/18 at 11:44 PM by Employee F, RN. [MEDICATION NAME] Sodium Tablet 40 mg. Give one tablet by mouth at bedtime - Scheduled 11/19/18 at 9:00 PM. Administered 11/19/18 at 11:44 PM by Employee F, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/20/18 at 9:00 PM. Administered 11/20/18 at 10:30 PM by Employee F, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/20/18 at 9:00 PM. Administered 11/21/18 at 12:23 AM by Employee F, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/20/18 at 9:00 PM. Administered 11/21/18 at 12:23 AM by Employee F, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/20/18 at 9:00 PM. Administered 11/20/18 at 22:30 PM by Employee F, RN. [MEDICATION NAME] Sodium Tablet 40 mg. Give one tablet by mouth at bedtime - Scheduled 11/20/18 at 9:00 PM. Administered 11/20/18 at 10:29 PM by Employee F, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/21/18 at 9:00 PM. Administered 11/22/18 at 12:06 AM by Employee G, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/21/18 at 9:00 PM. Administered 11/22/18 at 12:08 AM by Employee G, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/21/18 at 9:00 PM. Administered 11/22/18 at 12:06 AM by Employee G, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/21/18 at 9:00 PM. Administered 11/22/18 at 12:06 AM by Employee G, RN. [MEDICATION NAME] Sodium Tablet 40 mg. Give one tablet by mouth at bedtime - Scheduled 11/21/18 at 9:00 PM. Administered 11/22/18 at 12:06 AM by Employee G, RN. Med-Pass two times a day give 60 milliliter (ml) twice daily - Scheduled 11/22/18 at 9:00 PM. Administered 11/22/18 at 10:59 PM by Employee G, RN. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime - Scheduled 11/22/18 at 9:00 PM. Administered 11/22/18 at 11:01 PM by Employee G, RN. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day - Scheduled 11/22/18 at 9:00 PM. Administered 11/22/18 at 11:01 PM by Employee G, RN. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime - Scheduled 11/22/18 at 9:00 PM. Administered 11/22/18 at 10:59 PM by Employee G, RN. [MEDICATION NAME] Sodium Tablet 40 mg. Give one tablet by mouth at bedtime - Scheduled 11/22/18 at 9:00 PM. Administered 11/22/18 at 10:59 PM by Employee G, RN. A review of Resident #39's (MONTH) (YEAR) physician's orders [REDACTED]. Med-Pass two times a day give 60 milliliter (ml) twice daily. Ambien tablet 10 milligram (mg). Give 1 tablet by mouth at bedtime. [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth two times a day. [MEDICATION NAME] capsule 100 mg. Give 1 capsule at bedtime. [MEDICATION NAME] Sodium Tablet 40 mg. Give one tablet by mouth at bedtime. [MEDICATION NAME] Nebulizer Solution (2.5mg/3ml) 0.083% 3 ml inhale orally via nebulizer two times a day. Magic cup two times a day. Salon Pas [MEDICATION NAME] Gel Patch 4%. Apply one time a day. Leave on for eight hours, remove before applying new patch. [MEDICATION NAME] tablet 2.5 mg. Give one tablet by mouth one time a day. [MEDICATION NAME] Chloride tab 5 mg Give one tablet by mouth one time a day. [MEDICATION NAME] HCI 50 mg. Give one tablet by mouth one time a day. Senna Plus tablet. 8.6-50mg. Give two tabs by mouth one time a day. On 11/28/2018 at 8:10 PM, four nurses were observed on duty. Employees H, F, E, and G. Employee B, who had worked the day shift (7:00 AM - 7:00 PM), was observed documenting nursing notes. Employees F, H and B were seated at the nurse's station talking to each other. Employees F and H were asked why the medication passes had not started yet, and were also informed that their residents had complained about their medications being passed late consistently. Employee F was interviewed at 8:14 PM. When asked whether she had started her medication pass yet, she replied that she was waiting to be briefed by the day shift nurse, Employee B. During an interview with Employee H on 11/28/2018 at 8:19 PM, she stated that she normally started her medication pass at 8:00 PM, but if there was a newly admitted resident, that would take priority and would therefore delay the medication pass. During an interview with Employees E and G on 11/28/2018 at 8:23 PM, both nurses stated that it took them two hours to pass all of their medications. They usually finished by 10:00 PM. During an interview with Employee F on 11/28/2018 at 8:27 PM, she was asked whether she had discussed this issue with the Director of Nursing (DON). She stated neither the DON nor any of the managers ever came to the facility at night. There were times when there were three nurses scheduled for the facility. On such days, the nurse responsible for rooms 812-840 would also be responsible for the entire 700 hall. That was always my duty. On those days, residents did not receive their medications until midnight. Some residents took longer to medicate than others. The managers were aware that there was insufficient staffing at night and on the weekends. The night staff were part-time workers except Employees H and E. The pattern was three nurses instead of four nurses. We are always short. During an interview with Employee C, LPN, Weekend Supervisor, on 11/29/18 at 1:35 PM, he stated that sometimes at night there were only three nurses passing medication instead of four, and that would make the medication pass late. He confirmed the nurses had one hour before the scheduled time and one hour after to pass the medications. During an interview with the Director of Nursing (DON) on 11/29/2018 at 4:40 PM, she stated the expectation was that the nurses passing medications would pass them either an hour before or an hour after the scheduled time on the MAR. She indicated that she was aware that medications were being passed late. A review of the policy and procedure entitled 6.0 General Dose Preparation and Medication Administration, effective 12/01/2007, and revised last on 01/01/2013 revealed: 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 4.4.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. 3. A record review was conducted for Resident #51 which revealed an admission date of [DATE] and a re-entry date of 10/25/18. [DIAGNOSES REDACTED]. A record review was conducted for Resident #51 which noted medications were not given in a timely manner. The current Medication Administration Record [REDACTED]. On 11/22/18 the following medications were scheduled to be administered at 9:00 AM and were administered at 10:41 AM: Potassium Chloride 10 millequivalents (meq) orally everyday [MEDICATION NAME] 0.4 milligram (mg) orally everyday [MEDICATION NAME] 40 mg orally everyday [MEDICATION NAME] 100 mg every day [MEDICATION NAME] 25 mg orally every day On 11/22/18, the following medications were scheduled to be administered at 5:00 PM: [MEDICATION NAME] 40 mg twice a day which was administered at 6:20 PM, [MEDICATION NAME] Sodium 3 mg orally every evening and administered at 7:58 PM. On 11/24/18, the following medications were scheduled to be given at 9:00 AM: [MEDICATION NAME] 100 milligrams orally everyday [MEDICATION NAME] 25 mg orally everyday [MEDICATION NAME] 0.4 mg every day [MEDICATION NAME] 40 mg orally twice a day Potassium Chloride 10 meq everyday The medications were administered at 10:30 AM. There were multiple days the resident received his medication between 1.5 hours and 3 hours after the scheduled time. 4. A record review was conducted for Resident #26 which revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. The record review included a review of the current MAR (time stamped to show when medications were administered), which revealed medications were not given in a timely manner. On 11/19/18 the following medications were scheduled for 9:00 AM and were administered at 11:59 AM: [MEDICATION NAME] 60 mg every day [MEDICATION NAME] 25 mg orally twice a day [MEDICATION NAME] 5 mg orally every day [MEDICATION NAME] 40 mg orally everyday [MEDICATION NAME] 400 mg everyday Potassium chloride 20 meq Ranolazine 500 mg On 11/21/18 the following medications were scheduled to be administered at 9:00 PM and were administered at 11:25 PM: [MEDICATION NAME] 20 mg orally at bedtime Tamsulosin 0.4 mg orally twice a day Sodium Chloride 1 gram (gm) twice a day [MEDICATION NAME] extended release 25 mg orally twice a day Ranolazine 12 hour 500 mg 1 orally twice a day Nortripyline 10 mg orally twice a day On 11/22/18 the following medications were scheduled to be administered at 9:00 AM and were administered at 11:48 AM. [MEDICATION NAME] 5 mg [MEDICATION NAME] 25 mg Potassium Chloride 20 meq Ranolazine 500 mg [MEDICATION NAME] 10 mg On 11/24/18 the following medications were scheduled for 9:00 AM and were administered at 11:17 AM. [MEDICATION NAME] 60 mg Sodium Chloirde 1 gram [MEDICATION NAME] 5 mg Potassium Chloride 20 meq Ranolazine 500 mg [MEDICATION NAME] 40 mg [MEDICATION NAME] 10 mg [MEDICATION NAME] 25 mg [MEDICATION NAME] 400 mg Tamsulsosin 0.4 mg Aspirin 81 mg There were numerous days during which the resident received his medication two hours late or more. 5. An interview conducted with Resident #21 on 11/26/18 at 10:31 AM revealed a concern that she did not receive her medications on time, and they were sometimes administered as much as two to three hours late. Her main concern was her sleeping pill. A review of the time-stamped report of the Medication Administration Record [REDACTED] [MEDICATION NAME] 400 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:54 AM by Employee N, RN [MEDICATION NAME] 400 mg - Scheduled 11/9 at 9:00 PM. Administered 11/10 at 12:41 AM by Employee N, RN Ambien 10 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:54 AM by Employee N, RN Ambien 10 mg - Scheduled 11/9 at 9:00 PM. Administered 11/10 at 12:38 AM by Employee N, RN Ambien 10 mg - Scheduled 11/17 at 9:00 PM. Administered 11/17 at 23:12 PM by Employee O, LPN [MEDICATION NAME] 15 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:54 AM by Employee N, RN [MEDICATION NAME] 15 mg - Scheduled 11/9 at 9:00 PM. Administered 11/10 at 12:41 AM by Employee N, RN [MEDICATION NAME] 15 mg - Scheduled 11/17 at 9:00 PM. Administered 11/17 at 11:13 PM by Employee O, LPN [MEDICATION NAME] 0.5 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:54 AM by Employee N, RN [MEDICATION NAME] 0.5 mg - Scheduled 11/9 at 9:00 PM. Administered 11/10 at 12:41 AM by Employee N, RN [MEDICATION NAME] 0.5 mg - Scheduled 11/17 at 9:00 PM. Administered 11/17 at 11:13 PM by Employee O, LPN [MEDICATION NAME] 5 mg - Scheduled 11/7 at 9:00 Administered 11/8 at 12:54 AM by Employee N, RN [MEDICATION NAME] 5 mg - Scheduled 11/9 at 9:00 PM. Administered 11/10 at 12:38 AM by Employee N, RN [MEDICATION NAME] 5 mg - Scheduled 11/17 at 9:00 PM. Administered 11/17 at 11:12 AM by Employee O, LPN 6. On 11/26/18 at 1:15 PM an interview was conducted with Resident #58. She stated she had been receiving her evening medications late. She further stated medications were brought to her at midnight, but she thought they were scheduled for 10:00 PM. A review of the time-stamped report of the Medication Administration Record [REDACTED] Carvedilol 6.25 mg X3 18.75 mg - Scheduled 11/21 at 9:00 AM. Administered 11/21 at 12:04 PM by Employee P, LPN Carvedilol 6.25 mg X3 18.75 mg - Scheduled 11/27 at 9:00 AM. Administered 11/27 at 11:00 AM by Employee P, LPN [MEDICATION NAME] 100 mg X2 200 mg - Scheduled 11/21 at 9:00 AM. Administered 11/21 at 12:04 PM by Employee P, LPN [MEDICATION NAME] 100 mg X2 200 mg - Scheduled 11/27 at 9:00 AM. Administered 11/27 at 11:00 AM by Employee P, LPN [MEDICATION NAME] 100 mg X2 200 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:59 AM by Employee N, RN [MEDICATION NAME] 100 mg X2 200 mg - Scheduled 11/13 at 9:00 PM. Administered at 11/14 6:33 AM by Employee H, LPN [MEDICATION NAME] 40 mg - Scheduled 11/21 at 9:00 AM. Administered 11/21 at 12:04 PM by Employee P, LPN [MEDICATION NAME] 40 mg - Scheduled 11/27 at 9:00 AM. Administered 11/27 at 11:00 AM by Employee P, LPN [MEDICATION NAME] 50 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:59 AM by Employee N, RN [MEDICATION NAME] 50 mg - Scheduled 11/13 at 9:00 PM. Administered 11/14 at 6:33 AM by Employee H, LPN [MEDICATION NAME] 5 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:58 AM by Employee N, RN [MEDICATION NAME] 5 mg - Scheduled 11/13 at 9:00 PM. Administered 11/14 at 6:33 Am by Employee H, LPN Montelukast Sodium 10 mg - Scheduled 11/7 at 9:00 PM. Administered 11/8 at 12:58 AM by Employee N, RN Montelukast Sodium 10 mg - Scheduled 11/13 at 9:00 PM. Administered 11/14 at 6:33 AM by Employee H, LPN

Based on observations and interviews, the facility failed to ensure the dignity of one (Resident #61) out of one sampled residents related to assisted dining from a total sample of 40 residents. This placed the resident at risk for psychosocial harm. The findings include: On 11/26/18 at 8:01 PM, an interview was conducted with Resident #61 concerning care. When asked whether staff treated the resident with dignity and respect, the resident replied that there was a concern with the Certified Nursing Assistants (CNAs) feeding her too quickly. The resident stated she complained to management and they corrected the issue. On 11/26/18 at 1:13 PM, Employee J, CNA, was observed assisting the resident to eat while standing alongside the resident's bed. The resident's head was at the level of the CNA's stomach. The CNA had to extend her left arm to full length to reach the resident's mouth. On 11/27/18 at 12:54 PM, Employee J was observed a second time while assisting the resident with lunch. She was again standing alongside the resident's bed. She spoke with the resident, asking if she would like a drink, wanted salt, or more juice. She would then lean down to catch the resident's gaze, to determine whether the resident was ready for another bite. The resident's head was at the level of the CNA's stomach. The head of the bed was elevated 45 degrees. The pace of the assistance provided was moderate. On 11/28/18 at 1:11 PM, Employee K, CNA, was observed as she assisted the resident with lunch. She was seated next to the resident's bed, working at a slow, even pace. On 11/28/18 at 1:14 PM, an interview was conducted with the Director of Clinical Services (DCS) and the Administrator. When asked to describe the steps for assisting a resident with a meal, the DON stated one should introduce themself and explain what they were preparing to do. They should ensure the resident was alert and able to eat safely. When asked whether the CNA's position relative to the resident was important, the DCS hesitated to answer. The Administrator then stated this question was related to the 700 hallway, and the CNA who was standing while assisting a resident in bed to eat. The Administrator stated he saw this and had already corrected it. When asked why he corrected it, he stated the assistant should always be at eye level with the resident. The facility standard was for the assistant to be seated next to the resident with the table easily reachable, and to work at a pace that was comfortable for that resident. On 11/28/18 at 1:21 PM, an interview was conducted with Employee J, CNA. When asked what steps were critical when assisting someone to eat, she stated that one should be sure the amount of food on the spoon was correct, the pace was matched to what the resident expected and was comfortable with, and to watch for pocketing (holding food in the cheek) food. When asked what her position in relation to the resident should be, she stated that normally she sat next to the resident in the dining room, but in the resident's room, she usually stood next to the bed. When asked whether she should be at eye level with the resident, she replied that she was at eye level, because she was short. On 11/28/18 at 1:31 PM, an interview was conducted with Employee K, CNA. When asked what things were important to remember when assisting a resident to eat, she stated that one should ensure the resident did not choke, they were alert, and they knew what the CNA was doing. When asked if her position relative to the resident was important, she stated yes, she needed to be close enough to see what was happening and that the resident was okay. When asked whether she was corrected by the Administrator because she stood instead of sitting while assisting the resident to eat, she replied that yes, she had been corrected by the Administrator. On 11/28/18 at 1:42 PM, another interview was conducted with Resident #61. She was asked how she felt about being assisted to eat by someone standing at her bedside. She stated she felt badly that she could not feed herself, but having someone standing over her while assisting her with her meal made her feel small.

Based on record review, staff and family interviews, and facility policy review, the facility failed to prevent a significant medication error not observed during medication pass for 1 resident (Residents #1), out of 9 sampled residents who were admitted to the facility from the hospital with a [DIAGNOSES REDACTED]. The facility's failure to prevent significant medication errors related to transcription of orders placed all residents who received medications at risk for serious harm, injury, impairment, or death. Substandard Quality Care was determined at F333 S/S of J, F309 S/S of J. Cross reference F520 S/S of J and F155 S/S of J. The immediate jeopardy was ongoing at the time of exit on [DATE]. The findings include: Record review for Resident #1 revealed that he was transferred to the facility from the hospital on [DATE]. Review of the resident's hospital discharge summary dated [DATE] revealed a final [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the hospital's "Individualized Patient Discharge Instructions" for Resident #1, dated [DATE], found medications to be continued after hospitalization included [MEDICATION NAME] (a long acting insulin to control blood sugar) 20 units twice daily and [MEDICATION NAME] (a medication taken by mouth to control blood sugar) 50mg daily. Review of the hospital 3008 form for Resident #1 revealed teaching needs were circled for diabetic and cardiac. Review of Resident #1's "Admission Data Evaluation", dated [DATE], revealed that diabetes was checked as a contributing [DIAGNOSES REDACTED]. Review of Resident #1's Physician's Order Sheet (POS) dated [DATE] revealed that [MEDICATION NAME] 50 mg one tab by mouth daily for diabetes was transcribed from the hospital discharge summary onto the POS. The resident's prescribed [MEDICATION NAME]20 units twice daily was not transcribed onto the POS. Review of Resident #1's February, 2015 Medication Administration Record [REDACTED]. No blood sugar monitoring was documented on the resident's MAR indicated [REDACTED]. A complete review of Resident #1's record revealed that from the time of his admission to the facility on [DATE] until his re-hospitalization on [DATE], there was no documentation found to indicate that the resident received any of his prescribed insulin, or any blood sugar monitoring. The resident's [MEDICATION NAME] 50mg was administered on [DATE] and [DATE] as ordered. On [DATE] at 11:39am, in an interview with the Director of Clinical Services (DCS), she stated that when a resident is admitted to the facility from the hospital, the nurse transcribes the hospital discharge orders onto the resident's POS, and faxes the POS to the pharmacy. She said that during her investigation of Resident #1's insulin transcription error, the pharmacy informed her that they did not receive a POS from the facility with Resident #1's order for [MEDICATION NAME]transcribed. Review of Resident #1's Interim Plan of Care dated [DATE], revealed "At Risk for Complication from Diabetes Mellitus." Interventions included: monitor blood sugars as ordered, monitor for signs and symptoms of [MEDICAL CONDITION]/ [DIAGNOSES REDACTED] (elevated or low blood sugar), and administer medications as ordered. In an interview with Employee B, Licensed Practical Nurse (LPN), on [DATE] at 3:15pm, she stated that she transcribed Resident #1's hospital discharge orders onto the POS at admission on [DATE]. She said she remembered Resident #1's order for [MEDICATION NAME] insulin, and she knows she wrote it out on the resident's POS. She said that she also called the resident's physician, and read all of the resident's [DIAGNOSES REDACTED]. She said the physician did not make any changes to Resident #1's medications at that time. Employee B went on to say that she transcribed Resident #1's [MEDICATION NAME] onto a separate page of the POS. She said that Employee C, LPN, verified the orders she had transcribed for Resident #1. She recalled that the fax machine at the nurses' station was broken at the time that she transcribed the orders, and she went to another part of the facility to fax the resident's POS to the pharmacy. She explained that the MARs are produced as a carbon copy of the POS. She said that the page of the POS, and the attached MAR, for Resident #1's prescribed [MEDICATION NAME]was "gone." She said that the pharmacy later confirmed to her that they never got the page of Resident #1's POS that had the order for insulin transcribed on it. She recalled that 3 other residents were admitted around the same time that Resident #1 was admitted , and she did 3 of the 4 admissions that evening. Employee B said that she was not aware of the medication transcription error for Resident #1, until he went to the hospital on [DATE]. On [DATE] at 11:04am, in an interview with Resident #1's primary physician, he stated that he recalled that the nurse read the resident's medications to him, and that he told her to continue the medications. He said he did not recall the specific medications that the nurse read to him. The physician said that Resident #1 was sent back to the hospital from the facility, and the next day or so he was notified by the facility of a possible error in medication. He confirmed that the facility omitted the resident's prescribed insulin from the resident's POS and MAR. He pointed out that the resident was getting an oral hypoglycemic, and he stated that if the resident did not receive insulin for several days, there probably would not be any symptoms "unless the blood sugar was extremely high, well over 500." On [DATE] at 9:58am, in an interview with Employee C, LPN, she stated that she verified the transcribed admission orders [REDACTED]. She recalled that a page of the POS was stuck together with the other pages. She said she remembered this because Employee B told her at the time that she missed checking a page of the POS. She said she read the missed page, and she remembered that it had the resident's insulin order on it. She said she did not find any errors in the transcription. On [DATE] at 12:03pm, in an interview with Employee D, LPN, he stated that his job duties on the night shift included 24 hour chart audits. He said that he verified transcription of all admission orders [REDACTED]. He said he couldn't remember if he actually looked at Resident #1's admission chart. He said normally he takes his time going through the records, but there were at least 4 or 5 admissions on that day. He said he is more cautious since this medication error occurred with Resident #1. Review of Resident #1's record revealed that the 24 hour audit of physician orders, dated [DATE], was initialed by a nurse. On [DATE] at 4:04pm, in an interview with Employee A, Registered Nurse (RN) and Unit Manager, she said that new admission charts are reviewed by the interdisciplinary team at the "Change of Condition" meeting each day. She said at that meeting she looks at the medications, diagnoses, code status, and diet slip for new admissions. She said she also checks to verify that the orders were reviewed by 2 nurses. She said regarding Resident #1's medication orders, she did not compare them with the resident's hospital discharge orders. She stated, "After this incident, we learned our lesson." Interview on [DATE] at 7:17pm with Employee Y, LPN, revealed that she worked the night shift and she remembered Resident #1. She said he was nonverbal. She said she didn't know that the resident was a diabetic, and she didn't do blood sugar monitoring for him. She said the facility protocol for diabetic residents was to ask the doctor if he wanted blood sugars done on the resident. Review of both occupational and physical therapy notes for Resident #1, dated [DATE], revealed that the resident was "lethargic" (lack of energy) during therapy. Review of nurse's notes for Resident #1 dated [DATE] revealed that the physician was notified that the resident's urine was dark, and a urine test was ordered. During a [DATE] interview with Employee N, RN, at 7:07pm, she stated that she remembered sending Resident #1 out to the hospital with a high blood sugar on [DATE]. She said that someone came out of the resident's room and said that the resident needed help, "so we all ran in and responded." Employee N said she checked the resident's blood sugar with the glucometer, and "it just said Hi (high)." Review of the manufacturer's instructions for the Assure Platinum blood glucose meter, found at Arkrayusa.com, revealed that its range was from ,[DATE] mg/dl (milligrams per deciliter). A reading of "Hi" indicates that your blood glucose level is more than 600 mg/dL. Repeat the test using a new test strip. If this message appears again, contact a healthcare professional immediately! The DCS confirmed that the Assure Platinum blood glucose meter was the type that was used to check Resident #1's blood sugar on [DATE]. On [DATE] at 10:36am, in an interview with Employee E, LPN, she stated that she completed the physical assessment for Resident #1 on admission, and although she did not transcribe Resident #1's admission medications, she knew he was diabetic and that he had received 2 units of Humalog insulin at the hospital before he transferred to the facility. She said that the morning the resident was transferred back to the hospital, she was assigned as his nurse. She said she was starting the medication pass when a certified nursing assistant (CNA) reported to her that Resident #1 "wasn't acting right." She said Employee N asked her if the resident was diabetic. She said Employee N assessed the resident, and found he was not responsive. She said she went to the MAR indicated [REDACTED]. She said she found that no blood sugar monitoring had been done for the resident since admission, and there was not a page in the MAR indicated [REDACTED]. She said she then pulled the hospital discharge orders for Resident #1, and found there was an order for [REDACTED].#1, but she could not find any. She said at that point Employee N said the resident's breathing was labored, and that was when she called 911 for the resident. Review of the facility transfer form dated [DATE] revealed that Resident #1's blood sugar was elevated, patient "non-coherent," and breathing erratic. The resident's pulse oximeter reading was 97%. The resident was transferred to the hospital emergency room via rescue. Review of the hospital "Triage" form dated [DATE] at 9:16am revealed under Chief Complaint that Resident #1 was found unresponsive at the facility. Review of a Emergency Department physician's note for Resident #1 dated [DATE] at 9:26am revealed, "Suspect HHNS (Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], which left untreated can lead to life threatening dehydration) or DKA (Diabetic Ketoacidosis, due to having no insulin in the body, which leads the body to break down fat instead of glucose and builds toxins called [MEDICATION NAME] in the blood) based on blood sugar readings off the chart and (the) dehydrated individual before me." The resident's hospital record revealed a critical laboratory result, dated [DATE], at 10:27am with a glucose level of 843 mg/dL. The resident's condition was listed as critical, and the impression noted severe dehydration and [MEDICAL CONDITION]. The resident was intubated and transferred to ICU. Per the family's wishes he was weaned off of the ventilator 3 days later, and transferred to inpatient hospice on [DATE], where he died on [DATE]. Review of the facility policy titled "Nursing Care of the Resident with Diabetes Mellitus," revised [DATE], revealed that the management of individuals with diabetes should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring. Assist the resident with his/her specific medication regimen, as ordered and as needed. According to the manufacturer's prescribing information for [MEDICATION NAME] found at www.[MEDICATION NAME].com, the dose of [MEDICATION NAME] must be individualized based on clinical response. Blood glucose monitoring is essential in all patients receiving insulin therapy. Review of the facility policy titled "New Orders for Non-Controlled Substances" dated [DATE], last revised [DATE], stated under Procedure: 1. New Admission: Facility should provide information regarding a new admission order to pharmacy using a completed and reconciled physicians order sheet. 1.2 Facility should ensure all resident information is complete and accurate, has been reconciled and is verified by Physician/Prescriber before faxing or transmitting orders to the pharmacy. 2.1.1 Facility should ensure all resident information is complete and legible. .

Based on record review and staff interviews, the facility failed to provide a Quality Assurance Committee that was able to develop and revise plans to ensure that care practices were consistently applied. A physician did not attend the Quality Assurance Committee meetings quarterly, and the Director of Clinical Services did not attend the meetings for the last 2 months. As a result, the Medical Director was not aware that the facility has not completed Advanced Directives for residents timely involving 2 residents (Residents #1 and #2), or that on-going transcription errors have been identified for a minimum of 4 months without resolution involving 2 residents (Residents #1 and #3), including a significant medication error that resulted in a resident's death (Resident #1), resulting in immediate jeopardy starting on [DATE]. The facility's failure to provide an effective QA committee to ensure the consistent delivery of care related to transcription of medications and exercise of the right to accept or refuse medical care, placed all residents at risk for serious harm, injury, impairment, or death. Substandard Quality Care was determined at F333 S/S of J, F309 S/S of J. Cross reference F520 S/S of J and F155 S/S of J. The immediate jeopardy was ongoing at the time of exit on [DATE]. The findings include: Record review for Resident #1 revealed that he was admitted to the facility from the hospital on [DATE]. Review of the resident's hospital Discharge Summary dated [DATE] revealed a final [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. The resident's medication regimen included [MEDICATION NAME] insulin. Consultation with Neurology recommended conservative management and comfort care. Inpatient hospice was pending. Continue current medication for diabetes. Review of the hospital's "Individualized Patient Discharge Instructions" for Resident #1, dated [DATE], found medications to be continued after hospitalization included [MEDICATION NAME] (a long acting insulin to control blood sugar) 20 units twice daily, and [MEDICATION NAME] (a medication taken by mouth to control blood sugar) 50mg daily. Review of Resident #1's physician's orders [REDACTED]. The prescribed [MEDICATION NAME]20 units twice daily was not transcribed onto the POS. The resident's code status on the POS was marked "Full/Follow-up with Family." No orders for blood sugar monitoring were found on the POS. Review of Resident #1's February, 2015 Medication Administration Record [REDACTED]. No blood sugar monitoring was found documented on the resident's MAR indicated [REDACTED]. A complete review of the resident's record found no documentation that he received the prescribed insulin, or any blood sugar monitoring, from the time of his admission on [DATE] until his re-hospitalization on [DATE]. On [DATE] at 11:39am, in an interview with the Director of Clinical Services (DCS), she stated that the resident was not seen by a physician at any time during his stay in the facility. Review of a facility nurse's note for Resident #1 dated [DATE] at 8:15am revealed that the resident was found unresponsive with a blood sugar reading of "Hi" (high) on the glucometer (indicating a blood sugar over 600mg/dL). The resident's breathing was noted with increased labor, and became erratic. The nurse called 911, and the resident was transferred to the hospital. At 8:45am, the facility attempted to contact the resident's family, and a message was left to call the facility back. Review of Resident #1's transfer form, dated [DATE], revealed that he was a "Full Code." Review of Emergency Department physician's notes for Resident #1, dated [DATE], revealed a laboratory result at 10:27am with a glucose level of 843 mg/dL (critically high). "Suspect HHNS (Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], which left untreated can lead to life threatening dehydration) or DKA (Diabetic Ketoacidosis, due to having no insulin in the body, which leads the body to break down fat instead of glucose and builds toxins called [MEDICATION NAME] in the blood) based on blood sugar readings off the chart and (the) dehydrated individual before me." The hospital record revealed the resident's condition was listed as critical, and the impression noted severe dehydration and [MEDICAL CONDITION]. The physician's notes stated, "There was confusion as to the patient's DNR (Do Not Resuscitate) status. It appears DNR has not been signed. Family is enroute. In meantime, patient is to be admitted in intensive care." Review of a facility nurse's note for Resident #1 dated [DATE], the emergency room physician called the facility at approximately 1:30pm to clarify the resident's code status. The facility advised that the resident was a "full code." Review of the hospital History and Physical for Resident #1 dated [DATE] revealed that the resident was intubated in the emergency room . "The patient was supposed to be AND (a natural death) based on Palliative Medicine consultation in the previous hospitalization ." Discussed with the family [MEDICATION NAME] wean off of the ventilator. On [DATE] at 8:48am in an interview with Resident #1's son, he stated that when the resident was re-hospitalized on [DATE], he was intubated for several days. The son said that his dad didn't want that. The son said that he was his father's health surrogate, and he thought his father's DNR from his hospitalization 2 days prior to his return to the Emergency Department would follow him to the facility. He said the facility did not contact him about his father's DNR status when his father was admitted to the facility on [DATE]. A complete review of Resident #1's record found no documentation that the facility discussed the resident's code status with his son at any time during his stay from [DATE] to [DATE]. The son said his father came off the ventilator at the hospital on [DATE] and was transferred to hospice care, where he died on [DATE]. 2. Record review for Resident #2 revealed that she was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's POS dated [DATE] revealed that Resident #2's code status was "Full Code." Interview on [DATE] at 6:20pm with Resident #2's daughter revealed that the facility had not made any contact with her to discuss Advance Directives. She stated that she knows her mother's wishes, and her mother wanted a DNR. In an interview on [DATE] at 5:35pm with the Admissions Coordinator, she said that she sees every resident when they are first admitted to review the Advance Directives form and DNR status. If a resident can't speak for themselves, she said she contacts the family to determine who is the POA (Power of Attorney). If the resident does not want CPR, she puts the Advance Directives form in the Unit Manager's box and the Social Services box for follow-up. When asked if she had seen Resident #1 or his family during his stay in the facility from [DATE] to [DATE], she stated that she didn't. She said there is no one else in the facility to do this paperwork, so she is sometimes behind in her work. Regarding Resident #2's Advance Directive form, the Admissions Coordinator confirmed that the resident's DNR status had not been determined with the family yet. She said the resident "just came in last week." When the surveyor pointed out that the resident had been in the facility for 2 weeks, the Admissions Coordinator stated she had been out of the facility, and "no one picks up her paperwork for her." She said she had to "catch up" when she returned to the facility. In an interview on [DATE] at 7:30pm with the Social Services Director (SSD), she stated that she usually sees a new admission within "a day or two" to determine DNR status. She said if the resident is unable to tell her their DNR status, she is supposed to ask the family if the resident wants a DNR. She said she did not talk to Resident #1's family while he was in the facility. She said she reviewed Resident #1's hospital record for any Advance Directives information, but she did not find any. The surveyor showed the SSD the resident's Palliative Medicine consult located in the resident's record, which stated that the son was seeking full DNR for his father post hospital. The SSD said that she did not review Resident #1's medical record "in depth," and she did not see the consult in the record. She said that if she had seen the consult in the record, she would have contacted the son to sign the DNR "as soon as I read that document." She went on to say that she was "so far behind" on the Advance Directives paperwork. 3. Record review for Resident #3 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's hospital discharge physician orders [REDACTED]. Review of Resident #3's December, 2014 MAR indicated [REDACTED]. The [MEDICATION NAME] was initialed as given on [DATE], [DATE], and [DATE]. No doses of [MEDICATION NAME] were documented as given to the resident after [DATE]. [MEDICATION NAME] was transcribed onto the MAR indicated [REDACTED]. No orders were found in the resident's record to change the [MEDICATION NAME] dosing since the original order to administer daily. The [MEDICATION NAME] was initialed as given twice a day until the resident's discharge on [DATE]. In an interview on [DATE] at 2:32pm with the DCS, she confirmed that the resident's [MEDICATION NAME] was ordered for 14 days, and it was only transcribed as 4 days and administered on 3 days. She also confirmed that the resident's [MEDICATION NAME] was ordered once a day, not twice a day as transcribed onto the MAR. She said that she was not aware of these transcription errors. In an interview on [DATE] at 4:30pm with the Administrator, when asked whether the facility had identified medication errors as a problem in their Quality Assurance (QA) meetings, he stated, "It cranked up last summer. It has been ongoing since then." When asked who was involved in the QA meetings, he stated the dietary manager, the maintenance director, the housekeeping director, the MDS (Minimum Data Set) coordinator, both Unit Managers, the DCS, the Business Office Manager, the Admissions Coordinator, Human Resources, and Risk Management were in attendance. When asked whether the Medical Director was involved, he stated, " He doesn't come all the time. I think I've seen him at the meeting once in the last 10 months." On [DATE] at 8:27pm, in an interview with the DCS, she stated that the facility was "still coming up with continuing problems related to transcription errors and medication errors." She said this problem had been on-going since the last annual survey in October, 2014. She stated that the facility has been completing random audits of medication transcriptions for the past 3 months. She said that the medical records of new admissions are reviewed in their entirety by the Unit Managers, but despite this practice, transcription errors continued to occur in the facility. She said she doesn't know what else to do about the continuing transcription errors. She said the nurses no longer receive one-to-one education or on the spot education for their errors. She said the nurses have had ample time to get it, and "we are going to start corrective action with the nurses." When asked whether the facility had identified medication errors in the Quality Assurance and Program Improvement (QAPI) meetings, the DCS stated, "We initiated that after our annual survey on [DATE]. I did a Plan of Correction (POC), and talked about errors, and transcription; it was a broad discussion." On [DATE] at 4:54 p.m. in an interview with the DCS, when asked about how the facility handles medication errors, she said that the pharmacy, the medical director, and the physician involved are all notified. When asked if the facility maintained a medication error log, the DCS stated that she was trying to create one from the QA minutes, but she had not compiled the information. She said she had a list of residents with medication errors, but she would have to pull the records to see what the errors were. Review of the medication errors revealed Resident #3 listed in December, 2014; January, 2015; and February, 2015. One other resident (identified by initials only) was listed in January, 2015. Resident #1 was listed in February, 2015. A different nurse was listed for each error. There were no details about the type or severity of the errors, or corrective action taken. Regarding Advanced Directives, the DCS stated that not being up to date on the Advance Directive Care Plans was recognized as a problem at the [DATE] QAPI meeting. She said an audit tool was developed to identify undetermined Advance Directives. She said the SSD is new, and she was instructed to start with the new admissions and "go back as she was able, little by little; but she will never catch up completely. It will take a long time." On [DATE] at 1:53pm in an interview with the pharmacy consultant, she stated that the facility did not notify her regarding the medication error for Resident #1. She said she "wouldn't necessarily know about it." She said she "hadn't been able to make" the QA meetings. Regarding Resident #3, the consultant pharmacist said she reviewed his record on [DATE]. She said she reviewed the December, 2014 MAR. She said the resident was on [MEDICATION NAME] 100 mg twice a day. She said his [MEDICATION NAME] order was from [DATE] through [DATE]. She was asked if she reviewed the previous month's MAR, wouldn' t she have seen the [MEDICATION NAME] error on the resident's December, 2014 MAR? She said, "Yes, but it was a moot point at that time because it was a month later." She was asked if she would inform the facility when she found a transcription/medication administration error, and she replied, "Not necessarily." She said she usually checks the hospital discharge orders as part of her review, but stated, "Obviously I missed the [MEDICATION NAME]." During an interview on [DATE] at 5:06pm with the facility's Medical Director, when asked whether the facility notified him of the transcription error that occurred with Resident #1's insulin, he said that the facility had not notified him. The Medical Director agreed that the error was something he would have liked to have been notified about. He stated, "They don't report every little error to me, but they should report something like that to me. I would have liked to have heard about that." Regarding QAPI meetings, the Medical Director stated that he attended 8 or 9 QAPI meetings last year. When he reviewed the attendance forms for the meetings and noted the absence of his signature on many dates, he explained that he does not always sign the attendance forms. He said that he arrives late and stays about 10 to 15 minutes for each meeting. He said issues discussed at the meetings included medication errors, and patient returns to the hospital. He said he did not recall discussing problems with residents' Advance Directives or DNR status in the QAPI meetings. He said he felt "out of the loop" and didn't know what was going on with the facility right now. Record review of 11 sign-in sheets for the QAPI monthly meetings dated February, 2014 through January, 2015 revealed that the medical director signed 3 of the 11 attendance sheets. He signed May, June and July, 2014. No other physician was in attendance at any of the meetings. December, 2014 and January, 2015 attendance sheets were not signed by the DCS. The pharmacy consultant signed 1 QAPI attendance sheet dated [DATE].

Based on record review, staff and family interviews, and policy review, the facility failed to provide necessary care and services to attain the highest practicable well-being for 1 resident (Resident #1) out of 9 sampled residents with diabetes who were admitted from the hospital. The facility's failure to provide medication as prescribed, and monitor blood sugars for Resident #1 led to emergency hospitalization , resulting in death. This event resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing at exit on [DATE]. Substandard Quality Care was determined at F309 S/S of J, F 333 S/S of J. Cross reference F155 S/S of J and F520 S/S of J. The findings include: Resident #1 was admitted to the facility from the hospital on [DATE] following a massive stroke with right [MEDICAL CONDITION] (weakness on one side) and [MEDICAL CONDITION] (damage to the brain that makes it hard to read, write, and speak). His [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Discharge orders, dated [DATE], included medications to treat the resident's diabetes: [MEDICATION NAME] 20 units twice daily (a long acting insulin to control blood sugar), and [MEDICATION NAME] 50 mg one tab by mouth daily (an oral medication to control blood sugar). Review of Resident #1's hospital records, dated [DATE], prior to his admission to the facility, revealed his medication regimen included [MEDICATION NAME]for a past medical history of [REDACTED]. Review of Resident #1's Physician order [REDACTED]. [MEDICATION NAME] 50 mg one tab by mouth daily, but no order for the resident's prescribed [MEDICATION NAME]was transcribed onto the POS. Review of Resident #1's Medication Administration Record (MAR), dated February, 2015, revealed the prescribed [MEDICATION NAME]was not transcribed onto the resident's MAR. There was no blood sugar monitoring documented on the MAR or the Treatment Administration Record (TAR). A complete record review found that Resident #1 did not receive any insulin or blood sugar monitoring from the time of his admission to the facility on [DATE], until he was sent to the emergency roiagnom on [DATE]. Review of the Interim Plan of Care, dated [DATE], revealed At Risk for Complication from Diabetes Mellitus. Included in the interventions was to monitor blood sugars as ordered, monitor for signs and symptoms of [MEDICAL CONDITION]/[DIAGNOSES REDACTED], and administer medications as ordered. Review of Resident #1's transfer form to the emergency room (ER) dated [DATE] revealed that blood sugar was elevated, patient non-coherent, and breathing erratic. The pulse oximeter was 97%. Transferred to hospital ER via rescue. Review of emergency room hospital records for Resident #1 dated [DATE] at 9:26 a.m. revealed: "Suspect HHNS (Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], which left untreated can lead to life threatening dehydration) or DKA (Diabetic Ketoacidosis, Due to no insulin in the body, which leads the body to break down of fat, instead of glucose, and builds toxins called [MEDICATION NAME] in the blood, which untreated leads to DKA) based on blood sugar readings off the chart and (the) dehydrated individual before me. Laboratory results revealed a glucose level of 843 mg/dL (critically high). The resident's condition was listed as critical. He was intubated and transferred to ICU. Per the family's wishes he was weaned off of the ventilator, and transferred to inpatient hospice on [DATE], where he died on [DATE]." On [DATE] at 11:39 AM, in an interview with the Director of Clinical Services (DCS,) she confirmed that the pharmacy never received orders for Resident #1's prescribed insulin. On [DATE] at 3:15 PM in an interview with Employee B, Licensed Practical Nurse (LPN), she said that she transcribed Resident #1's hospital discharge orders dated [DATE] onto the POS after verifying the orders with the resident's physician. She said the physician did not make any changes to Resident #1 medication's at that time. She said she did not discuss blood sugar monitoring for the resident with the physician. She said she specifically remembered transcribing the insulin order onto a separate page of the POS. She said the fax machine at the nurses' station was broken, so she went to another location in the building to fax the orders to pharmacy. She explained that when the POS is written out, it automatically transcribes onto the MAR via carbon. She said that the whole insulin page of the POS, which included the copy of the MAR, was "gone." She said she was not aware of the error until Resident #1 went back to the hospital. On [DATE] at 4:04 PM in an interview with Employee A, Registered Nurse and Unit Manager, said the interdisciplinary team reviews new admission charts in the daily Change of Condition meeting. She said she looks at the medications, diagnoses, code status, diet and diet slip. She said she did not compare Resident #1 medication's with the hospital discharge orders. She said she did not discuss blood sugar monitoring for the resident with the interdisciplinary team. She stated, "After the incident, we learned our lesson." On [DATE] at 9:58 AM in an interview with Employee C, LPN, she stated that she was asked to verify the admission orders [REDACTED]. She said she remembers that because Employee B told her she missed checking a page. She said she read the page she had missed, and she remembered it was the insulin page, written on a separate page. She stated she checked the orders written on the POS against the hospital orders. She said she did not find any errors. On [DATE] at 12:03 PM in an interview with Employee D, LPN, he stated that part of his night job duties was to verify all new orders, including new admission orders [REDACTED]. He said he couldn't remember if he actually looked at Resident #1's chart. He said normally he takes his time going through the records, but there were at least 4 or 5 admissions that night. He said he is more cautious since the error occurred with Resident #1. Interview on [DATE] at 7:17pm with Employee Y, LPN, revealed that she worked the night shift and she remembered Resident #1. She said he was nonverbal. She said she didn't know that the resident was a diabetic, and she didn't do blood sugar monitoring for him. She said the facility protocol for diabetic residents was to ask the doctor if he wanted blood sugars done on the resident. On [DATE] at 10:36 AM, during an interview with Employee E, LPN, she said she completed Resident #1's admission physical on [DATE]. She said she knew that the resident was diabetic by looking at the report from the hospital, and that he received 2 units of insulin at the hospital before he was transferred to the facility. She said she did not care for the resident again until the day he went to the hospital ([DATE]). She was his nurse that morning, and recalled that a certified nursing assistant came to her and said the patient "wasn't acting right." She said the resident was not responsive. She said she went to the MAR to check the resident's morning blood sugar. She said that was when she saw that no blood sugar monitoring had been done on the resident since admission. She said she checked the resident's orders, and there was not a page for insulin found. She said when she pulled the hospital discharge orders she discovered there was an order for [REDACTED]. She said she checked the medication cart for insulin dispensed for the resident, and could not find it. She said at that point the resident's breathing was labored, and she called 911. During a [DATE] interview with Employee N, RN, at 7:07 p.m., she said she remembered that resident with the high blood sugar and having to send him out (Resident #1). She said that someone came out of the resident's room and said that the resident needed help, "So we all ran in and responded." The therapist was in the room and said that this was not his (the resident's) normal way. She said they got the crash cart and she took the resident's blood sugar. She said "The glucometer just said, 'Hi' (high). Review of the manufacturer's instructions for the Assure Platinum blood glucose meter, found at Arkrayusa.com, revealed that its range was from ,[DATE] mg/dl (milligrams per deciliter). A reading of "Hi" (high) indicates that your blood glucose level is more than 600 mg/dL. Repeat the test using a new test strip. If this message appears again, contact a healthcare professional immediately! The DCS confirmed that the Assure Platinum blood glucose meter was the type that was used to check Resident #1's blood sugar on [DATE]. Review of facility policy revised [DATE] entitled "Nursing Care of the Resident with Diabetes Mellitus" stated the management of individuals with diabetes should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring. Assist the resident with his/her specific medication regimen, as ordered and as needed. According to the manufacturer's prescribing information for [MEDICATION NAME] found at www.[MEDICATION NAME].com, the dose of [MEDICATION NAME] must be individualized based on clinical response. Blood glucose monitoring is essential in all patients receiving insulin therapy. .

Based on record review, staff and family interviews, and policy review, the facility failed to ensure that residents exercised their right to accept or refuse medical care and formulate advance directives for 3 residents (Residents #1, #2, and #4), out of 9 residents reviewed for Advance Directives. This failure led to a resident being intubated for 3 days during an emergency hospitalization , against his family's expressed wishes regarding the right to care and services, resulting in Immediate Jeopardy commencing on [DATE]. The facility's failure to ensure that residents exercised their right to accept or refuse medical care, and honor the way residents' want to die, placed those residents in the facility who did not desire resuscitation at risk for serious injury or harm due to undue suffering and mental anguish related to invasive procedures against their wishes. Immediate Jeopardy was ongoing on exit on [DATE]. Cross reference F520 S/S of J. The findings include: 1. Record review for Resident #1 revealed that he was admitted to the facility from the hospital on [DATE]. Review of Resident #1's hospital Discharge Summary, dated [DATE], revealed a final [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Consultation with Neurology found extensive stroke, and recommendation was for conservative management and comfort care. Inpatient hospice was pending. Continue current medication for diabetes. Pacer will be turned off. Due to the resident's condition on admission to the facility, he could not communicate his wishes. The family's goals after hospitalization were well documented in the resident' s record, including a Palliative Medicine consult dated [DATE] that revealed the resident was [AGE] years old with findings of a large ischemic (restriction of blood flow) stroke. Resident remained with dense right [MEDICAL CONDITIONS], and [MEDICAL CONDITION] (abnormal brain function). The resident's son was his health care surrogate, and he desired to honor the resident's Advance Directives with DNR (Do Not Resuscitate) status. Family was aware and accepting of the resident's high risk for ongoing decline, and limited hope for functional and cognitive improvement. Code status was documented as limited, with health care surrogate (son) desiring durable DNR for after hospital care. Family goal was to transition the resident to long term care with hospice, and "do not re-hospitalize" plan of care. Focus was on comfort, and prognosis was poor. Limited code status was confirmed with no desire for compressions, defibrillation or intubation and ventilation. A copy of this consult was found in the resident's record at the facility. Review of the hospital's "Individualized Patient Discharge Instructions" for Resident #1, dated [DATE], revealed orders to continue [MEDICATION NAME] (a long acting insulin to control blood sugar) 20 units twice daily, and [MEDICATION NAME] (a medication taken by mouth to control blood sugar) 50mg daily. Review of Resident #1's Physician's Order Sheet (POS), dated [DATE], revealed that the resident's order for [MEDICATION NAME]20 units twice daily was not transcribed on admission from the hospital discharge orders to the POS. No orders for blood sugar monitoring were found on the resident's POS. The resident's code status on the POS was marked "Full/Follow-up with Family." Review of Resident #1's February, 2015 Medication Administration Record [REDACTED]. No blood sugar monitoring was found documented on the resident's MAR indicated [REDACTED]. A complete review of the resident's record found no documentation that he received the prescribed insulin, or any blood sugar monitoring, from the time of his admission on [DATE] until his re-hospitalization on [DATE]. Record review revealed that Resident #1 was not seen by a physician during his stay in the facility. Review of a facility nurse's note for Resident #1 dated [DATE] at 8:15am revealed that the resident was found unresponsive with a blood sugar reading of "Hi" (high) on the glucometer (indicating that the blood sugar was greater than 600mg/dL). The resident's breathing was noted with increased labor, and became erratic. The nurse called 911, and the resident was transferred to the hospital. At 8:45am, the facility attempted to contact the resident's family, and message was left to call the facility back. Review of Resident #1's transfer form, dated [DATE], revealed that he was a "Full Code." Review of Emergency Department physician's notes for Resident #1, dated [DATE], revealed a laboratory result with a glucose level of 843 mg/dL (critically high) at 10:27am. "Suspect HHNS (Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], which left untreated can lead to life threatening dehydration) or DKA (Diabetic Ketoacidosis, due to having no insulin in the body, which leads the body to break down fat instead of glucose and builds toxins called [MEDICATION NAME] in the blood) based on blood sugar readings off the chart and (the) dehydrated individual before me." The hospital record revealed the resident's condition was listed as critical, and the impression noted severe dehydration and [MEDICAL CONDITION]. The physician's notes stated "there was confusion as to the patient's DNR status. It appears DNR has not been signed. Family is en-route. In meantime, patient is to be admitted in intensive care." Review of a facility nurse's note for Resident #1, dated [DATE], revealed that the emergency room physician called the facility at approximately 1:30pm to clarify the resident's code status. The facility advised that the resident was a "full code." Review of the hospital's History and Physical for Resident #1 dated [DATE] revealed that the resident was intubated in the emergency room . "The patient was supposed to be AND (Allow Natural Death) based on Palliative Medicine consultation in the previous hospitalization . Discussed with the family [MEDICATION NAME] wean off of the ventilator." Interview on [DATE] at 10:23am with the Director of Clinical Services (DCS) revealed that when she contacted Resident #1's family on [DATE] to notify them of the insulin transcription error that had occurred, and the resident's subsequent hospitalization , the family asked, "Why was Dad not a DNR"? She said the family wanted to know who signed the resident in to the facility, and if we read his hospital record. The DCS said she met with the family later that day and informed them that all of the nurses were being "re-inserviced" on obtaining residents' DNR status. On [DATE] at 8:48am in an interview with Resident #1's son, he stated that when the resident was re-hospitalized on [DATE], he was intubated for several days. The son said that his dad didn't want that. The son said that he was his father's health surrogate, and he thought his father's DNR from his hospitalization 3 days prior to his return to the Emergency Department would follow him to the facility. He said the facility did not contact him about his father's DNR status when his father was admitted to the facility on [DATE]. A complete review of Resident #1's record found no documentation that the facility discussed the resident's code status with his son at any time during his stay from [DATE] to [DATE]. The son said his father came off the ventilator at the hospital on [DATE] and was transferred to hospice care, where he died on [DATE]. Review of the facility grievance log revealed that Resident #1's son filed a grievance with the facility on [DATE] regarding his father's code status. In an interview on [DATE] at 10:13am with the Social Services Director (SSD), she stated that she spoke with Resident #1's son about his grievance. The SSD stated that the son believed his father was a DNR status, and asked why he did not have a DNR in place from the hospital. The SSD explained to the surveyor that Advance Directives are addressed in the resident admission packet. She stated that she usually sees a new admission within "a day or two," and she asks the resident, "Do you want a DNR?" She said if the resident is unable to tell her their DNR status, she is supposed to ask the family if the resident wants a DNR. She said she did not talk to Resident #1's family while he was in the facility from [DATE] to [DATE]. She said she reviewed Resident #1's hospital record for any documentation regarding a DNR or Advance Directives, but she did not find any. The surveyor showed the SSD the resident's Palliative Medicine consult located in the resident's record, which stated that the son was seeking full DNR for his father post hospital. The SSD said that she did not review Resident #1's medical record "in depth," and she did not see the consult in the record. She said that if she had seen the consult in the record, she would have contacted the son to sign a DNR "as soon as I read that document." She went on to say that she was "so far behind" on the Advanced Director paperwork for the residents. In an interview on [DATE] at 3:11pm with the DCS, she confirmed that the facility was behind on the residents' Advance Directives. She said the SSD is new, and she was instructed to start with the new admissions and "go back as she was able, little by little; but she will never catch up completely. It will take a long time." In an interview on [DATE] at 5:35pm with the Admissions Coordinator, she said that she sees every resident when they are first admitted . "When they come in, I see them that day." She said her duties included review of the Advance Directives form with the resident. She said she asks the residents if they have Advance Directives or a Living Will, and "Do you want CPR (cardiopulmonary resuscitation) or not?" If the resident says they do not want CPR, she said she puts the form in the Unit Manager's box and the Social Services box for follow-up. She said if a resident couldn't speak for himself, she would have to call the family to determine who was the POA (Power of Attorney). When asked if she had contacted Resident #1 or his family during his stay in the facility from [DATE] to [DATE], she said, "No, he left before I could see him." She said she didn't know why Resident #1's admission paperwork was never completed. She said she normally would have contacted the resident's family within the time period that Resident #1 was in the facility, "but I didn't." She said there is no one else in the facility to do this paperwork, so she is sometimes behind in her work. 2. Record review for Resident #2 revealed that she was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's POS, dated [DATE], revealed that the resident's code status was "Full Code." No "Advance Directive Statement" was found in the resident's record when it was reviewed on [DATE]. The SSD confirmed this at the time of the record review. 3. Record review for Resident #4 revealed that the resident was [AGE] years old, and admitted to the facility on [DATE]. No Advance Directives or DNR status was found documented in the record. The SSD confirmed this during the record review on [DATE]. An Advance Directive Statement dated [DATE] was emailed by the facility to the surveyor after exit on [DATE]. In response to the statement: "In the event that I experience a cardiopulmonary arrest," the resident placed her initials next to the statement: "I do not want CPR measures to be taken on my behalf." The form was signed by a representative of the resident, and a facility representative. There was no order for a DNR located in the resident's record. The facility emailed an "Advanced Directive Statement" for Resident #2 to the surveyor on [DATE]. Review of the statement revealed that it was signed by the skilled nursing center representative (no date). There was no signature by the resident/ guardian. "Facility representative to have a brief conversation about Advance Directives with all parties involved" was initialed. The sections on the form to indicate the resident's wishes regarding resuscitation, hydration, nutrition, and hospital transfer were blank. Interview on [DATE] at 6:20pm with the Resident #2's daughter revealed that the facility had not made any contact with her to discuss Advance Directives. She stated that she knows her mother's wishes, and her mother wanted a DNR. In an interview on [DATE] at 5:35pm with the Admissions Coordinator, she confirmed that Resident #2's DNR status had not been determined with the family yet. She said she talked to the resident's daughter yesterday, and she (the Admissions coordinator) signed and initialed the resident's Advance Directive form. She said the resident "just came in last week." When the surveyor pointed out that the resident had been in the facility for 2 weeks, the Admissions Coordinator stated she had been out of the facility, and "no one picks up her paperwork for her." She said she had to "catch up" when she returned to the facility. In an interview on [DATE] at 2:30pm with Employee B, Licensed Practical Nurse, when asked how she determined a resident's code status, she replied that she referred to the resident's chart. She stated that if a yellow DNR form was not in the resident's chart, then the resident was considered a full code. Interview on [DATE] at 4:25pm with the Administrator revealed that the process for obtaining DNR status starts in the admissions office. He said the last step was the social worker, who "gets the DNR done." He said, "That last step was the one that got dropped. That's why you didn' t find any (in the records)." He reiterated that the admissions office gives the social worker the statement regarding whether the resident wants a DNR, and the social worker gets the DNR. He said, "That has not been happening." When asked how the nurses knew whether a resident had a DNR, he replied, "I don't know." He said they were currently doing a "sweep of the whole building for DNRs." He said the social worker started in October, 2014, and "the process was broken before she arrived." He said, "I don't know that we've ever done it right in the 10 months that I've been here." He then said he was not aware of this problem until the surveyors identified it on [DATE]. The DCS, who was present during this interview, was asked how the nursing staff knew if a resident had a DNR. The DCS said that a sticker is placed on the inside front cover of the chart if the resident is a DNR. In a further interview on [DATE] at 7:35pm with the DCS she stated that a copy of the Advance Directive form, if completed, goes with the resident to the hospital, so the hospital will be aware of the resident's DNR status. Complete review of Resident #1' s record revealed no Advance Directive forms were in the facility record. During a [DATE] interview with the facility's Medical Director at 5:06pm, he said that a resident's DNR status should be determined the first day or two after admission to the facility. Review of the facility policy titled Advanced Directives, dated ,[DATE] and last revised [DATE], revealed under the heading "Policy Overview" : On admission the Admissions Director or designee will notify and provide information to each resident or responsible party regarding his/her right to make an Advance Directive. Advance Directives are a written method through which a resident may provide directions or wishes as to their medical care. Advance Directives are used when a resident is unable to make or communicate his/her decisions about medical treatment. Under the heading " Policy Detail " : On admission, the resident or responsible party or agent should be provided with a copy of the resident ' s rights under State law to accept or refuse treatment and to formulate an Advance Directive. Each resident should be asked at admission if he/she has executed an Advance Directive. If the resident answers "Yes," a copy of the Advance Directive should be obtained and placed in the resident's medical record. The resident's physician should be informed of the Advance Directive so that appropriate orders can be obtained in the resident's medical plan of care. Obtain state specific out of hospital DNR as indicated. The Social Services Department is responsible for assisting residents and/or their families in preparing Advance Directives. Social Services should verify that there is an appropriate physician's order in the resident's medical record that complies with residents' request. .