Every finding on record at Georgia Manor Nursing Home

Based on observation, interview, and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 out of 2 medication carts (Hall A and Hall B Medication Carts) reviewed for pharmacy services. The facility failed to ensure that drug records for controlled substances were accurately maintained, verified, and periodically reconciled by licensed nursing staff during shift exchanges. This failure could place all residents receiving controlled medications at risk for medication errors, drug diversion, and a lack of therapeutic continuity due to unverified narcotics inventories across 100% of the facility's medication carts (2 out of 2) over a six-month period.Findings Included: During a record review on 06/04/2026 at 9:26 AM, it was noted that narcotic books were not filled out completely with signatures for both morning and night shifts on the Hall A medication cart. It was noted that signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/26, 1/30/26, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026.During an interview on 06/04/2026 at 9:26 AM, LVN G stated that two nurses were not verifying the narcotic count by signing the book, and if the count was off, no one would know who to contact to see why it was off and what happened. LVN G confirmed that accountability rests with both the nurse taking over the cart and the nurse leaving.During an observation on 06/04/2026 at 9:35 AM, the narcotic book for Hall B medication cart were missing signatures on 5/3/2026 and 5/30/2026.During an interview on 06/04/2026 at 9:53AM, LVN F stated that two nurses are not verifying the narcotic count by signing the book, and if the count was off, there is no actual proof to verify two nurses counted, and there was no transfer of responsibility. The LVN confirmed that accountability rests with both the nurse taking over the cart and the nurse leaving.During an interview on 06/04/2026 at 10:35 AM, the DON revealed when the narcotic book lacks signatures, the count could be incorrect, directly affecting the medications the resident receives.During an interview on 06/04/2026 10:37 AM, the ADM revealed missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for the residents.During an interview on 06/04/2026 at 11:01 AM, the CCN stated without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. Record review of the facility's policy and procedures titled Controlled Medications - Administration (dated 4/6/26) revealed the following directives: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure: At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Resident #1, Resident #37, and Resident #44) of 13 residents reviewed for resident rights.The facility failed to ensure Resident #1, Resident #37, and Resident #44 did not have hairy chins.This failure could put residents at risk of embarrassment, feelings of insecurity, and/or diminished self-esteem.Findings Included:1. Record review of Resident #1's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of muscle weakness.Record review of Resident #1's quarterly MDS assessment completed on 04/25/26 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #1 was dependent on staff for toileting and required partial/moderate to supervision/touching assistance across the rest of her ADLs.Record review of Resident #1's care plan completed on 03/18/26 revealed she had an ADL self-care performance deficit and required staff assistance with bathing.Record review of Resident #1's shower documentation in her EHR revealed she was showered on 06/02/26.During an observation on 06/03/26 at 11:17 AM Resident #1 was seated in the dining room at a table participating in an activity. She was neatly dressed and had several white, approximately one-inch-long hairs on her chin.During an observation and interview on 06/04/26 at 08:22 AM Resident #1 had several one-inch-long white hairs on her chin. She grabbed the hairs with her left hand and stated they bothered her. Resident #1 stated, I am waiting on the beauty shop ladies to come because they usually take and shave it (her chin hair) off for me. She stated CNAs never shaved her chin. Resident #1 stated the beauty shop ladies came every 3 weeks.2. Record review of Resident #37's admission record dated 06/03/26 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with a diagnosis of muscle weakness.Record review of Resident #37's quarterly MDS assessment completed on 05/12/26 revealed a BIMS score of 7 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #37 was dependent or required partial/moderate assistance across all ADLs except eating, where she required supervision/touching assistance.Record review of Resident #37's care plan completed on 05/08/26 revealed she had an ADL self-care deficit and required one staff member to assist her with bathing.Record review of Resident #37's shower documentation in her EHR revealed she received a shower on 06/02/26.During an observation on 06/03/26 at 09:01 AM Resident #37 was lying on her back in bed. She had several dark and light grey hairs sprinkled across her chin. The hairs were approximately half an inch long.During an observation on 06/03/26 at 11:11 AM Resident #37 was lying on her back in bed. She had several dark and light grey hairs sprinkled across her chin. The hairs were approximately half an inch long.During an observation on 06/03/26 at 12:19 PM Resident #37 was lying on her back in bed. She had several dark and light grey hairs sprinkled across her chin. The hairs were approximately half an inch long.During an observation on 06/03/26 at 02:12 PM Resident #37 was lying on her back in bed with the head of the bed raised to seated. She had several dark and light grey hairs sprinkled across her chin. The hairs were approximately half an inch long.During an interview on 06/05/26 at 10:19 AM Resident #37's family member stated Resident #37 would not choose to have a beard. Family member stated when at home Resident #37 used a trimmer to remove unwanted chin hair. She stated that CNAs shaved Resident #37's chin when they showered her.3. Record review of Resident #44's admission record dated 06/05/2 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), lack of coordination, and muscle weakness.Record review of Resident #44's quarterly MDS assessment completed on 05/29/26 revealed a BIMS score of 7 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #44 was dependent across all ADLS except for eating where she required supervision or touching assistance.Record review of Resident #44's care plan completed on 06/03/26 revealed she had impaired cognitive function and an ADL self-care performance deficit. She required the assistance of two staff members for bathing.Record review of Resident #44's shower documentation in her EHR revealed she was showered on 06/02/26.During an observation on 06/03/26 at 08:45 AM Resident #44 had long, white, curling hairs on both sides of her chin.During an observation and interview on 06/06/26 at 09:15 AM Resident #44 stated it bothered her to have chin hair. She stated she did not like it. Resident #44 stated she could shave her chin if she had a razor. She stated CNAs had shaved her chin the past and she did not know why they had not shaved it lately.During an interview on 06/04/26 at 08:46 AM Resident #44's family member stated having chin hair bothered Resident #44. He stated he had never seen Resident #44 with chin hair before she came to the facility. He stated if he brought up the chin hair to Resident #44, she would become emotional and embarrassed. Resident #44's family member stated Resident #44 had always been well-groomed in the past and would never have been seen in public with chin hairs.During an observation on 06/04/26 at 09:45 AM Resident #44 had long, white, curling hairs on both sides of her chin.During an interview on 06/05/26 at 08:58 AM LVN E stated female residents should not have beards unless they wanted them. She stated nurses were responsible to ensure female residents did not have beards. LVN E stated having an unwanted beard could negative affect a female resident by causing her to have low self-esteem.During an interview on 06/05/26 at 09:05 AM RN D, who was working on the hall of all three residents, stated female residents should not have beards unless they wanted them. She stated all staff were responsible to ensure female residents did not have beards. RN D stated a female resident's dignity could be negatively impacted by having an unwanted beard.During an interview on 06/05/26 at 09:12 AM LVN C stated female residents should not have beards unless they wanted them. She stated CNAs were primarily responsible to ensure female residents did not have beards, but all staff members could play a part. LVN C stated an unwanted beard could negatively impact a female resident's dignity and self-esteem.During an interview on 06/05/26 at 09:18 AM CNA B stated female residents should not have beards unless they wanted them. She stated CNAs were responsible to ensure female residents did not have beards. CNA B stated female residents with unwanted beards could be subject to ridicule by other residents. She recently told DON staff needed an in-service on shaving. She stated she shaved Resident #44's beard on 06/04/26 and she shaved part of Resident #37's beard on 06/04/26 and asked the LVN on duty to chart that Resident #37 would not let her finish. CNA B stated she shaves female resident's chins every time she bathes them if they need to be shaved. She stated she worked on 06/04/26, but it was her day off. CNA B stated she did not know why Resident #37 and Resident #44 chins were not shaved by CNAs on the other rotation. CNA B stated she did not see Resident #1's beard.During an interview on 06/05/26 at 09:26 AM CNA A, who was working on the hall of all three residents, stated female residents should not have beards unless they wanted them. She stated CNAs were responsible to ensure female residents did not have beards. CNA A stated having an unwanted beard could negatively impact female residents mentally.During an interview on 06/05/26 at 09:30 AM DON stated CNAs were responsible for shaving the female residents who did not want beards. DON stated she did not think there would be a negative outcome to a female resident if she had an unwanted beard Unless they are particularly [NAME].During an interview on 06/05/26 at 09:39 AM ADM stated she did not think female residents should have beards. She stated it could negatively impact their dignity. ADM stated all nursing staff were responsible to ensure female residents did not have unwanted beards.During an interview on 06/05/26 at 09:48 AM MDS RN stated female residents should not have unwanted beards. She stated CNAs and nurses were responsible to ensure female residents did not have unwanted beards. MDS RN stated a female resident having an unwanted beard could lead to emotional problems and/or insecurity.Record review of pages 4-6 of the facility's admission packet dated 09/01/25 and titled, Resident's Rights revealed the following: . You have the right to: Be treated with dignity, courtesy, consideration, and respect. Receive all care necessary to have the highest possible level of health.Record review of an undated facility policy titled, Resident Rights revealed the following, . The resident has a right to a dignified existence, . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment tha t [sic] promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Respect and dignity - The resident had a right to be treated with respect and dignity, including: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Self-determination - the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. 2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #37) of 13 residents reviewed for accommodation of needs.The facility failed to ensure Resident #37's call light was in reach on 06/03/26.This failure could place residents at risk of unmet needs, injury, and/or feelings of helplessness and frustration.Findings Included:Record review of Resident #37's admission record dated 06/03/26 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, vascular dementia with agitation (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), intermittent explosive disorder (repeated sudden outbursts of anger), muscle weakness, unsteadiness on feet, and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke).Record review of Resident #37's quarterly MDS assessment completed on 05/12/26 revealed a BIMS score of 7 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #37 used a wheelchair and had impairment to both sides of her lower extremities. She was dependent or required partial/moderate assistance across all ADLs except eating, where she required supervision/touching assistance. Section H Bladder and Bowel revealed Resident #37 was always incontinent of bladder and bowel.Record review of Resident #37's care plan completed on 05/08/26 revealed she had an ADL self-care deficit and one of the interventions listed was Encourage the resident to use bell to call for assistance. Resident #37 was noted to be at risk for falls. Staff were to encourage her to utilize staff assistance for transfers and Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During an observation on 06/03/26 at 09:01 AM Resident #37 was lying on her back in bed. Her call light was on the floor between her bed and the wall at the foot of her bed.During an observation on 06/03/26 at 11:11 AM Resident #37 was lying on her back in bed. Her call light was on the floor between her bed and the wall at the foot of her bed.During an observation and attempted interview on 06/03/26 at 12:19 PM Resident #37 was lying on her back in bed. Her call light was on the floor between her bed and the wall at the foot of her bed. She did not answer when asked if she had a call light or had ever used a call light.During an observation on 06/03/26 at 02:12 PM Resident #37 was lying on her back in bed with the head of the bed raised to seated. Her call light was on the floor between her bed and the wall at the foot of her bed.During an interview on 06/03/26 at 02:54 PM Resident #37's family member stated Resident #37 was capable of using her call light and would sometimes push her call light just to mess with them (staff).During an interview on 06/05/26 at 08:58 AM LVN E stated call lights should be in reach of residents. She stated CNAs and nurses were responsible to ensure call lights were in reach of residents. LVN E stated if a call light was out of reach of a resident the resident could not tell staff what they needed and could have an accident or need to use the bathroom.During an interview on 06/05/26 at 09:05 AM RN D stated call lights should be in reach of residents. She stated all nursing staff were responsible for ensuring correct call light placement. RN D stated call lights out of reach of residents could result in the residents falling or being injured.During an interview on 06/05/26 at 09:12 AM LVN C stated call lights were to be in reach of residents at all times. She stated all staff members were responsible for ensuring call lights were in reach of residents. LVN C stated residents might not receive the help they need or might fall if call lights were out of reach.During an interview on 06/05/26 at 09:18 AM CNA B stated call lights should be in reach of residents at all times. She stated all staff were responsible for ensuring call lights were in reach of residents. CNA B stated residents could fall trying to help themselves or could feel aggravated that no one was helping them if their call lights were out of reach.During an interview on 06/05/26 at 09:26 AM CNA A stated call lights were to be in reach of residents at all times. She stated CNAs were responsible for ensuring call lights were within reach. CNA A stated a resident could be negatively impacted mentally and physically if their call light was out of reach due to not getting the assistance they needed and/or trying to help themselves and getting injured. During an interview on 06/05/26 at 09:30 AM DON stated call lights should be in reach of residents. She stated all staff were responsible for ensuring proper placement of call lights. DON stated if a call light was out of reach of a resident the resident might be in need of help and not get the help they needed.During an interview on 06/05/26 at 09:39 AM ADM stated call lights should be in reach or residents at all times. She stated all staff were responsible for ensuring call lights were in reach of residents. ADM stated a resident could be negatively impacted if their call light was out of reach and something happens and they can't pull (the) call bell. She stated all department heads had several rooms assigned to them which they were responsible for checking twice during each shift and part of the checking included call light placement. ADM stated HR checked Resident #37's room twice a day.During an interview on 06/05/26 at 09:48 AM MDS RN stated call lights should be in reach of residents because that is how they talk to us. She stated all staff were responsible for ensuring call lights were in reach of residents. MDS RN stated a resident could be negatively impacted if their call light was out of reach due to not being able to get needed help.During an interview on 06/05/26 at 09:49 AM HR stated she checked on Resident #37 two times between 08:00 AM and 05:00 PM on 06/03/26. She stated Resident #37's call light was in reach both times.Record review of pages 4-6 of the facility's admission packet dated 09/01/25 and titled, Resident's Rights revealed the following: . You have the right to: Receive all care necessary to have the highest possible level of health.Record review of an undated facility policy titled, Resident Rights revealed the following, . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on observations and interviews the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 out of 13 residents (Resident #55) reviewed for privacy/confidentiality of medical records. The facility failed to ensure the protected health information, personal identifiers, and clinical medical charts were adequately safeguarded against unauthorized viewing, public disclosure, on 06/4/2026 at 8:39 AM and 8:42 AM. This failure could result in a breach of personal privacy, lead to medical identity theft, or cause emotional distress and humiliation to the residents due to the unauthorized exposure of their private medical history and diagnoses.Findings Included: During an observation on 06/04/2026 at 8:39 AM of medication pass on Hall B, LVN F was observed walking away from the medication cart to administer medications. The cart's computer monitor was left active and unsecured, visibly displaying the eMAR and private clinical details of a resident. At the time of this observation, the medication cart was positioned in the hallway near rooms [ROOM NUMBERS], exposing the screen to residents passing through the corridor. During an observation on 06/04/2026 at 8:42 AM, LVN F was observed walking away from the Hall B medication cart a second time to retrieve keys from another nurse. The computer screen was again left fully open and active, publicly displaying residents' private eMAR information. During an interview on 06/04/2026 at 8:50 AM, regarding the unsecured computer screen, LVN F acknowledged that leaving a resident's personal health information visible on an open monitor constitutes an unauthorized sharing of patient information and was a HIPAA violation. During an interview on 06/04/2026 at 10:35 AM, the DON stated that the negative outcome of leaving an active computer screen open was that someone could walk by and see information that is supposed to be protected and private. The DON confirmed that maintaining screen security is the sole responsibility of the nurse assigned to that specific cart and unit. During an interview on 06/04/2026 at 10:37 AM, the ADM stated that leaving a computer active with resident information on display is a HIPAA violation that allows other residents and family members to see information that isn't supposed to be shared. The Administrator stated electronic privacy is the responsibility of all staff, particularly the nurse working in that specific hallway. During an interview on 06/04/2026 at 11:01 AM, the CCN stated leaving a computer terminal open with private records allows family members and other residents to access information that is private and not authorized for disclosure. During a record review of the facility's undated policy titled Resident Rights revealed the following mandates under the section Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal medical records.The facility must respect the resident's right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications.The resident has a right to secure and confidential personal and medical records. During a record review of the facility's standard Resident admission Packet, revised on September 1, 2025, revealed that under the Privacy and Confidentiality section, residents are guaranteed the right to: Have facility information about you maintained as confidential.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #7) of 13 residents reviewed for accuracy of assessment.The facility coded Resident #7 as having significant weight loss in the last month when, in fact, he had not had significant weight loss.This failure could place residents at risk of receiving unnecessary care/medication/supplementation.Findings Included:Record review of Resident #7's admission record dated 06/03/26 revealed a 63-yeaer-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified protein-calorie malnutrition and dehydration.Record review of Resident #7's quarterly MDS assessment completed on 03/23/26 revealed a BIMS score of 9 which indicated moderately impaired cognition. Section K Swallowing/Nutritional Status question K0300 was answered with a 2 which indicated Resident #7 had lost 5% or more in the last month or 10% or more in the last 6 months not on physician-prescribed weight-loss regimen.Record review of Resident #7's care plan completed on 03/25/26 revealed the following focus area: The resident has a significant unplanned/unexpected weight loss Poor food intake-also anxiety issues. This focus area was initiated on 10/16/25.Record review of Resident #7's weights for the last 6 months revealed no weight loss of 5% in one month or 10% in 6 months relative to the ARD date (03/22/26) of his quarterly MDS assessment completed on 03/23/26. On 03/22/26 he weighed 119 pounds, on 02/20/26 he weighed 117.2 pounds, and on 09/24/25 he weighed 120 pounds.During an interview on 06/05/26 at 08:58 AM LVN E stated MDS RN was responsible for completing MDS Assessments. She stated an inaccurate MDS assessment could cause delays in getting proper care and could cause the care plan to be inaccurate.During an interview on 06/05/26 at 09:05 AM RN D stated MDS RN was responsible for completing MDS Assessments. She stated an inaccurate MDS assessment could negatively impact resident care and the care plan.During an interview on 06/05/26 at 09:18 AM CNA B stated MDS RN was responsible for completing MDS Assessments. She stated an inaccurate MDS assessment could cause residents to not receive needed assistance with ADLs.During an interview on 06/05/26 at 09:30 AM DON stated MDS RN was responsible for completing MDS Assessments. She stated an inaccurate MDS assessment would not affect resident care. DON stated, It (MDS assessment) doesn't change how we provide care. Regardless of what MDS (assessment) says, we do what we need to do.During an interview on 06/05/26 at 09:39 AM ADM stated MDS RN was responsible for completing MDS Assessments. She stated an inaccurate MDS assessment could cause a resident not to get the care they need.During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for completing MDS assessments. She stated Resident #7's weight had fluctuated and changes in his medications seemed to have affected his weight. She stated that was her reason for coding him for significant weight loss, not any real weight loss during the look back period. She stated she used the RAI as her policy when completing MDS assessments.Record review of facility policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy and dated 08/2025 revealed the following, . The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . K0300: Weight Loss Steps for Assessment This item compares the resident's weight in the current observation period with their weight at two snapshots in time: At a point closest to 30 days preceding the current weight. At a point closest to 180 days preceding the current weight. The resident's weight captured closest to these two time points are the only two weights considered for this item, . Coding instructions . Code 0, no or unknown if the resident has not experience weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days . Coding Tips A resident may experience weight variances in between the snapshot time periods. Although these require follow up at the time, they are not captured on the MDS.

Based on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #53) of 13 residents reviewed for preadmission screening.The facility failed to perform an accurate preadmission screening for Resident #53 prior to admission on [DATE].This failure could place residents at risk of not receiving needed services. Findings Included:Record review of Resident #53's admission record dated 06/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder unspecified with a diagnosis date of 05/27/26.Record review of Resident #53's baseline care plan initiated on 05/27/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan.Record review of Resident #53's care plan completed on 06/04/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan. Record review of Resident #53's admission MDS assessment completed 06/03/26 revealed a BIMS of 14 which indicated intact cognition. Section I Active Diagnoses revealed a diagnosis of bipolar disorder.Record review of Resident #53's PL 1 revealed it was completed at a local hospital on [DATE]. Resident #53 was coded as having no mental illness.During an interview on 06/05/26 at 09:30 AM DON stated MDS RN was responsible for completing PL 1's at or prior to admission. She stated if a resident was coded by the hospital as having no mental illness but had an active diagnosis of mental illness the facility would correct the PL 1.During an interview on 06/05/26 at 09:39 AM ADM stated MDS RN made sure the facility had a PL 1 prior to a resident being admitted . She stated if a resident was coded on the PL 1 as having no mental illness but had a diagnosis of mental illness they might not receive PASARR services timely.During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for ensuring residents had correctly coded PL 1's at or prior to admission. MDS RN stated when she received a PL 1 from a hospital she checked it for accuracy against the resident's diagnoses. She stated she had recently taken time off and that was probably why she missed Resident #53's inaccurate PL 1. She stated if a resident was coded as having no mental illness but had a diagnosis of mental illness, They don't get the treatment they need.Record review of facility policy titled, PASRR Level 1 Policy and Procedure and dated 03/06/19 revealed the following: . It is the policy of [name of corporate] facilities to obtain a PL 1 screening form from the RE prior to admission to the NF. 3. The facility will review the PL 1 screening for completion and correctness prior to admission. The facility will maintain PL 1 Best Practices as followed: . Review the PL 1 Form for completion and correctness before admission.

Based on observations, interviews, and a review of facility records, the facility failed to safely store all drugs and biologicals in locked areas at the correct temperatures. Additionally, the facility failed to ensure that all medications were properly labeled with professional instructions, cautionary warnings, and valid expiration dates for 2 out of 2 medication carts and the only medication storage room reviewed for pharmacy services. The facility failed to ensure that medication carts were kept free of loose, unidentified pills. The failed to maintain a consistent tracking system for medication refrigerator temperatures to protect the stability and therapeutic potency of stored pharmaceuticals. These failures could result in residents receiving degraded or ineffective medications from unmonitored temperature variations, or lead to medication errors and accidental ingestion from loose, unaccounted-for pills left inside medication carts.Findings Included: An observation and inspection of the Hall B medication cart on 06/04/2026 at 8:46 AM, in the presence of LVN F, revealed one loose, small, light-purple tablet inside the cart drawer. At the surveyor's request, LVN F removed and identified the medication as Levothyroxine 75 mcg. During an interview on 06/04/2026 at 8:49 AM, regarding the loose medication, LVN F stated the negative outcome of having unsecured pills in the cart was that it could be given to a resident who it doesn't belong to. LVN F also stated that it could throw off medication counts and impact residents by preventing them from receiving all the medications they paid for. An observation and inspection of the Hall A medication cart was conducted on 06/04/2026 at 9:26 AM in the presence of LVN G. The inspection revealed one loose, large, red, oval-shaped tablet inside the cart drawer. When asked to remove and identify the tablet, LVN G was unable to identify the medication. The unknown tablet was subsequently disposed of by LVN G. An inspection of the facility's single medication storage room on 06/04/2026 at 9:46 AM revealed that the medication refrigerator temperature logs were incomplete. Daily temperature recordings were omitted for the AM shift on June 1, 2026, as well as both the AM and PM shifts on June 3, 2026. During an interview on 06/04/2026 at 9:46 AM, about the missing temperature records, LVN G stated that failing to monitor refrigerator temperatures could affect the medications and their effectiveness, and it was the responsibility of both the day and night shift floor nurses. During an interview on 06/04/2026 at 10:35 AM, the DON stated the negative outcomes of failing to monitor refrigerator temperatures include medications becoming too hot or frozen, which renders them not as effective to residents. The DON confirmed that floor nurses are responsible for completing these temperature checks every shift. Regarding loose pills, the DON stated they must be discarded due to contamination, and not knowing who it belongs to could cause residents to miss a dosage or incur financial costs for replacement pills. During an interview on 06/04/2026, the ADM stated that failing to check temperatures directly threatens the effectiveness of the medications. Regarding loose pills, the Administrator stated that medications are wasted, residents can miss critical doses, and it negatively affects pharmacy reordering schedules. During an interview on 06/04/2026 at 11:01 AM, the CCN stated that unmonitored storage temperatures negatively impact the effectiveness of meds and them not working as well for the residents. For loose pills, she noted the facility is forced to reorder medications prematurely, which causes financial costs to the facility and increases the risk of residents missing a dose. A record review of the facility policy and procedures titled Storage of Medication (dated 3/3/2002) revealed the following procedure mandate: The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. A record review of the facility policy titled Medication Storage (dated 3/3/2002) revealed the following requirement: Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier.

Based on interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 (Residents #8 and #44) of 13 residents reviewed for quality of care. The facility failed to ensure nursing staff were aware of residents who were diagnosed with PTSD and their triggersThe facility failed to develop and ensure staff were educated in PTSD triggers and interventions for Resident's #8 and #44. The facility failed to monitor for signs and symptoms of anxiety, depression and suicidal thoughts for Resident #44 This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Resident #8Resident #8 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, (a mood disorder that causes a persistent feeling of sadness), schizophrenia (a mental condition that can cause visual and auditory hallucinations), PTSD (a condition triggered by experiencing or witnessing a terrifying or life-threatening event), and alcohol dependence.Record Review of Resident #8's Quarterly MDS dated [DATE] documented a BIMS score of 6 out of 15 which indicated severely impaired cognition. Section I Active Diagnoses documented Resident #8 had an active diagnosis of PTSD.Record review of Resident #8's Care Plan dated 3/11/26 documented resident was incontinent, at risk for falls, required antidepressant medications, and had impaired visual function.Record review of Resident #8's Treatment Administration Record revealed there was no documentation of behavior monitoring specific approaches, measurable objectives or the residents' goals for care related to PTSD. In an interview on 6/3/26 at 11:30 am, Resident #8 stated she had PTSD and her main trigger was leaving the facility. She stated she got anxious when she had to go out of the facility. She stated she only had to go to dr appointments. She stated no one in the facility had ever spoken to her about her PTSD or being anxious. She stated she did not think staff knew she did not like to leave the facility. Resident #44Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, PTSD ( a condition triggered by experiencing or witnessing a terrifying or life threatening event), chronic pain, generalized anxiety disorder, obesity, and major depressive disorders ( a mood disorder that causes a persistent feeling of sadness).Record review of Resident #44's MDS dated [DATE] documented a BIMS score of 5 out of 15 which indicated severely impaired cognition. Section I Active Diagnoses documented Resident #44 had an active diagnosis of PTSD.Record review of Resident #44's Care Plan dated 6/3/26 documented resident had limited physical mobility, was incontinent, and needed assistance with ADLs. Care Plan also documented: Focus: Resident had a history of trauma/PTSD that may have had a negative impact. The trauma was past sexual and physical abuse from loved ones. Goal: Staff will assist in avoiding triggers through next review date. Date initiated:11/1/24 Interventions: Arrange to License Mental Health Provider. Consult with family regarding resident's conditions as appropriate. Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse. included monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse.Record review of Resident #44's Comprehensive care plan did not have any documentation of behavior monitoring specific approaches, measurable objectives or the residents' goals for care related to PTSD. Record review of Resident # 44's Treatment Administration Record did not have any documentation of behavior monitoring specific approaches, measurable objectives or the residents' goals for care. Record review of Resident #44's Psychological Services progress note, dated 5/30/26 revealed: Current Risk Factors: trauma screening positive with current symptoms. Mental Status Exam revealed resident was depressed anxious and felt worthless. Patient stated to the therapist that she felt anxious, sad and depressed. There were no interventions listed. In an interview on 6/5/26 at 9:10 am LVN E stated she had been trained on trauma informed care and knew what PTSD was. She stated she was not aware of the residents who had PTSD in the facility. She stated she had not been aware that Resident #44 and Resident #8 had been listed as having PTSD. She stated she did not know what the triggers were for either resident. She stated the consequences of not knowing who had PTSD and not knowing the triggers for each resident could cause residents to have more behaviors. LVN D stated she looked at care plans, and stated PTSD would be in the resident's care plan. In an interview on 6/5/26 at 9:15 am, RN D stated she did not know about Trauma Informed Care and had not been trained by the facility on Trauma Informed Care or PTSD. She stated there were no residents in the facility with PTSD at that time. She stated a negative outcome of not knowing residents had PTSD would be that you could cause further harm to the residents or others by not knowing about the behaviors. In an interview on 6/5/26 at 9:20 am CNA B stated she was aware of Trauma Informed Care and she had not been aware Resident # 44 or Resident #8 were listed as having PTSD. She stated she had not been aware of their triggers and did not know if the residents had been care planned for trauma. She stated a negative outcome of not knowing about trauma could be causing outbursts and behaviors in residents. In an interview on 6/5/26 at 9:40 am, the DON stated Trauma Informed Care was from past trauma. She stated all staff were trained to pay attention to residents' behaviors. She stated staff did not always know all of the triggers a resident may have. She stated if the behaviors affected the care, the CNAs should know what the triggers were. The DON stated knowledge about the trauma would come from the SW and the Care Plan. The DON stated she did not know if the triggers were on the care plan for each resident, but thought they should be. She stated the SW would know what the triggers were and would let the staff know what the triggers were by discussing it with staff. The DON stated as behaviors came up the staff dealt with it. When asked about Resident # 8, she stated she was not aware of what trauma she had in the past and did not know what her triggers were. She stated of Resident # 44 she was not aware of what her trauma was and was not sure what her triggers were. An interview by phone was attempted on 6/5/26 with the SW at 9:45 am. A message was left with no return calls received. In an interview on 6/5/26 at 10:05 am, the MDS RN stated she was aware trauma informed care referred to PTSD. She stated she was aware there were several residents in the facility with PTSD. She stated sometimes staff were not aware of trauma and did not understand what trauma was and did not understand what triggers were. She stated the SW would do an informal training on trauma when a behavior came up. She stated PTSD should be included in a resident's care plan because staff would need to know what was causing a behavior. She stated a resident could be negatively affected if PTSD was not in their care plan because they might not get the care or feeling of safety they needed. The MDS RN stated the care plan should include triggers the resident had and staff should be educated on said triggers so they (staff) could provide trauma-informed care for the resident. An interview by phone was attempted on 6/5/26 with the SW at 11:35 am. A message was left with no return calls received. An interview by phone was attempted on 6/5/26 with the SW at 1:00 pm. A message was left with no return calls received. Record review of the facility's policy dated October/2022 titled Trauma Informed Care Policy revealed: Purpose: The facility must ensure residents who are trauma survivors receive culturally competent, trauma informed care by professional standards of practice and accounting for residents experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Assessment: Facilities should use a multi-pronged approach to identifying a residents history of trauma as well as his or her cultural preferences. This would include asking a resident about triggers that would be stressors as well as the RAI, admission assessment, history and physical and others. Triggers: Facilities must identify triggers that may retraumatize residents with a history of trauma. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Resident-specific approaches must be developed and included in the resident's care plan. These interventions must be provided consistently, and supervising staff should monitor the delivery of care and staff interactions with the resident to assure they are implemented as written. Care Planning to address Past Trauma: The facility should collaborate with resident trauma survivors and family members, friends and any other health care professionals to develop and implement individualized interventions.Facilities are responsible to try to identify triggers that may retraumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident.

Based on interview and record review, the facility failed to implement a comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Residents #8 and #53) of 13 Residents reviewed for comprehensive care plans. -The facility failed to address the diagnosis of PTSD in Resident # 8's care plan. -The facility failed to address the diagnosis of bipolar disorder in Resident # 53's care plan These failures could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #8Resident #8's admission record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, (a mood disorder that causes a persistent feeling of sadness) , schizophrenia (a mental condition that can cause visual and auditory hallucinations), PTSD ( a condition triggered by experiencing or witnessing a terrifying or life-threatening event), and alcohol dependence.Record Review of Resident #8's Quarterly MDS assessment dated [DATE] documented a BIMS score of 6 out of 15 which indicated severely impaired cognition. Section I Active Diagnoses revealed Resident #8 had an active diagnosis of PTSD.Record review of Resident #8's Care Plan dated 3/11/26 documented resident was incontinent, at risk for falls, required antidepressant medications, and had impaired visual function. Record review of Resident # 8 Comprehensive Care Plan Treatment Administration Record revealed there was no documentation of trauma informed care or PTSD and did not have behavior monitoring specific approaches, measurable objectives or the residents' goals for care.Record review of Resident # 8 Treatment Administration Record did not have any documentation of behavior monitoring specific approaches, measurable objectives or the residents' goals for care related to PTSD. In an interview on 6/3/26 at 11:30 am, Resident #8 stated she had PTSD and her main trigger was leaving the facility. She stated she got anxious when she had to go out of the facility. She stated she only had to go to dr appointments. She stated no one in the facility had ever spoken to her about her PTSD or being anxious. She stated she did not think staff knew she did not like to leave the facility. She stated she often had to ride the van to go to dr appointments and the van driver had never said anything to her about being anxious. Resident #53Record review of Resident #53's admission record dated 06/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder unspecified with a diagnosis date of 05/27/26. Record review of Resident #53's admission MDS assessment completed 06/03/26 revealed a BIMS of 14 which indicated intact cognition. Section I Active Diagnoses revealed a diagnosis of bipolar disorder. Record review of Resident #53's baseline care plan initiated on 05/27/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan. Record review of Resident #53's care plan completed on 06/04/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan. During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for completing care plans. She stated a diagnosis of bipolar disorder should be included in a care plan. MDS RN stated if the diagnosis was not included in the care plan the resident might not get the care or the medication they need. She stated PTSD should be included in a resident's care plan because staff would need to know what might set it (PTSD) off. She stated a resident could be negatively affected if PTSD was not in their care plan because they might not get the care or feeling of safety they need. MDS RN stated the care plan should include what triggers the resident had and staff should be educated on said triggers so they (staff) could provide trauma-informed care for the resident. During an interview on 06/05/26 at 08:58 AM LVN E stated nursing staff were responsible for completing care plans. She stated a diagnosis of bipolar disorder should be included in the care plan or a resident's behavior would not be addressed. She stated residents might not get the medication they need if staff are unaware of a mental illness diagnosis and therefore overlook behaviors. During an interview on 06/05/26 at 09:05 AM RN D stated MDS RN was responsible for completing care plans. She stated a diagnosis of bipolar disorder and PTSD should absolutely be included in the care plan. RN D stated a resident might not receive correct treatment if a diagnosis of mental illness was not included in the care plan. She stated a negative outcome of not knowing residents had PTSD would be possibly causing harm to the residents or others by not knowing about the behaviors. During an interview on 06/05/26 at 09:12 AM LVN C stated care plans were completed by several staff members including nursing staff and MDS RN. She stated a diagnosis of bipolar disorder should be included in the care plan because it is important to know. LVN C stated staff would know better how to care for a resident and what to expect from a resident if the care plan included any mental illness diagnoses. During an interview on 06/05/26 at 09:18 AM CNA B stated several staff members were responsible for completing portions of care plans with MDS RN being responsible for the final product. She stated a diagnosis of bipolar disorder and PTSD should be included in a care plan so staff would know how to approach and care for the resident. During an interview on 06/05/26 at 09:26 AM CNA A stated DON and MDS RN along with other staff members were responsible for completing care plans. She stated a diagnosis of bipolar disorder and PTSD should be included in the care plan. She stated staff might not know how to properly care for a resident if a mental illness diagnosis was not included in the resident's care plan. During an interview on 06/05/26 at 09:30 AM DON stated MDS RN was ultimately responsible for completing care plans. She stated if a resident was not receiving medication for a mental illness diagnosis the diagnosis might not need to be in the care plan. She stated she did not think there would be a negative outcome to a resident if a diagnosis of bipolar disorder was not included in the resident's care plan. During an interview on 06/05/26 at 09:39 AM ADM stated care plans were completed by an interdisciplinary team. She stated a diagnosis of bipolar disorder should be included in a care plan. ADM stated otherwise the mental illness could go untreated which could lead to a negative outcome for the resident. During an interview on 6/5/26 at 9:40 am, the DON stated Trauma Informed Care was from past trauma. She stated all staff were trained to pay attention to residents' behaviors. She stated staff did not always know all of the triggers a resident may have. She stated if the behaviors affected the care the CNAs should know what the triggers were. The DON stated knowledge about the trauma would come from the SW and the Care Plan. The DON stated she did not know if the triggers were on the care plan for each resident but thought they should be. During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for completing care plans. She stated a diagnosis of bipolar disorder should be included in a care plan. MDS RN stated if the diagnosis was not included in the care plan the resident might not get the care or the medication they needed. She stated PTSD should be included in a resident's care plan because staff would need to know what might set it (PTSD) off. She stated a resident could be negatively affected if PTSD was not in their care plan because they might not get the care or feeling of safety they need. MDS RN stated the care plan should include what triggers the resident had and staff should be educated on said triggers so they (staff) could provide trauma-informed care for the resident. Record review of the undated facility policy titled, Comprehensive Care Planning revealed the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives timeframes to meet a residents medical nursing, mental and psychological needs that are identified in the comprehensive assessment. Person-centered care plans make an effort to understand what each resident is communicating verbally and nonverbally, identifying what is important to each resident, and having an understanding of a resident's life before residing in the nursing home. Residents' goals set the expectation for the care and services he/she wishes to receive. Measurable objectives describe the steps toward achieving the residents' goals and can be measured, quantified and /or verified. The care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services implemented. Record review of the facility policy dated 10/2022, titled Trauma Informed Care Policy revealed: Purpose: The facility must ensure residents who are trauma survivors receive culturally competent, trauma informed care by professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Care Planning to address Past Trauma: The facility should collaborate with resident trauma survivors and family members, friends and any other health care professionals to develop and implement individualized interventions. Facilities are responsible to try to identify triggers that may retraumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident. Trigger specific interventions should identify ways to decrease the resident's exposure to triggers that retraumatize resident as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could place residents at risk of food borne illnesses. Findings include: Observation of the kitchen food prep activities on 4/15/25 from 11:15 a.m. to 12:15 p.m. revealed the following: At 12:00 p.m., [NAME] B was observed in the kitchen serving the noon meal. [NAME] B changed her gloves, picked up plates and set them on the serving line, took lids off food, touched the plates, picked up a knife and laid the knife on the serving line. [NAME] B picked up a plate and plated one piece of chicken. [NAME] B put the plate down and picked up the knife with her gloved hands. [NAME] B then placed her right hand over the chicken piece and began slicing the chicken into strips on the plate. [NAME] B then rearranged the chicken on the plate with her gloved hands. [NAME] B put the knife down and picked up the plate of chicken. [NAME] B plated the rest of the meal, using her gloved hands to touch the serving utensils and the plates. [NAME] B placed the plate on the serving cart. [NAME] B picked up another plate and serving utensils and plated another piece of chicken. [NAME] B picked up the knife and began cutting the chicken into strips. [NAME] B put her right hand on the chicken to hold it in place while she cut the chicken. [NAME] B then put the knife down and rearranged the chicken on the plate. [NAME] B picked up the plate and serving utensils and plated the rest of the meal. [NAME] B did not make any attempts to change her gloves or wash her hands. In an interview on 4/15/25 at 12:10 p.m., [NAME] B was asked if she realized she touched the chicken while cutting the food after touching numerous surfaces in the kitchen. [NAME] B did not speak English. The DM was also present and observed [NAME] B touching the food after touching multiple surfaces. The DM stated [NAME] B was not supposed to touch the food and should have used utensils and should have washed hands and changed gloves between tasks. The DM stated the consequences of not washing hands and changing gloves would be risk of food borne illness. The DM stated she trained the staff in hand washing and glove use and expected all staff to wash hands and change gloves between tasks. Record review of the undated facility policy titled Dietary Department Glove Standard Protocol documented: Per the Texas Food Establishment Rules, there will be no bare hand to food contact in the kitchen. Use tongs, spoons, deli tissue paper .If a glove must be used, such as for sandwich assembly, hands will be washed prior to putting on a glove and immediately after removing it. Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can lead to cross contamination. Gloves will not be worn on the tray line. Instead pre -assembly and /or prep work will be done prior to tray line service .

46534 Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 (Resident #3, Resident #13, Resident #41, and Resident #43) of 12 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #3 received O2 via NC at the rate of 2 l/m as ordered by her physician. 2. The facility failed to ensure Resident #13 received O2 via NC at the rate of 2 l/m as ordered by her physician. 3. The facility failed to ensure Resident #41 received O2 via NC at the rate of 5 l/m as ordered by his physician. 4. The facility failed to ensure Resident #43 received O2 via NC at the rate of 4 l/m as ordered by hi physician. These failures could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: 1. Record review of Resident #3's admission record dated 04/15/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly). Record review of Resident #3's annual MDS assessment completed 03/22/2025 revealed a BIMS of 15 which indicated intact cognition. Section O-Special Treatments, Procedures, and Programs indicated she was receiving oxygen therapy while a resident. Record review of Resident #3's care plan completed 03/37/25 revealed a focus area of The resident has oxygen therapy as needed r/t COPD. This focus area was revised on 01/18/24 and included the following intervention Oxygen per physician orders. This intervention was revised on 02/13/25. Record review of Resident #3's active orders dated 04/16/2025 revealed the following order: Order start date 02/11/25 May use oxygen @ 2 l/m via nasal canula every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. During an observation and interview on 04/16/25 at 07:56 AM Resident #3 was in bed receiving oxygen via NC at between 3.0 and 3.5 lpm. Resident #3 opened her eyes and stated. Everything is fine. During an observation on 04/16/25 at 10:55 AM Resident #3 was lying in bed with her eyes closed receiving oxygen via NC at between 3 and 3.5 lpm. 2. Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, emphysema, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), chronic respiratory failure with hypoxia (failure of lungs to provide oxygen), dependence on supplemental oxygen, and pleural effusion (abnormal build-up of fluid in space around lungs, causes pressure on lungs resulting in shortness of breath, coughing, and chest pain). Record review of Resident #13's significant change MDS revealed a BIMS of 6 which indicated severely impaired cognition. Section O-Special Treatments, Procedures, and Programs revealed she was receiving oxygen therapy while a resident. Record review of Resident #13's care plan completed on 04/10/25 revealed the following focus areas and corresponding interventions: [Resident #13] has Emphysema/COPD. This focus area was revised on 03/28/23 and included the intervention Give oxygen therapy as ordered by the physician. This intervention was initiated on 10/31/18. [Resident #13] has Oxygen Therapy. This focus area was revised on 03/28/23. Record review of Resident #13's active orders dated 04/15/25 revealed the following orders: Order start date 11/20/22 Change humidifier water. one time a day every Sun for O2 therapy. Order start date 11/18/22 change O2 cannula/tubing prn if damaged or visibly soiled as needed for O2 therapy. Order start date 10/16/22 Change oxygen tubing, nasal cannula or mask PRN or when visibly soiled every night shift every Sun or Oxygen therapy. Order start date 11/23/24 Check O2 sat Q shift every shift. Order start date 11/23/24 may use oxygen @ 2 l/m via nasal canula every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA During an observation on 04/15/25 at 09:50 AM Resident #13 was in her bed receiving O2 via NC at 3 lpm. During an observation on 04/15/25 at 12:20 PM Resident #13 was in her bed receiving O2 via NC at 3 lpm. During an observation on 04/16/25 at 08:27 AM Resident #13 was in her bed receiving O2 via NC at 2.5 lpm. During an observation on 04/16/25 at 02:48 PM Resident #13 was in her bed receiving O2 via NC at 2.5 lpm. 3. Record review of Resident #41's admission record dated 04/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (failure of lungs to provide oxygen) and congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue). Record review of Resident #41's quarterly MDS completed on 03/25/25 revealed a BIMS of 13 which indicated intact cognition. Section O-Special Treatments, Procedures, and Programs revealed he was receiving oxygen therapy while a resident. Record review of Resident #41's care plan completed on 03/27/25 revealed the following focus areas and corresponding interventions: The resident has Congestive Heart Failure. This focus area was initiated on 12/07/24 and included the intervention Oxygen therapy as ordered. This intervention was revised on 04/02/25. The resident has Oxygen Therapy. This focus area was initiated on 12/07/24 and included the intervention Oxygen therapy as ordered. This intervention was revised on 04/02/25. Record review of Resident #41's active order summary dated 04/15/25 revealed the following orders: Order start date 03/16/25 May use humidified Oxygen for resident comfort-change o2 bottle and tubing weekly at bedtime every Sun for comfort. Order start date 12/07/24 May use oxygen at 5 L via nasal canula continuously. every shift. During an observation on 04/15/25 at 09:02 AM Resident #41 was seated on the edge of his bed. His NC was next to him on the bed. His O2 concentrator was running and set to 2 lpm. He stated he was on continuous oxygen but was not wearing his NC at the moment due to just transferring to the bed from the wheelchair. Resident #41 stated he had been receiving oxygen for the last few months. During an observation on 04/16/25 at 10:21 AM Resident #41 was seated at a table in the dining room receiving O2 via NC from the tank hanging on the back of his wheelchair at 2 lpm. During an observation on 04/16/25 at 02:52 PM Resident #41 was seated on the edge of his bed. He was not receiving O2. He stated, I don't use it (O2) 24 hours a day, only when I feel anxious. 4. Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), chronic cough, and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #43's quarterly MDS completed on 02/19/25 revealed a BIMS of 15 which indicated intact cognition. Resident #43 was not coded as receiving oxygen therapy while a resident. Record review of Resident #43's care plan completed on 03/27/25 revealed the following focus areas and corresponding interventions: The resident has Congestive Heart Failure. This focus area was initiated on 01/28/25 and had Oxygen therapy as an intervention. This intervention was revised on 04/02/25. The resident has Emphysema/COPD. This focus area was revised on 02/14/25 and had Give oxygen therapy as ordered by the physician as an intervention. This intervention was initiated on 01/28/25. The resident has Oxygen Therapy. This focus area was initiated on 01/28/25 and had Oxygen therapy as ordered as an intervention. This intervention was initiated on 04/02/25. Record review of Resident #43's active order summary dated 04/15/25 revealed the following orders: Order start date 01/28/25 Change nasal canula every 12 hours as needed. Order start date 01/28/25 Check O2 sat Q shift and PRN as needed. Order start date 01/28/25 Check O2 sat Q shift and PRN every shift. Order date 01/28/25 Ear Padding for Continuous Oxygen via Nasal Cannula. Order start date 01/28/25 May use oxygen @ 4 l/m via nasal canula every shift. During an observation on 04/15/25 at 09:50 AM Resident #43 was lying in bed with her eyes closed receiving O2 via NC at 5 lpm. During an observation on 04/15/25 at 12:20 PM Resident #43 was lying in bed with her eyes closed receiving O2 via NC at 5 lpm. During an observation and interview on 04/16/25 at 08:23 AM Resident #43 was lying in bed receiving O2 via NC at 5 lpm. She stated she had been on O2 for a couple of years for congestive heart failure and COPD. During an interview on 04/17/25 at 09:22 AM RN A stated nurses were responsible for setting flow rates on oxygen concentrators and oxygen tanks. She stated they knew what rate to set the oxygen to by looking the physician's order. RN A stated a resident could be negatively affected by receiving oxygen at lower rates than it was ordered. She stated, They are not receiving enough oxygen for body so not oxygenating whole entire system appropriately. She stated receiving oxygen at higher rates than ordered could negatively impact the resident. RN A stated, I don't know exactly, but I know too much oxygen also be bad. RN A stated she did not know why Resident #41 and Resident #13 were receiving incorrect levels of oxygen. She stated regarding Resident #43's oxygen, On her, I know that sometimes she cranks it (oxygen flow rate) up and we (facility staff) try to adjust it. During an interview on 04/17/25 at 09:22 AM the DON reported that she was aware that Resident #3 was getting her oxygen at a dose that was higher that Resident #3's current orders, that she (the DON) had contacted the nurse practitioner to discuss the issue and had received new orders for Resident #3's oxygen to be administered at 2-4L/min from now on. The DON reported that she was having an issue with the night shift changing oxygen administration levels based on the residents needs and not contacting the physician. The night shift was not reporting the issue and getting an order. The DON stated that her expectation was for staff to get an order for any medication change prior to changing a medication and that included oxygen. The DON reported that if a staff member did not administer a resident medication as it was ordered such as with the oxygen then that resident could become more dependent, it could make their COPD worse, and it could affect their overall health. During an interview on 04/17/25 at 09:28 AM ADON stated nurses were responsible for setting oxygen flow rates. She stated they know what rate to set the oxygen to by referring to the orders. ADON stated residents receiving oxygen at lower rates than ordered can hallucinate from low oxygen. She stated residents receiving oxygen at higher rates than ordered can have too much CO2. During an interview on 04/17/25 at 09:37 AM DON stated nurses were responsible for setting oxygen flow rates. She stated the correct flow rate is in the orders. She stated the oxygenation of residents receiving oxygen at lower rates than ordered by the physician won't be where it should be. DON stated residents receiving oxygen at higher rates than ordered might change their need levels prematurely. She stated she did know why Resident #13 was receiving oxygen at higher rates than ordered. She stated Resident #41 was with it enough to adjust his own O2 rates as he feels better. DON stated Resident #43 probably changes her oxygen flow rate as well. Record review of facility policy titled Oxygen Administration and dated 02/13/07 revealed the following: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) . to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen . and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 5 (Resident #2, #13, #18, #41, and #43) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #2 for oxygen therapy on her 03/08/25 MDS assessment. -The facility failed to accurately assess Resident #13 for antidepressant medication therapy on her 03/26/25 MDS assessment. -The facility failed to accurately assess Resident #18 for weight loss on his 03/22/25 MDS assessment. -The facility failed to accurately assess Resident #41 for antibiotic therapy on her 03/16/25 MDS assessment. -The facility failed to accurately assess Resident #43 for anticoagulant therapy and oxygen therapy on her 02/18/25 MDS assessment. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Resident #2 Record review of Resident #2's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Parkinsonism (a disorder of the central nervous system that affects movements to include tremors), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), epilepsy, and congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Record review of Resident #2's quarterly MDS dated [DATE] revealed she had a BIMS of 14 indicating she was cognitively intact, and she had a functionality of being dependent on staff for most of her ADL's and activities. Record review of Section O - Special Treatments, Procedures, and Programs listed Resident #2 as not having oxygen therapy while a resident. Record review of Resident #2's Treatment Administration Record (TAR) with treatment administered from 03/01/25 to 03/31/25 listed Resident #2 as having the following: - Continuous Oxygen via Nasal Canula @ 3 liters N/C @ HS with ear padding at bedtime -D/C Date- 03/28/2025. (Received daily 03/01/205 through 03/08/25 - the 7-day look back period for the 03/08/25 MDS assessment) Record review of Resident #2's care plan with admitted [DATE] revealed the following care plan: -Focus: Resident has Congestive Heart Failure. -Intervention/Tasks: Oxygen therapy as ordered. During an observation and interview on 04/17/25 at 08:10 AM Resident #2 was observed in bed with the head of her bed elevated and she was eating her breakfast. Resident #2 appeared in good condition but was noted to be short of breath with effort such as conversation. Resident #2 verified that she does use oxygen but mostly at night. During an interview on 04/17/25 at 08:26 AM the MDS/RN verified that Resident #2 did not have oxygen marked on her 03/08/25 MDS and that her TAR had that Resident #2 had received oxygen during the 7-day look back period. The MDS/RN stated, I missed that one. The MDS/RN reported that the facility uses the RAI Manual to complete all MDS assessments. Resident #13 Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included major depressive disorder recurrent (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #13's significant change MDS revealed a completion date of 03/26/25. Section C-Cognitive Pattern revealed a BIMS of 6 which indicated severely impaired cognition. Section I-Active Diagnoses revealed a diagnosis of depression. Section N-Medications revealed Resident #13 was not receiving antidepressant medication. Record review of Resident #13's care plan completed on 04/10/25 revealed a focus area of [Resident #13] requires antidepressant medication. This focus area was initiated on 12/20/22. One of the interventions which was also initiated on 12/20/22 was Give antidepressant medications ordered by physician. Record review of Resident #13's active orders dated 04/15/25 revealed an order for antidepressant medication with a start date of 04/19/22. The instructions for this order were: Give 1 capsule by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. Resident #18 Record review of Resident #18's face sheet printed 12-5-2024 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), intermittent explosive disorder (a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand), malnutrition (lack of proper nutrition), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) with hemiplegia (a condition characterized by sever or completed paralysis on once side of the body, typically resulting from brain damage), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to left hand. Record review of Resident #18's MDS assessment dated [DATE] revealed he had a BIMS of 7 indicating he was severely cognitively impaired, he had a functionality of requiring partial/moderate assistance with most of his activities of daily living, and for Section K - Swallowing/Nutritional Status Resident #18 for question K0300 Weight Loss-loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Resident #18 was marked yes. Record review of Resident #18's care plan with admitted [DATE] revealed the following care plan: Focus: Resident is on a regular/thin diet. Date initiated 04/05/24. Goal: Resident will maintain ideal weight x 90 days. Target date 06/04/25. During an observation and interview on 04/15/25 at 09:23 AM Resident #18 was leaving his room in a specialized wheelchair to go for a smoke break. Resident #18 appeared in good condition and was wheeling himself independently. Resident #18 reported no concerns and that his care had been good. Record review of Resident #18's weight record revealed he had been weighed on 03/10/25 (the closest weight to the 03/22/25 MDS) at 200 lbs. and he was weighed on 02/07/25 at 201 lbs. for a weight loss of 0.05% in the last month and Resident #18's weight on 10/02/24 was 184.8 lbs. for a weight gain of 0.823% in the last 6 months. During an interview on 04/17/25 at 08:26 AM the MDS/RN reported that she started as the MDS coordinator for the facility approximately 1 month ago. The MDS/RN reviewed Resident #18's 03/22/25 quarterly MDS and verified that Resident #18 was marked with weight loss in section K. The MDS/RN reviewed Resident #18's weights and reported that he lost less than 5% in the previous 30 days (1 month) and gained weight in the last 180 days (6 months). The MDS/RN reported that she marked him as Answer #2-yes for the weight loss questions because he was having weight fluctuations. The MDS/RN was asked to read the RAI manual instructions which she did and for section K Weight loss/gain she read that a resident was supposed to be marked Code #2-yes if the resident had a 5% weight loss in the last 30 days (1 month) or a 10% weight loss in the last 180 days (6months) and the resident was not on a physician prescribed weight loss program. The MDS/RN reported that she understood she was allowed to mark the resident as Code #0-no weight loss/gain or Code #2-yes if the resident was having weight fluctuations. The MDS/RN reported that the facility uses the RAI Manual to complete all MDS assessments. Resident #41 Record review of Resident #41's admission record dated 04/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, urinary tract infection. Record review of Resident #41's quarterly MDS with ARD date of 03/16/25 revealed a completion date of 03/25/25. Section C-Cognitive Patterns revealed Resident #41 had a BIMS of 13 which indicated intact cognition. Section I-Active Diagnoses revealed the Resident #41 did not have a urinary tract infection. Section N-Medications revealed Resident #41 was taking antibiotic medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #41's care plan completed on 03/27/25 revealed no mention of antibiotic medication. Record review of Resident #41's active order summary dated 04/15/25 revealed no mention of antibiotic medication. Record review of Resident #41's discontinued orders revealed one order for an antibiotic medication with an order start date of 12/07/25 and an order end date of 12/14/25. Record review of facility matrix dated 04/15/25 revealed Resident #41 was marked for receiving antibiotic medication. Resident #43 Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), atherosclerotic heart disease (hardening of arteries due to plaque buildup), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #43's quarterly MDS with ARD date of 02/18/25 revealed a completion date of 02/19/25. Section C-Cognitive Patterns revealed Resident #43 had a BIMS of 15 which indicated intact cognition. Section N-Medications revealed Resident #43 was taking anticoagulant medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Section O-Special Treatments, Procedures, and Programs revealed the following instructions: Check all of the following treatments, procedures, and programs that were performed . b. While a Resident Performed while a resident of this facility and within the last 14 days. Resident #43 was not coded as receiving oxygen therapy while a resident. Record review of Resident #43's care plan completed on 03/27/25 revealed the following focus areas: The resident is on Anticoagulant therapy This focus area was initiated on 01/28/25. The resident has Congestive Heart Failure This focus area had Oxygen therapy as an intervention. The resident has Emphysema/COPD This focus area had Give oxygen therapy as ordered by the physician as an intervention which was initiated on 01/28/25. The resident has Oxygen Therapy This focus area was initiated on 01/28/25. Record review of Resident #43's oxygen saturation report during the 14-day look-back period for her quarterly MDS 02/04/25 to 02/18/25 revealed 15 entries. Resident #43 was noted to be receiving Oxygen via Nasal Cannula for 13 of the 15 entries. Record review of Resident #43's active order summary dated 04/15/25 revealed no mention of anticoagulant medication. The order summary did reveal the following orders: Ear Padding for Continuous Oxygen via Nasal Cannula This order was dated 01/28/25. May use oxygen @ 4 l/m via nasal canula every shift This order had a start date of 01/28/25. Record review of Resident #43's discontinued orders revealed one order for an anticoagulant medication with a start date of 01/29/25 and an end date of 02/08/25. During an interview on 04/17/25 at 08:26 AM MDS RN stated she was responsible for completing MDS assessments. She stated she used the RAI manual as her policy. She stated she gathered information from the MAR and TAR as well as looking at nursing and CNA notes and orders within the last 7 days in order to complete the MDS assessments accurately. MDS RN stated she did not think an inaccurate MDS assessment would affect the care of the resident. She stated, It is more on the money side, because either you are going to code something, or you missed something that could add more money to that resident. But it doesn't necessarily affect the resident. MDS RN stated a lack of funding could absolutely affect resident care, Because you are not gonna be able to pay your staff. During an interview on 04/17/25 at 09:32 AM ADM stated an inaccurate MDS assessment could negatively affect a resident in that, It can lead to having an inaccurate care plan and an inaccurate care plan can lead to having inaccurate care given to our residents. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: Section O - Special Treatments, Procedures, and Programs Respiratory Treatments: C1. Oxygen Therapy a. On Admission b. While a Resident c. At Discharge Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. Section K - Swallowing/Nutritional Status K0300. Weight Loss Loss of 5% or more in the last month or loss of 10% or more in last 6 months 0. No or unknown 1. Yes, on physician-prescribed weight-loss regimen 2. Yes, not on physician-prescribed weight-loss regimen Coding Instructions: o Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. SECTION N: MEDICATIONS N0415: High-Risk Drug Classes: Use and Indication C. Antidepressant 1. Is takin 2. Indications noted o N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415C2. Antidepressant: Check if there is an indication noted for all antidepressant medications taken by the resident any time during the observation period. (or since admission/entry or reentry if less than 7 days). N0415: High-Risk Drug Classes: Use and Indication F. Antibiotics 1. Is taking 2. Indications noted. Coding Instructions o N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415F2. Antibiotic: Check if there is an indication noted for all antibiotic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). N0415: High-Risk Drug Classes: Use and Indication E. Anticoagulant 1. Is taking 2. Indications noted. Coding Instructions o N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). 46534

Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one of one oxygen tanks observed during the lunch meal. -an unsecured oxygen bottle was observed in the dining room during the lunch meal with 16 residents and 10 staff present. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, and feeling of isolation. Findings include: During an observation on 04/15/25 at 12:08 PM 16 resident and 10 staff were present in the dining room. Noted in the dining room by the exit door to the patio was a freestanding oxygen bottle that was unsecured. During an observation on 04/15/25 at 12:14 PM the HRD moved the unsecured oxygen tank to the back of the closest resident's chair and placed the oxygen tank in an oxygen tank holder. During an interview on 04/16/25 at 01:03 PM the HRD who reported she is a CNA reported that she removed the unsecured oxygen canister from the dining room on 04/15/25, that an oxygen tank should not be left on the floor unsecured. The HRD reported that if an oxygen tank was left unsecured it can fall and explode or it can fall and land on someone's toe, basically it could hurt a resident. The HRD reported that they have been trained on the proper storage of an oxygen tanks and that they discussed this incident in report this AM and plan on doing another training ASAP. The HRD could not remember when the last training on oxygen safety was completed and who presented the training. During an interview on 04/17/25 09:08 AM the ADM reported that the facility did not have a policy for oxygen tank storage/safety. During an interview on 04/17/25 at 09:26 AM the DON reported that oxygen tanks should be stored in the oxygen storage room in a rack for safety because they can fall and turn into a torpedo. The DON reported that if an oxygen tank was to fall then it would be possible for anyone to get hurt. During an interview on 04/17/25 at 09:49 AM the ADM presented an Inservice Training Report started 04/16/25 and currently signed by 28 staff members that had the following information: When taking off someone oxygen bottle to take them out to smoke make sure you are not leaving them on the ground unsecure. This could cause it to fall over and hurt a resident or staff member . The ADM reported that the facility had no previous trainings on Oxygen Bottle Safety that she could find.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #13 and Resident #43) of 12 residents reviewed for comprehensive care plans. 1. The facility failed to include Resident #13's diagnosis of PTSD in her care plan. 2. The facility failed to remove anticoagulant medication from Resident #43's care plan and to include in her care plan her bipolar disorder diagnosis and the fact that she was receiving anticonvulsant medication. These failures could lead to residents not receiving needed care and/or consideration from staff as care is provided and/or receiving improper care/treatment. Findings Included: 1. Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder acute (mental health condition caused by a traumatic event that affects your ability to function normally). The PTSD diagnosis had an onset date of 03/20/20. Record review of Resident #13's significant change MDS revealed a completion date of 03/26/25. Section C-Cognitive Pattern revealed a BIMS of 6 which indicated severely impaired cognition. Section I-Active Diagnoses revealed a diagnosis of PTSD. Record review of Resident #13's care plan completed on 04/10/25 revealed no mention of PTSD except in the diagnoses list on the bottom of the last page of the care plan. Record review of Resident #13's active orders dated 04/15/25 revealed no mention of PTSD except in the list of diagnoses at the top of the first page of the report. 2. Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), atherosclerotic heart disease (hardening of arteries due to plaque buildup), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #43's quarterly MDS with ARD date of 02/18/25 revealed a completion date of 02/19/25. Section C-Cognitive Patterns revealed Resident #43 had a BIMS of 15 which indicated intact cognition. Section I-Active Diagnoses revealed a diagnosis of bipolar disorder. Section N-Medications revealed Resident #43 was taking anticoagulant and anticonvulsant medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #43's care plan completed on 03/27/25 revealed no mention of bipolar disorder or anticonvulsant medication. The care plan did include the following focus area: The resident is on Anticoagulant therapy This focus area was initiated on 01/28/25. Record review of Resident #43's active order summary dated 04/15/25 revealed no mention of anticoagulant medication. The order summary did reveal the following: An order with a start date of 04/02/25 for an antidepressant medication. The instructions for this order were, Give 1 capsule by mouth at bedtime related BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. An order with a start date of 02/28/25 for an anticonvulsant medication. The instructions for this order were, Give 500 mg by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. Record review of Resident #43's discontinued orders revealed one order for an anticoagulant medication with a start date of 01/29/25 and an end date of 02/08/25. During an interview on 04/17/25 at 08:26 AM MDS RN stated she just recently discovered she was fully responsible for care plans. She stated she let administration and nursing know she would need nursing to assist by letting her know when a medication was discontinued, or a new one was started. She stated all the care areas identified in the MDS needed to be included in the care plan. MDS RN stated, pain, nutrition, potential for ulcers, or if they have a wound, diet, all meds should be included in a resident's care plan. She stated if a care plan was not complete and person-centered it could negatively affect the resident, because if you are looking for something and it is not in the care plan then how are you to know that they are to receive that care? MDS RN stated mental health diagnoses should absolutely be addressed in the care plan. She stated if mental health diagnoses are not addressed in the care plan, They [residents] don't get the care they need. MDS RN did not think there would be a negative outcome to a resident if a discontinued medication was still in the care plan. She stated, In my opinion I don't think so because it [the medication] might just be held for surgery or dental stuff. During an interview on 04/17/25 at 09:32 AM ADM stated the interdisciplinary team was responsible for care plans. She stated mental health diagnoses like PTSD should be addressed in the care plan. She stated if they were not addressed, It could trigger the resident's PTSD and go unaddressed and be exacerbation of the PTSD. ADM stated, an inaccurate care plan can lead to having inaccurate care given to our residents. Record review of undated policy titled Comprehensive Care Planning revealed the following: The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Person-centered care includes making an effort to understand what each resident is communicating . identifying what is important to each resident . and having an understanding of the resident's life before coming to reside in the nursing home. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. 'Professional standards of quality' means care and services are provided according to accepted standards of clinical practice.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #43) of 12 residents reviewed for PASRR. The facility failed to refer Resident #43 for a level II PASRR upon receipt of a bipolar diagnosis. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder current episode depressed moderate (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) dated 02/28/25 and listed as her primary diagnosis. Record review of Resident #43's quarterly MDS completed on 02/19/25 revealed in Section C-Cognitive Patterns a BIMS of 15 which indicated intact cognition. Section D-Mood revealed Resident #43 felt down, depressed or hopeless and had little interest or pleasure in doing things 2-6 of the previous 14 days. Section I-Active Diagnoses revealed Resident #43 had a diagnosis for bipolar disorder. The instructions for this section were Active Diagnoses in the last 7 days-Check all that apply. Section N-Medications indicated Resident #43 was receiving antidepressant medication and anticonvulsant medication. Record review of Resident #43's care plan completed on 03/27/25 revealed Resident #43 was receiving antidepressant medication but made no mention of bipolar except in the list of diagnoses on the last page of the care plan. The care plan did not mention anticonvulsant medication. Record review of Resident #43's active order summary dated 04/15/25 revealed an order for an antidepressant medication with the following instructions, Give 1 capsule by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. This order had a start date of 04/02/25. The active order summary revealed an order for an anticonvulsant medication with the following instructions Give 500 mg by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. This order had a start date of 02/28/25. Record review of Resident #43's Miscellaneous tab in her EHR revealed one PASRR. Record review of Resident #43's PASRR revealed it was completed on 01/28/25. Question C0100 revealed the following: Is there evidence or an indicator this is an individual that has a Mental Illness? The answer to this question was No. During an interview on 04/16/25 at 10:12 AM MDS RN stated she was responsible for ensuring PASRRs are completed as required. MDS RN stated she began working for the facility in March of 2025 and if a new PASRR was performed on Resident #43 following her diagnosis of bipolar disorder she (MDS RN) did not know where it would be. She stated, I don't even know where to start looking for that, but I can start asking around. During an interview on 04/16/25 at 11:44 AM ADM and MDS RN stated the previous MDS coordinator did not catch Resident #43's new diagnosis of bipolar disorder and a new PASRR was not completed. During an interview on 04/16/25 at 03:15 PM a PASRR policy was requested from ADM. During an interview on 04/17/25 at 08:26 AM MDS RN stated if a resident was admitted to the facility with a negative PASRR and after admission received a qualifying diagnosis the resident should have a new PASRR completed. She stated a resident could absolutely be negatively affected if a new PASRR was not completed. MDS RN stated, They could be getting a treatment they really didn't need. They could have just had a bad day. During an interview on 04/17/25 at 09:32 AM ADM stated, We need to initiate a PASRR II when a resident who was already admitted to the facility received a new qualifying diagnosis like bipolar disorder. She stated if a PASRR II was not initiated the resident would be at risk of not receiving services they require or are eligible for. During an interview on 04/17/25 at 10:28 AM ADM stated the facility did not have a PASRR policy. She stated PASRR was covered in their Comprehensive Care Planning policy. Record review of undated facility policy titled Comprehensive Care Planning did not address when to perform a PASRR.

Based on observation, interview, and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #4) of 6 residents reviewed for pain management. The facility failed to allow sufficient time for pain medication to take effect prior to changing Resident #4's wound vac on 05/30/24. This failure could place residents at risk of pain and/or anxiety related to pain. Findings Included: Record review of Resident #4's admission record dated 06/27/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acquired absence of unspecified leg above knee, polyneuropathy (malfunction of many peripheral nerves throughout the body), and atherosclerosis of native arteries of extremities (fats, cholesterols, and other substances collected on the inner walls the arteries) with rest pain right leg. Record review of Resident #4's admission MDS revealed a completion date of 06/04/24. Section C noted a BIMS score of 12 which indicated moderately impaired cognition. Section GG indicated use of a w/c. Section J indicated use or offer of PRN pain medication as well as pain experienced frequently. Resident #4 rated her pain at an 8 out of 10. Section M indicated Resident #4 had a surgical wound. Record review of Resident #4's care plan completed on 06/13/24 indicated Resident #4 was at risk for falls due to AKA. Resident #4 was at risk for uncontrolled pain. The interventions listed were initiated on 05/31/24 and included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The care plan indicated Resident #4 had a surgical site to: right stump (AKA). An intervention to address the surgical site was, Observe for s/s pain during treatment and medicate PRN per physician's order. Record review of Resident #4's progress notes revealed in part: A note from 05/30/24 written by ADON Went into res room to do wound care on res. Introduced myself and explained what I would be doing. Res asked if she was in pain and res stated no Res transferred self into bed began wound care. Res dressing taken off and once packing taken out res began to yell. Wound care stopped and this nurse asked charge nurse to medicate res. Nurse called pcp to get an order for [NAME] #3 d/t hydrocodone not in e-kit. Order received for Tylenol #3 one tab po Q4hrs prn and Tylenol #3 taken from e-kit. Res medicated at this time. This nurse began cutting packing to wound size while medication took effect. Wound care completed on res, Res asked for television to be turned on and res resting with eyes closed. A note from 05/31/24 written by SW SW met with res to complete Social history. Res reported her wound care was painful and she felt mistreated by nursing. Admin notified. Record review of Resident #4's active orders dated 06/27/24 revealed the following order: Nurse to call PCP if pain level not controlled with pain medication. Notify DON/Administrator immediately. four times a day for PAIN TO WOUND TO RIGHT BKA. Record review of Resident #4's discontinued orders revealed the following: An order for Tylenol with Codeine #3 oral tablet 300-30 MG one tablet given by mouth every 4 hours as needed for pain. The order had a start date of 05/30/24 and an end date of 05/31/24. An order for Tylenol with Codeine #3 oral tablet 300-30 MG two tablets given by mouth every 4 hours as needed for pain. The order had a start date of 05/31/24 and an end date of 06/03/24. An order for resident to ensure wound vac flowing at 125mg and be changed weekly on Friday. The order had an order date of 05/30/24. An order for surgical wound to be cleaned with wound cleanser and wound vac to wound bed to be set at -125mmHg continuously and to be changed weekly on Friday. The order had a start date of 06/05/24 and an end date of 06/14/24. Record review of Resident #4's MAR for May of 2024 revealed no record of Resident #4 receiving any medication for pain on 05/30/24. The MAR revealed Resident #4 had an order for Tylenol with Codeine #3 which was ordered as 1 tablet by mouth every 4 hours as needed for pain. During an observation and interview on 06/26/24 Resident #4 was seated on the side of her bed dressed in a hospital gown with her left leg hanging toward the floor and her right leg which had been amputated above the knee lying on the bed with a bandage on the end of the stump. She stated when she got to the facility on [DATE] and the nurse was attaching the wound vac to her stump it was pain like she had never experienced. Resident #4 stated she started hollering and at that time the nurse who was attaching the wound vac told her they had given her some pain medication earlier that should have been kicking in. Resident #4 stated the pain medication did not seem to help at all. Resident #4 stated she did not know the name of the staff person who was attaching the wound vac, but she did know the staff person was still working in the facility because she knew the face. Resident #4 stated she did not feel like the staff person listened to her and took her pain into consideration during the application of the wound vac. During an interview on 06/27/24 at 01:51 PM OTR stated she was in the therapy clinic which was around a corner and down the hall from Resident #4's room on 05/30/24 during the application of Resident #4's wound vac. OTR stated she could hear Resident #4 crying out in agony and at one point she heard Resident #4 say, I just can't take this anymore. OTR stated, What I thought was so sad was I could hear her from her room, around the corner, and into our gym. OTR stated she thought nursing staff tried to give Resident #4 pain medication prior to the procedure. She added, But I don't think they gave it enough time to kick in. OTR stated ADON told her the medication did not have enough time to take effect. OTR stated she had witnessed wound vacs being applied in other settings and she had never heard anyone express the kind of pain Resident #4 was expressing. During an interview on 06/27/24 at 03:41 PM MDS LVN stated her office is across the hall from the therapy clinic. She stated she did not hear Resident #4 crying during her wound vac change on 05/30/24 until OTR came into her office to notify her of Resident #4 crying. MDS LVN stated at that point she stepped out of her office into the hall and I did hear some crying. She stated, I heard her crying, I couldn't make out what she was saying. I could tell it was to do with pain. That she was having pain. During an interview on 06/27/24 at 03:49 PM LVN B stated she was the charge nurse who called Resident #4's PCP to get an order for pain medication the facility had on hand in the e-kit. She stated she gave Resident #4 the pain medication before the wound vac was applied. During an interview on 06/28/24 at 09:05 AM MD E stated, Some patients are more sensitive to the wound vacs than others. She stated some of Resident #4's pain was stemming from anxiety. MD E stated, She was a lot more sensitive on the stump area, even just touch sensitive. I think there was some neuropathy going on there. MD E stated she was not a witness to the first wound vac change on 05/30/24 but ADON called and told her everything they had done during the procedure. MD E stated ADON told her wipes were used to get the adhesive to loosen. MD E stated, The only thing I think they could have done differently was maybe call primary (PCP) for other/different meds for pain or anxiety. MD E stated she was in the facility for the next wound vac change and Resident #4 was very anxious to receive care. During an interview on 06/28/24 at 09:12 AM ADON stated she was the nurse changing Resident #4's wound vac on 05/30/24. She stated she knew Resident #4 was in pain because she was screaming. She stated she asked Resident #4's charge nurse LVN B to give her a pain pill but the charge nurse stated because Resident #4 was a new admit her hydrocodone was not in the facility. ADON stated she told LVN B to call the PCP and get an order for something we have in e-kit. ADON stated she told previous DON to walk with LVN B to the e-kit as they were calling the PCP to get the order so the process could be accomplished quickly. ADON said, We administered 2 Tylenol 3s (a medication consisting of acetaminophen and codeine). ADON stated LVN B was the nurse who administered the medication. She stated the medication did not seem to work. ADON stated they waited 15 minutes after the medication was administered to begin working on the wound vac application. When asked if she thought that was long enough for the medication to take effect, ADON answered, She (Resident #4) said it was okay. ADON stated as she continued with the procedure Resident #4 was waving her arm in the air and crying Lord Jesus. During an interview on 06/28/24 at 09:53 AM previous DON stated ADON was the facility wound care nurse and the facility policy was if a resident was admitted with a wound vac the facility would change the wound vac so it was compatible with the equipment the facility owned. DON stated she was in the room with ADON as the wound vac was being changed. She stated she was on standby. DON stated Resident #4 was immediately in pain when ADON began the procedure. DON stated she asked ADON if they should get Resident #4 something for the pain. DON stated she asked repeatedly if we should stop and give her time or find another way to do things. DON stated, It was hurting her (Resident #4) so bad. She was screaming and saying, 'Please help me Jesus, make the pain stop!' DON stated ADON did not use antiadhesive wipes to get the adhesive to loosen. She stated, I'm not sure she realized at that point that we had them (antiadhesive wipes). DON stated, I have never seen a patient have this much pain with removal (of a wound vac). DON stated at that point she told ADON they were going to give Resident #4 a break and she (DON) was going to call the PCP for pain medication. DON stated she left the room to get the medication from the e-kit and when she returned with the medication ADON had already pulled the packing from Resident #4's wound and was cutting the new packing to insert into the wound. DON stated she told ADON they had to give Resident #4 some time for the medication to work. DON stated ADON waited about 10 minutes and started repacking the wound. DON stated Resident #4 started to scream and holler again at that point. DON stated she told ADON they needed to give Resident #4 more time and ADON said, The faster we get it over the faster she will stop hurting and continued the procedure. DON stated she stayed with Resident #4 after the procedure and tried to verbally console her. She stated Resident #4's pain began to subside 30-45 minutes after the procedure was finished. DON stated, Everything [ADON] did was appropriate to the procedure. What she failed to do was properly assess the patient's pain, call the doctor, and see if there was anything else we could do. DON stated 10 minutes was not long enough to wait for the pain medication to take effect. She stated, I think we should have waited at least 45 minutes to an hour. During an interview on 06/28/24 at 11:58 AM MD D stated 15 minutes was not long enough to wait for pain medication to take effect. He stated, It has to be absorbed and it takes longer than that. He stated the time varies for everybody but there is typically not much of an effect for 30-40 minutes. Record review of facility investigation into incident of Resident #4's wound vac being applied revealed a written statement by OTR detailing her concerns regarding Resident #4's pain. Record review of facility wound care, abuse/neglect, pain management in-service taught by CRN on 05/31/24 to DON and ADON revealed the following subject matter: 1. Before performing wound care, offer pain medication to the resident. 2. While performing wound care if the resident is in pain, offer pain medication and give resident time for the medication to work. 3. If you are in the middle of wound care and the resident is in pain, cover the wound with a loose dressing, administer pain medication, and document. 4. If pain medication is not helping, call MD and have medication scheduled, increased, or changed if not working for the pain. 5. Always make sure resident is comfortable, call light within reach, and ask about pain after completing wound care. Record review of facility policy Pain Management, Assessment Scale dated 05/25/16 revealed in part: Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals . 3. Resident expresses a feeling of comfort and relief from pain. 1. Assess resident's physical symptoms of pain, . 2. Perform comfort measures to promote relaxation. 9. Have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use pain rating scale when assessing effectiveness of medications and assessing for pain intensity. 12. Talk with the resident about pain and assess for pain relief after interventions. 13. Monitor for effectiveness of pain interventions.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #5) of 6 residents reviewed for reporting of abuse, neglect, exploitation or mistreatment. The facility failed to report to the state within 2 hours when Resident #5 hit Resident #2. This failure could place residents at risk of continued abuse. Findings Included: Record review of Resident #2's admission record dated 06/27/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder. Record review of Resident #2's quarterly MDS revealed a completion date of 04/24/24. Section C indicated a BIMS score of 11 which indicated moderately impaired cognition. Record review of Resident #2's care plan completed on 04/18/24 indicated Resident #2 had depression and was receiving antidepressant medication. Record review of Resident #2's progress notes revealed in part: A note written by SW on 05/23/24 SW met with res as she was tearful and upset. Res said she was upset with several people that recently frustrated her. She proceeded to say she was 'flipped off' by another res. When she asked him to put his finger down he swung and hit her arm. Res said she was not in pain and it did not bother her, but another res around her witnessed and became upset at what happened. SW notified ADON and Admin. Record review of Resident #5's admission record dated 06/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), schizoaffective disorder depressive type (a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), major depressive disorder with psychotic symptoms (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), mood disorder, generalized anxiety disorder (inability to control constant worrying), hemiplegia and hemiparesis following cerebral infarction (partial paralysis following stroke) affecting right dominant side, cognitive communication deficit, and aphasia (a disorder that affects the ability to communicate, read, write, and understand language caused by damage or injury to the specific area of the brain responsible for language). Record review of Resident #5's quarterly MDS revealed a completion date of 04/09/24. Section C indicated no BIMS score. The staff assessment for mental status revealed Resident #5 had moderately impaired cognition. Section E indicated Resident #5 refused care 1-3 days of the 7-day look back period. No other behaviors were noted in Section E. Section N revealed Resident #5 was receiving antipsychotic and antidepressant medications. Record review of Resident #5's care plan completed on 04/22/24 revealed Resident #5 had potential to demonstrate physical behaviors toward staff and other residents. Interventions included notifying the doctor of any danger to self or others and notifying the charge nurse of any physically abusive behaviors. The care plan indicated Resident #5 was sent to a psychiatric facility for evaluation and treatment. Resident #5 was care planned for receiving antidepressant and antipsychotic medications. Record review of Resident #5's progress notes revealed in part: A note written on 05/23/24 at 03:47 PM by SW another Res reported [Resident #5] 'flipped her off'. When she asked him to put his finger down he swung and hit her arm. SW notified ADON and Admin. A note written on 05/23/24 at 03:59 PM by ADON Res punched another res, after flipping off another res and that res asking this res not to flip her off. Res punched at res, barely touched res. Res redirected at this time. Will cont. to monitor. Called [name of psychiatrist]'s office and spoke with [name] concerning res and situation and n/o received to send to psych unit at this time. [First name of previous ADM] administrator notified at this time. A note written on 05/23/24 at 5:25 PM by SW Referral was faxed to [name of behavioral hospital] for treatment due to aggressive behaviors. Per psychiatrist, [name of psychiatrist], request. A note written by SW on 05/24/24 Res unable to consent for inpatient psych treatment due to being non-verbal. SW completed emergency detention paperwork and submitted to [Name of County] county court per Admin. request. A note written by MDS LVN on 06/13/24 Report called from [name of nurse] at [name of behavioral hospital]. [Resident #5] is expected to admit back to facility today around 11. [name of nurse at behavioral hospital] states . that [Resident #5] has not been aggressive with staff, how ever he has flipped off all staff regularly. Informed ADON and Charge nurse of report received. During an interview on 06/26/24 at 09:10 AM ADON stated Resident #5 was not really interviewable. She stated, He will probably flip you off. During an observation and interview on 06/26/24 at 09:11 AM Resident #2 was seated at a table in the dining room with Resident #3 and another resident. Resident #5 was seated at a table near them. Resident #2 stated she remembered the incident when Resident #5 flipped her off and hit her. She said she was not hurt. Of Resident #5 flipping her off, Resident #2 stated, That is how he talks to us. She stated on 05/23/24 she had just returned from a smoke break and Resident #5 flipped her off. Resident #2 stated she approached Resident #5 to tell him to 'stop that' and he went for her. She stated she saw him coming and pulled her arm back so Resident #5 just grazed her arm with his hand. Resident #2 stated it was no big deal. During an observation and interview on 06/26/24 at 09:14 AM Resident # 5 was seated in his w/c at a table in the dining room. When asked how he was doing he raised his left hand with only the middle finger pointing up. During an observation and interview on 06/26/24 at 09:36 AM Resident #3 was seated at a table in the dining room. She stated she remembered the incident when Resident #5 flipped off Resident #2 and hit Resident #2. Resident #3 stated, He just slapped at her lightly, didn't hurt her at all. During an interview on 06/26/24 at 12:44 PM SW stated she remembered Resident #2 telling her about Resident #5 flipping her off hitting her. SW stated Resident #2 was crying when she was speaking with SW but that she was not upset about the incident with Resident #5, she was crying about other things that had transpired that day. SW stated Resident #2 did not even seem that upset about it happening. SW stated Resident #2 just mentioned it (Resident #5 flipping her off and attempting to hit her) to me in passing. SW stated the facility responded to the incident by referring Resident #5 to a behavioral hospital for evaluation and treatment. SW stated she told ADON and the previous ADM about the incident the day of the incident. During an interview on 06/28/24 at 08:12 AM Resident #5's family member stated it was normal behavior for Resident #5 to flip people off. She stated Resident #5 lived on the streets for years and had a bunch of mental issues. She stated Resident #5 had hit people in the past and had been hit by others. She stated, I mean, when you get a bunch of people like that in there it is bound to happen. During an interview on 06/28/24 at 08:52 AM RN G stated if suspected abuse of a resident was not reported timely it could continue to happen. During an interview on 06/28/24 at 09:12 AM ADON stated if suspected abuse of a resident was not reported timely, It can happen again. Record review of facility Incident by Incident Type report revealed Resident #2 and Resident #5 were listed under Behavior Incidents on 05/23/24. Record review of facility report to HHSC regarding the incident of Resident #5 hitting Resident #2 on 05/23/24 revealed a report date of 05/29/24. Record review of facility investigation into the incident with Resident #2 and Resident #5 revealed Resident #3 was a witness to the incident. Record review of facility in-service taught by previous ADM on 05/23/24 revealed in part: . Abuse, neglect must be reported immediately. The abuse coordinator is [name of previous ADM] and if she isn't available you can report to the DON or ADON. Record review of facility policy Abuse/Neglect dated 03/29/18 revealed in part: . Residents should not be subjected to abuse by anyone, including, . other residents, . E. Reporting 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a. If allegations involve abuse or result in serious bodily injury, the report must be made within 24 hours of the allegation.

Based on observation, interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (Resident #4) of 6 residents reviewed for accuracy of records. The facility failed to document the administration of pain medication on 05/30/24 to Resident #4. This failure could place residents at risk of receiving medications in doses other than those ordered. Findings Included: Record review of Resident #4's admission record dated 06/27/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acquired absence of unspecified leg above knee, polyneuropathy (malfunction of many peripheral nerves throughout the body), and atherosclerosis of native arteries of extremities (fats, cholesterols, and other substances collected on the inner walls the arteries) with rest pain right leg. Record review of Resident #4's admission MDS revealed a completion date of 06/04/24. Section C noted a BIMS score of 12 which indicated moderately impaired cognition. Section GG indicated use of a w/c. Section J indicated use or offer of PRN pain medication as well as pain experienced frequently. Resident #4 rated her pain at an 8 out of 10. Section M indicated Resident #4 had a surgical wound. Record review of Resident #4's care plan completed on 06/13/24 indicated Resident #4 was at risk for falls due to AKA. Resident #4 was at risk for uncontrolled pain. The interventions listed were initiated on 05/31/24 and included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The care plan indicated Resident #4 had a surgical site to: right stump (AKA). An intervention to address the surgical site was, Observe for s/s pain during treatment and medicate PRN per physician's order. Record review of Resident #4's progress notes revealed in part: A note from 05/30/24 written by ADON Went into res room to do wound care on res. Introduced myself and explained what I would be doing. Res asked if she was in pain and res stated no Res transferred self into bed began wound care. Res dressing taken off and once packing taken out res began to yell. Wound care stopped and this nurse asked charge nurse to medicate res. Nurse called pcp to get an order for [NAME] #3 d/t hydrocodone not in e-kit. Order received for Tylenol #3 one tab po Q4hrs prn and Tylenol #3 taken from e-kit. Res medicated at this time. This nurse began cutting packing to wound size while medication took effect. Wound care completed on res, Res asked for television to be turned on and res resting with eyes closed. Record review of Resident #4's discontinued orders revealed the following: An order for Tylenol with Codeine #3 oral tablet 300-30 MG one tablet given by mouth every 4 hours as needed for pain. This order had a start date of 05/30/24 and an end date of 05/31/24. Record review of Resident #4's MAR for May of 2024 revealed no record of Resident #4 receiving any medication for pain on 05/30/24. The MAR revealed Resident #4 had an order for Tylenol with Codeine #3 which was ordered as 1 tablet by mouth every 4 hours as needed for pain. During an observation and interview on 06/26/24 Resident #4 was seated on the side of her bed dressed in a hospital gown with her left leg hanging toward the floor and her right leg which had been amputated above the knee lying on the bed with a bandage on the end of the stump. She stated when she got to the facility and the nurse was attaching the wound vac to her stump it was pain like she had never experienced. Resident #4 stated she started hollering and at that time the nurse who was attaching the wound vac told her they had given her some pain medication earlier that should have been kicking in. Resident #4 stated she did not remember receiving any medication prior to or during the wound vac application. During an interview on 06/27/24 at 03:49 PM LVN B stated she was the charge nurse who called Resident #4's PCP to get an order for pain medication the facility had on hand in the e-kit. She stated she gave Resident #4 the pain medication before the wound vac was applied. LVN B stated she did not know why the MAR did not reflect Resident #4 receiving Tylenol #3 on 05/30/24. She stated, It should be on there. During an interview on 06/28/24 at 08:52 AM RN G stated the nurse who administered a medication was responsible for documenting in the MAR. He stated the documentation should happen at the time the medication was administered. He stated if he had to use medication from the e-kit he would retrieve the medication using his personal passcode and return to this computer to enter the medication into the MAR of the resident. He said if a medication was administered and not documented it might be given by someone else and it is just false documentation. During an observation and interview on 06/28/24 at 09:12 AM ADON stated she was the nurse changing Resident #4's wound vac on 05/30/24. She stated she knew Resident #4 was in pain because she was screaming. She stated she asked Resident #4's charge nurse LVN B to give her a pain pill but the charge nurse stated because Resident #4 was a new admit her hydrocodone was not in the facility. ADON stated she told LVN B to call the PCP and get an order for something we have in e-kit. ADON stated she told previous DON to walk with LVN B to the e-kit as they were calling the PCP to get the order so the process could be accomplished quickly. ADON said, We administered 2 Tylenol 3s. ADON stated LVN B is the nurse who administered the medication. ADON searched her computer and was unable to find any documentation of Resident #4 being given Tylenol #3 on 05/30/24. ADON stated a possible negative outcome not documenting medication administration was the resident could receive too much medication. During an interview on 06/28/24 at 09:53 AM previous DON stated on 05/30/24 she was in the room when ADON was changing Resident #4's wound vac. She stated Resident #4 was expressing pain and she (DON) told ADON they were going to give Resident #4 a break and she (DON) was going to call the PCP for pain medication. DON stated she left the room to get the medication from the e-kit. DON stated after the medication was administered to Resident #4 she (DON) told ADON they had to give Resident #4 some time for the medication to work. Record review of facility policy Purpose and Requirements Medical Records dated 2015 revealed in part: THE MEDICAL RECORD IS A LEGAL DOCUMENT THAT SERVES THE PURPOSE OF: 1. Providing an accurate assessment of each resident's condition. 3. Proof of care, treatments, medications, diet, etc. as ordered by the attending physician.

Based on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident # 1) of 6 residents reviewed for quality of care. The facility failed to enter physician's orders in the EHR which resulted in Resident #1 missing an appointment on 05/21/24 to have an ILR placed. This failure could place residents at risk of not receiving necessary care and/or treatment. Findings Included: Record review of Resident' #1's admission record dated 06/27/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), acute respiratory failure with hypoxia (below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath), anemia (lower than normal amount of healthy red blood cells), and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #1's quarterly MDS revealed a completion date of 04/30/24. Section C indicated intact cognition with a BIMS score of 14. Section I indicated active diagnoses which included heart failure and respiratory failure. Section N indicated Resident #1 was receiving anticoagulant (blood thinning) and diuretic (increases urine output and decreases fluid retention medication. Record review of Resident #1's care plan completed on 06/24/24 revealed Resident #1 was to be given her cardiac medications as ordered to remain free of s/s of congestive heart failure. The care plan indicated Resident #1 had potential for fluid deficit r/t diuretic use. Resident #1's care plan indicated she was receiving anticoagulant therapy and had a heart monitor r/t atrial fibrillation. Record review of Resident #1's progress notes revealed in part: A note written by SW on 05/21/24 at 11:07 AM SW went to remind res of appt today. She stated she was unaware of her procedure with [name of cardiology office] to have Loop recorder implanted. SW had previously spoke with RN, [first name of RN F] regarding the appt. SW contacted [name of cardiology office] to follow up and clarify appt for res. They (cardiology office) stated orders were sent to stop specific meds and all eating for a specific time frame. They also reported ot have spoken with RN, [first name of RN F] to inform her. SW went to get ADON to have her speak with [name of cardiology office]. ADON, [first name of ADON] requested they speak with charge nurse [first name of LVN B] as she is the nurse. SW notified [name of cardiology office] and they (cardiology office) requested the admin come and speak. Admin. [first name of previous ADM] met with Nurse (from cardiology office) via phone and gathered information. Appt will be rescheduled at a later date. [Name of cardiology office] will notify nursing facility of new appt. time. A note written by ADON on 05/21/24 at 11:40 AM [Name of cardiology office] called to notify that his res did not have blood thinners placed on hold and procedure could not be done. A note written by CRN on 06/06/24 Appointment with [name of cardiology office] rescheduled for June 11th at 800 am for pre procedure appt. Procedure to be done on June 17th. Pre op instructions will be given to nurse at appointment on June 11th. A note written by ADON on 06/12/24 Called [sic] received from [initials of cardiology office], res will have a [sic] implanted loop recorded procedure done 6/17/24. Res is to be NPO at midnight on 6/17/24. [Brand name of anticoagulant medication] to be held beginning 6/15/24-6/17/24. [Brand name of diuretic medication] to be held the morning of the procedure. Record review of Resident #1's order summary dated 06/27/24 revealed in part: The following phone order with order date of 06/12/24 and start date of 06/14/24: Res (resident) will have a implanted loop recorder procedure done 06/17/24. 1) NPO @ midnight Monday 6/17/24. 2) [Brand name of anticoagulant medication] to be held 6/15/24-6/17/24. 3) [Brand name of diuretic medication] to be held 6/17/24 The morning of the procedure. The following phone order with order and start date of 12/25/23: [Brand name of anticoagulant medication] Oral Tablet 5 MG Give 1 tablet by mouth two times a day . The following verbal order with order and start date of 02/12/23: [Brand name of diuretic medication] Oral Tablet 20 MG Give 1 tablet by mouth one time a day for edema. During an observation and interview on 06/26/24 at 09:00 AM Resident #1 was lying on her back in bed. She stated she had the procedure she needed and still had staples in her chest from the procedure. She did not seem to remember she was originally scheduled to have the procedure 27 days earlier than it was done. She stated she did not think she experienced any negative outcome from missing the original appointment. During an interview on 06/27/24 at 02:57 PM SW stated she spoke to RN F regarding Resident #1's appointment on 05/21/24. SW stated RN F put a sticky note on her (SW's) door. SW stated after the appointment was missed she reminded RN F that she (RN F) put the sticky note on her (SW's) door. During an interview on 06/27/24 at 03:00 PM RN F stated she no longer worked for the facility. She stated she remembered the incident with Resident #1 missing her cardiologist appointment/procedure. She stated she was at lunch when the cardiologist office called with the verbal orders regarding Resident #1's pre-procedure. RN F stated an agency nurse named [first name of LVN A] took the orders over the phone and wrote them on a sticky note. RN F stated when she came back from lunch LVN A handed her the sticky note and told RN F she (LVN A) would put the orders in as soon as she received the fax. RN F stated she placed the sticky note on the door of SW's office because SW was responsible for arranging transportation to and from appointments. RN F stated the fax did not come in during that shift and she briefed the on-coming nurse, LVN C, about the orders, the sticky note, and to be watching for the fax. RN F stated she did not think about the orders again because they were the responsibility of LVN A, as she was the one who answered the phone and took the orders. RN F stated it was a few weeks later when the previous ADM asked her about the orders, and she (RN F) told ADM that LVN A had taken the orders and she (RN F) had briefed on-coming LVN C to be watching for the fax. During an interview on 06/27/24 at 03:26 PM LVN C stated she did not remember a conversation with RN F about orders for Resident #1, a sticky note, and a fax. During an interview on 06/28/24 at 08:52 AM RN G stated the nurse who answered the phone and received orders was the one responsible to enter the orders into the EHR. He stated, Because if you give it to someone else it might be miscommunicated and the resident might not get the treatment needed. During an interview on 06/28/24 at 09:12 AM ADON stated it was the responsibility of nurses to enter orders into the EHR. She stated if a nurse received an order over the phone that nurse was the one who should enter the order into the EHR. She stated a resident might not receive the care they need if orders are not entered into the EHR. ADON stated the procedure Resident #1 missed was for an ILR. She stated an ILR helps with the rhythm of her heart. ADON stated Resident #1 did not experience any issues between missing her procedure and receiving the rescheduled procedure 27 days later. On 06/28/24 at 10:43 AM and at 10:45 AM attempts were made to contact LVN A via telephone. She did not answer or respond to text messages. During an interview on 06/28/24 at 11:58 AM MD D stated the procedure Resident #1 missed was for long term monitoring of her heart rhythm. He stated the ILR was just a recording device, not for treatment, but for diagnosis. Record review of facility's investigation into Resident #1's missed appointment revealed a typed sheet of paper signed by the previous ADM. The previous ADM noted a nurse from the cardiologist's office told the previous ADM that she (nurse from cardiologist office) spoke to RN F on 05/14/24 and relayed the orders regarding NPO and holding of anticoagulant and diuretic medication. The nurse from the cardiologist office told the previous ADM that she faxed the orders to the facility on [DATE] as well. Record review of facility in-service taught on 05/21/24 to RN F revealed in part: 1. If you are given orders by any physician, it is your responsibility to make sure the orders are processed and followed through. If the orders require follow through past your shift, it is your responsibility to pass the information on and put it on your communication board in PCC. 2. You are to document in pcc (a kind of EHR software) under progress notes anytime a physician rounds in facility, if your resident goes out to any appointment, or if a physician office calls with any concerns. Record review of facility policy Physician's Orders dated 2015 revealed in part: . Verbal or Telephone Orders by the Physician or Nurse Practitioner 1. Nurse will receive the order and read the order back to the prescriber to ensure it is correct. 3. The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order. Preventing Verbal or Telephone Order Errors: . 5. Immediately transcribe verbal/telephone orders into the patient's medical record or onto a prescription pad as they are being communicated.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the residents to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 5 residents reviewed for abuse/neglect. The facility failed to report an injury of staff inflicted injury (fingernail wound marks to Resident #1's right hand) on 4/16/24 to the Administrator and to the state within 24 hours. This failure could place residents at risk of not having incidents of possible abuse and neglect reviewed and investigated in a timely manner by the facility and state survey agency. This could place residents at risk of continued and/or unrecognized abuse or neglect. Findings included: Record review of Resident #1's admission record dated 05/20/2024 revealed a [AGE] year-old female admitted to the facility on 11/22/2023 with diagnoses that included, but were not limited to, Schizoaffective Disorder Bipolar Type (experience psychotic symptoms like hallucinations or delusions and mood disorder of mania and depression), Metabolic Encephalopathy (neurological disorder caused from systemic illness like kidney failure, diabetes, liver disease, and heart failure), Acute Kidney Failure with Tubular Necrosis ( a condition causing lack of oxygen blood flow to kidneys damaging them), Essential Hypertension abnormally high blood pressure), Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning), Dyspnea ( (difficulty breathing or shortness of breath), and Acute Respiratory Failure with Hypoxia (not enough oxygen in the tissues of your body). Record review of Resident #1's Annual MDS completed on 04/11/24 revealed a BIMS of 03 which indicated severely impaired cognitive functioning. Resident #1 was noted to have impaired cognition due to dementia. Section GG revealed Resident #1utilized a wheelchair for mobility and is totally dependent for toileting, rolling in bed right and left, Section H revealed Resident #1 is always incontinent of bowel and bladder. Record review of Resident #1's care plan with a last review/revision date of 05/01/24 revealed Resident #1 continues to have bladder and bowel incontinence with intervention to check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. Record review of Resident #1's orders dated 04/02/24 through 5/02/24 revealed no mention of Right hand wound or alleged abuse. Record review of facility's investigation of Resident #1's incident revealed it was reported to State authorities on 04/24/24 at 10:45AM. Staff interviews attached to the facility's investigation revealed on 4/16/24 CNA A and CNA B were at Resident 1's bedside to change her. CNA A turned resident towards CNA B. CNA A saw CNA B 'clawing her fingernails into the skin of Resident #1. CNA A reported hearing Resident #1 yelling, Let me go you black bitch. I'm going to report you. It will show up on my skin. CNA A told CNA B she was going to report her. CNA A reported to the Night Charge LVN C. Record review of facility's in-service for staff on reporting following the failure to report Resident #1's bruise revealed a sign- in sheet attached to facility's Abuse/Neglect policy. This policy did include information regarding reporting of abuse and/or neglect. The policy dated 3/29/2018 on page 3, Section E. Reporting.3. a & b states: a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Facility Administrator also included that all incidents are to be reported immediately to the Charge Nurse and the Administrator is to be called. During an interview on 5/20/24 at 5:25AM CNA A stated she received an in-service on 4/24/24 ANE and Reporting in a Timely manner. During an interview by phone on 5/20/24 at 12:01PM with CNA E, she stated she had attended Inservice on ANE, Reporting in a Timely Manner, and Resident Rights. During an observation and interview on 5/20/24 at 900AM Resident# 1 was lying on her left side in her bed with Head of Bed (HOB) raised. 45 degrees watching TV. Alert and friendly, wearing gown and covered with two blankets. Cup of apple juice with straw on bedside table next to resident. When questioned Resident #1 stated she does remember a CNA 'poking' her with her fingernails on the Right hand. Stated she is happy that she doesn't see that CNA anymore. She stated the other CNAs are nice to her. Resident allowed inspection of her Right hand. No wounds or scabs present. Skin is clean, clear, and dry. Resident stated she has no complaints about her care. During an interview on 5/20/24 at 126PM the Administrator was asked about the ANE allegation of Resident #1 which occurred on 4/16/24 but wasn't reported until 4/26/24, why she waited eight days to report from date of the incident. She stated, I wasn't told about it until 4/26/24 by LVN C when we were meeting in my office. She said forgot to tell me. I reported it, got written statements from CNA A and LVN C and started Inservice's on ANE and Reporting in a Timely Manner. During an interview on 5/21/24 at 105PM return phone call from LVN C. She confirmed she was working night shift on 4/16/24 at about 9:00PM CNA A came up to her and told her Resident #1 stated she didn't want CNA B in her room because she was mean. LVN C wrote a statement to verify this interaction with CNA A. She said during the phone interview, she had forgotten about the incident until she was talking with the Administrator on 4/26/24 and told her at that time. During an interview on 5/20/24 at 515AM CNA A was asked what a negative outcome could be for not reporting injuries or incidents from known or unknown sources, she stated, someone could get really sick or hurt badly and no one would know what happened. During an interview on 5/20/24 at 252PM Regional Compliance RN D was asked if the facility has its own policy for reporting ANE. She stated the reporting incident guidelines the facility uses are the State Guidelines. They had an Inservice to train staff to notify Charge Nurses and Administrator immediately if any incidents occur on 4/24/24. Employee Record Review of CNA B shows a hire date of 4/12/24. She was out sick since incident on 4/16/24. Administrator called to suspend her employment. She was incarcerated and was in jail. She has not been in the building since 4/16/24. Record review of facility policy titled Abuse/Neglect and dated 3/29/2018 revealed the following: Definitions of and descriptions of various types of Abuse and Neglect .B. Training through orientation and Inservice's on issues related to abuse/neglect C. Prevention 1. The facility will post in public areas .how to report concerns, incidents, and grievances without fear of retribution.E. Reporting-3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of Resident a. If allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.b. If the allegation does not involve abuse or serious bodily injury, the report must be made with 24 hours of the allegation.

Based on interview and record review; it was determined the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice for 1 of 9 residents reviewed for Quality of Care (Resident #1). LVN A incorrectly administered another resident's [MEDICATION NAME] 25mg sublingual and [MEDICATION NAME] 160mg Extended Release to Resident #1. The significant medication errors caused Resident #1 to have an altered level of consciousness requiring transfer to the local hospital for further evaluation. Due to the significant medication errors, Resident #1 required admission to the hospital from 1/11/18 until 1/15/18 with the [DIAGNOSES REDACTED]. This was determined to be an Immediate Jeopardy situation from 1/10/18 until 1/11/18, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to ensure each resident received treatment and care in accordance with professional standards of practice could 12 residents on Hall C receiving oral medication administration at risk for medication errors, lack of medical treatment, improper medical treatment, [MEDICAL CONDITIONS], and death. Findings include: Record Review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE] with readmission on 1/15/18. She had [DIAGNOSES REDACTED]. Record Review of Resident #1's MDS, dated [DATE], stated: Resident #1 has impaired vision and hearing; BIMS-10; Depression-3; requires extensive 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has no upper or lower extremity impairment; is occasionally incontinent of bowel and bladder; has frequent complaints of pain requiring medication; and is at risk pressure sores. Record Review of the care plan for Resident #1, dated 1/10/18, stated: Resident #1 has vision, hearing, mobility, communication and cognitive impairment, has a urinary tract infection, has oxygen dependence, has an ADL deficit requiring at least 1 person assist, has pain, anxiety, depression, bowel and bladder incontinence, is at risk for injuries related to diabetes, hypertension, anticoagulant use, and is at risk for falls, dehydration, dyspnea, weight loss and pressure sores. Record Review of the physician's orders [REDACTED]. Record Review of Resident #1's MAR, dated 1/1/18 - 1/31/18, stated: On 1/10/18 at 8:00 p.m., LVN A documented she administered [MEDICATION NAME] 20mg (a sleeping aid) by mouth at bedtime. Record Review of the MAR for 1/10/18 for Resident #5 (the MAR of the Resident that revealed the medication and doses that Resident #1 incorrectly received), stated: On 1/10/18 at 7:30 p.m., LVN A documented she administered [MEDICATION NAME] 25mg. On 1/10/18 at 7:00 p.m., LVN A documented she administered [MEDICATION NAME] ([MEDICATION NAME]) Extended Release 160mg. NOTE: This would indicate 160mg of [MEDICATION NAME] Extended Release was given, opposed to [MEDICATION NAME] 80mg ER as indicated in DON interview, Medication Error Forms, and the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing. Record Review of the Individual Control Drug Record for 1/1/18 - 1/31/18 for Resident #5 (the Narcotic Count Sheet of the Resident that revealed the medication and doses that Resident #1 incorrectly received), stated: On 1/10/18 at 7:30 p.m., LVN A documented she administered [MEDICATION NAME] 25mg. On 1/10/18 at 7:00 p.m., LVN A documented she administered [MEDICATION NAME] ([MEDICATION NAME]) Extended Release 160mg. NOTE: This would indicate 160mg of [MEDICATION NAME] Extended Release was given, opposed to [MEDICATION NAME] 80mg ER as indicated in DON interview, Medication Error Forms, and the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing. Record Review of the Nurses' Notes for Resident #1, stated: 1/11/18 at 8:25 a.m.: Resident continues somnolent, ate only a few bites for breakfast then returned to sleep. Charge nurse instructed to continue to monitor VS and report changes to practioner (sic) and DON. - DON 1/11/18 at 9:25 a.m.: This DON spoke with family and they are aware resident received dose of PO [MEDICATION NAME] last night and we have been monitoring resident over night. She remains sleepy this A.M. but is arousable to verbal stimuli. - DON 1/11/18 at 2:00 p.m.: Resident continues somnolent, did not eat lunch. VSS BS WNL. O2 greater than 90 percent on O2 at 3lpm. Notified FNP of continues somnolence (sic). Orders received to administer [MEDICATION NAME] 0.4mg SQ. - DON 1/11/18 at 2:15 p.m.: [MEDICATION NAME] 0.4mg subQ to left deltoid area. Within 20 minutes residents awake and responsive to verbal commands. Resident drinking fluids recognizing family. Charge nurse aware to continue to monitor and report recurrence of somnolence to DON and physician. - DON 1/11/18 at 6:14 p.m.: Repositioned in bed. HOB elevated. Skin pink, warm, dry. Drank few sips of Ensure Vanilla. Few bites of food for CNA. Pushing staff hands away. Makes eye contact with nurse when name is called. Report given to night shift nurse. - LVN B 1/11/18 at 8:00 p.m.: Family requested resident goes to hospital as they feel she has increased right sided weakness and facial drooping. Resident has history of right sided weakness and facial drooping but family feels it is more pronounced. Resident voices I am fine. BP 127/83, HR 78, resp 16, SPO2 94% on O2 at 3LPM. FNP notified of family request to send resident to ER. Ambulance called and report called to ER. - DON During an interview on 1/30/18 at 9:03 a.m., LVN A confirmed she was the nurse that committed the medication errors while caring for Resident #1. When asked how the error occurred, she stated, There is such crunch time because the medications (from pharmacy) are delivered about that time now too so she was in a hurry, and there was no name on the door. I had Resident #1's chart pulled up, and I gave her the wrong medication. They (Resident #1 and Resident #5) were 2 new residents, and I had never seen them before. She confirmed the medication errors were Resident #1 received another Resident's [MEDICATION NAME] and [MEDICATION NAME] ER. LVN A stated she did not remember the doses, but she stated the doses would be on the MAR and Individual Control Drug Record. She stated she did not notify the DON or ADM of the medication error on 1/10/18. She confirmed all residents on Hall C receive oral medications. During a confidential interview on 1/25/18 at 11:31 a.m., Individual D stated she was the nurse caring for Resident #1 at the hospital on [DATE]. She stated Resident #1 was sent to the emergency room to rule out a stroke. She stated Resident #1 was very lethargic and unable to maintain her oxygen saturation without a high concentration mask (an oxygen mask that delivers around 90% oxygen). She stated Resident #1's oxygen level would drop to 70%, if she was changed to a nasal cannula. She stated the CAT scan did not reveal a stroke. She confirmed the admission [DIAGNOSES REDACTED].#1 was given 10 mg [MEDICATION NAME] on 1/10/18 about 8:00 p.m., and Resident #1 was not given [MEDICATION NAME] until 1/11/18 about 2:00 p.m. She stated when she spoke with Resident #1's family, she was informed Resident #1 was transferred to the ER because she was acting different. During a confidential interview on 1/25/18 at 3:09 p.m., Individual C stated Resident #1 received another Resident's medication on 1/10/18 about 8:00 p.m. She stated Resident #1 was not transferred for almost 24 hours after the medication errors. She stated the family was not notified of medication errors until 1/11/18. She stated Resident remained very sleepy and unable to eat or drink without falling asleep before she finished one bite or drink. She stated Resident #1 had virtually no oral intake of fluids for 24 hours, and she stated, they kept trying to drip water into her mouth, but nothing was working. She stated Resident #1 could barely stay awake and would fall asleep mid-conversation. She stated Resident #1 required oxygen via a mask or her oxygen level would drop. She confirmed Resident admitted for several days for a [MEDICATION NAME] Overdose. During an interview on 1/29/18 at 9:13 a.m., Resident #1 was unable to recall any of the events from the evening of 1/10/18 and 1/11/18. She stated the first thing she remembers was being at the hospital a day or so after I was admitted . She stated, They told me I got the wrong medicine, but I don't remember much. I was pretty wiped out. During an interview on 1/29/18 at 10:25 a.m., DON stated she was notified the morning of 1/11/18 that LVN A made the medication errors on the evening of 1/10/18. She stated LVN A stated she gave Resident #1 another Resident's [MEDICATION NAME] 10mg [MEDICATION NAME] about 8:00 p.m. She stated LVN A notified the on-call provider, but failed to notify administration or family. When DON arrived the morning of 1/11/18 and was informed of the medication error, she immediately went to assess Resident #1. She stated Resident #1 was responsive to verbal stimuli and lethargic. She stated the half-life of [MEDICATION NAME] was 4-6 hours. She stated had Resident #1 received [MEDICATION NAME] only, she should have been more awake, and even back to her normal state by the morning of 1/11/18. She stated, something just didn't add up; she shouldn't been that sedated that long. She stated was concerned, and she contacted the provider and obtained a one-time order for [MEDICATION NAME] (a short-term opioid, narcotic reversal agent). DON stated Resident #1 awoke after the [MEDICATION NAME] administration, and she ate a little dinner. DON stated she offered to send (Resident #1) to the ER earlier in the day, but the family refused. That evening someone new in the family came in, and they felt she needed to be evaluated. Resident #1 was sent to the ER due to facial drooping. DON stated Resident #1 was transferred to the hospital about 8:00 p.m. on 1/11/18. She stated that after the medication error, LVN A received 1:1 in-service training and computer based training on 1/11/18. DON stated, during the facility's investigation on 1/11/18, it was discovered LVN A failed to report that Resident #1 received [MEDICATION NAME] 80mg PO Extended Release, in addition to the [MEDICATION NAME] 10mg. DON stated LVN A did not report the [MEDICATION NAME] medication error or do any charting regarding the medication error. When asked how the knowledge of Resident #1 receiving [MEDICATION NAME] 80mg ER, in addition to the [MEDICATION NAME], would have changed her care, she stated, I would have called 911 then, or we could have prevented the transfer by giving her [MEDICATION NAME] every 4 hours. NOTE: DON interview regarding the doses of [MEDICATION NAME] and [MEDICATION NAME] conflicts with the Individual Control Drug Record that indicates [MEDICATION NAME] 160mg ER was given and [MEDICATION NAME] 25mg. During an interview on 1/29/18 at 10:55 a.m., MD confirmed the on-call provider was notified of the [MEDICATION NAME] medication error on 1/10/18. However, he stated he was not notified of the medication error of the [MEDICATION NAME] administration until 1/11/18. He stated [MEDICATION NAME] alone would not have caused the long-acting lethargy and altered level of consciousness experienced by Resident #1. He confirmed [MEDICATION NAME] Extended Release would have caused the lethargy and altered level of consciousness. He stated had he known of the [MEDICATION NAME] medication error on 1/10/18, he would have started the [MEDICATION NAME] much sooner and would have given her several doses. He confirmed the hospital admission ruled out a possible stroke, and confirmed Resident #1 had a Narcotic Overdose. During an interview on 1/29/18 at 2:30 p.m., ADM, DON, and RCN were informed the significant medication errors placed Resident #1 in an Immediate Jeopardy situation from 1/10/18 to 1/11/18. They were informed the sample would be expanded, and the survey would be extended. During an interview on 1/29/18 at 3:46 p.m., DON was asked How do you think this incident (Immediate Jeopardy) in area of neglect and Quality of Care related to Significant Medication Errors came about? She stated, LVN A failed to use the tools and resources that were available. She added, if you don't know the resident, go ask someone. She acted directly outside of our policies, and everything I teach them. During an interview on 1/29/18 at 10:02 a.m., ADM was asked How do you think this incident (Immediate Jeopardy) in area of neglect and Quality of Care related to Significant Medication Errors came about? She stated, Unfortunately, human error by a nurse .She got in a hurry, and she made a human error. She confirmed the incident was not reported to her until 1/11/18, right before morning meeting. Record Review of the Medication Error Form (first report generated after being informed of the [MEDICATION NAME] medication error) for Resident #1, dated 1/11/18, stated: Date of Occurrence: 1/10/18 at 7:30 p.m. Description of Incident: went into the wrong resident's room. Administered wrong medication. [MEDICATION NAME] 25mg sublingual. Remarks by person committing the violation: had 2 new residents. Got them confused. Didn't realize until later in the medication pass. Record Review of the Medication Error Form (second report generated after being informed of the [MEDICATION NAME] ER medication error) for Resident #1, dated 1/12/18, stated: Date of Occurrence: 1/10/18 at 7:30 p.m. Description of Incident: It was discovered during the investigation of another error that nurse also administered [MEDICATION NAME] 80mg extended release to the wrong resident. Remarks by person committing the violation: When asked why she did not disclose terror immediately she reports she was nervous and forgot to tell DON when she asked if other medications were given. Record review of the Hospital's History and Physical, dated 1/12/18, for Resident #1, stated: Chief Complaint EMS stated that Patient was given 10mg of [MEDICATION NAME] at the nursing home accidentally given someone else's medication. History of Present Illness This is an [AGE] year old woman ., apparently it was discovered the patient was given someone else's [MEDICATION NAME] at the nursing home last night which was 10mg of [MEDICATION NAME]. When she arrived to the ER she had altered mentation, somnolence and difficulty speaking. In the ER she responded well to [MEDICATION NAME]. Diagnoses 1. Medication Overdose. Due to the nursing home giving her someone else's medication which was 10 mg of [MEDICATION NAME] apparently. Record Review of the Hospital Medication Orders, dated 1/11/18, for Resident #1, stated: [MEDICATION NAME] ([MEDICATION NAME], a medication used to temporarily reverse opioid, narcotic overdose) 0.4mg Intravenous Push given 1/11/18 at 10:21 p.m. [MEDICATION NAME] ([MEDICATION NAME]) continuous infusion 2mg in [MEDICATION NAME] 5% in Water 500 ml to be run at 5 ml/hr. Oxygen via non-rebreather mask (delivers 100% oxygen). Record Review of the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing completed by the facility, stated: Incident/Conduct On 1/10/18 at 7:30 p.m., (LVN A) administered [MEDICATION NAME] liquid 25mg and [MEDICATION NAME] 80mg (Extended Release) tab to the wrong Resident. She failed to disclose the [MEDICATION NAME] administration to Director of Nursing. Resident remained somnolent for greater than 24 hours requiring hospitalization with a [MEDICATION NAME] drip . Record Review of the facility's policy for Medication Incident Report Procedure, dated 2003, stated: Policy: All medication incidents will be documented. Medication administration errors will be reported to the resident's attending physician and family member. Procedure: 4. The resident's clinical record will include documentation as follows: a. The medication error. b. Name of attending physician, and date and time notified of error. c. Physician subsequent orders. d. Resident's reaction/response/condition. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from 1/10/18 to 1/11/18. The facility took the following actions to correct the non-compliance on 1/11/18: LVN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 5 rights of medication administration was provided to LVN A, training for all staff administering medications was begun covering the 5 rights of medication administration, the Resident Identification while administering medication, policy training for medication errors, and all nursing staff administering medications were audited and observed on the medication cart on three separate occasions by the Director of Nursing, Assistant Director of Nursing, and Regional Corporate Nurse. After discovering LVN A failed to disclose all the incorrect medication administered to Resident #1, she was terminated prior to any further Resident contact. The training for all staff administering medication was conducted over several days and completed by the beginning of the survey on 1/29/18. This surveyor confirmed that the facility's plan of removal was implemented as evidenced by: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the LVN A had not worked since 1/11/18. 3) Interviews with all available licensed nurses and medication aides to confirm they had been audited and observed passing medications on three different occasions by the RCN, DON and ADON. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 1/29/18, documented a census of 12 residents on Hall C with 12 residents receiving oral medications (LVN A interview).

Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 9 residents reviewed for medication errors (Resident #1). LVN A incorrectly administered another resident's [MEDICATION NAME] 25mg sublingual and [MEDICATION NAME] 160mg Extended Release to Resident #1. The significant medication errors caused Resident #1 to have an altered level of consciousness requiring transfer to the local hospital for further evaluation. Due to the significant medication errors, Resident #1 required admission to the hospital from 1/11/18 until 1/15/18 with the [DIAGNOSES REDACTED]. This was determined to be an Immediate Jeopardy situation from 1/10/18 until 1/11/18, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to ensure that residents remained free of any significant medication errors could place 12 residents on Hall C receiving oral medication at risk for shallow breathing, [MEDICAL CONDITION], low blood pressure, poor cerebral perfusion, poor blood circulation to other vital organs, peripheral blood clots, deep vein thrombus, [MEDICAL CONDITION] thrombus, coma and death. Findings include: Record Review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE] with readmission on 1/15/18. She had [DIAGNOSES REDACTED]. Record Review of Resident #1's MDS, dated [DATE], stated: Resident #1 has impaired vision and hearing; BIMS-10; Depression-3; requires extensive 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has no upper or lower extremity impairment; is occasionally incontinent of bowel and bladder; has frequent complaints of pain requiring medication; and is at risk pressure sores. Record Review of the care plan for Resident #1, dated 1/10/18, stated: Resident #1 has vision, hearing, mobility, communication and cognitive impairment, has a urinary tract infection, has oxygen dependence, has an ADL deficit requiring at least 1 person assist, has pain, anxiety, depression, bowel and bladder incontinence, is at risk for injuries related to diabetes, hypertension, anticoagulant use, and is at risk for falls, dehydration, dyspnea, weight loss and pressure sores. Record Review of the physician's orders [REDACTED]. Record Review of Resident #1's MAR, dated 1/1/18 - 1/31/18, stated: On 1/10/18 at 8:00 p.m., LVN A documented she administered [MEDICATION NAME] 20mg (a sleeping aid) by mouth at bedtime. Record Review of the MAR for 1/10/18 for Resident #5 (the MAR of the Resident that revealed the medication and doses that Resident #1 incorrectly received), stated: On 1/10/18 at 7:30 p.m., LVN A documented she administered [MEDICATION NAME] 25mg. On 1/10/18 at 7:00 p.m., LVN A documented she administered [MEDICATION NAME] ([MEDICATION NAME]) Extended Release 160mg. NOTE: This would indicate 160mg of [MEDICATION NAME] Extended Release was given, opposed to [MEDICATION NAME] 80mg ER as indicated in DON interview, Medication Error Forms, and the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing. Record Review of the Individual Control Drug Record for 1/1/18 - 1/31/18 for Resident #5 (the Narcotic Count Sheet of the Resident that revealed the medication and doses that Resident #1 incorrectly received), stated: On 1/10/18 at 7:30 p.m., LVN A documented she administered [MEDICATION NAME] 25mg. On 1/10/18 at 7:00 p.m., LVN A documented she administered [MEDICATION NAME] ([MEDICATION NAME]) Extended Release 160mg. NOTE: This would indicate 160mg of [MEDICATION NAME] Extended Release was given, opposed to [MEDICATION NAME] 80mg ER as indicated in DON interview, Medication Error Forms, and the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing. Record Review of the Nurses' Notes for Resident #1, stated: 1/11/18 at 8:25 a.m.: Resident continues somnolent, ate only a few bites for breakfast then returned to sleep. Charge nurse instructed to continue to monitor VS and report changes to practioner (sic) and DON. - DON 1/11/18 at 9:25 a.m.: This DON spoke with family and they are aware resident received dose of PO [MEDICATION NAME] last night and we have been monitoring resident over night. She remains sleepy this A.M. but is arousable to verbal stimuli. - DON 1/11/18 at 2:00 p.m.: Resident continues somnolent, did not eat lunch. VSS BS WNL. O2 greater than 90 percent on O2 at 3lpm. Notified FNP of continues somnolence (sic). Orders received to administer [MEDICATION NAME] 0.4mg SQ. - DON 1/11/18 at 2:15 p.m.: [MEDICATION NAME] 0.4mg subQ to left deltoid area. Within 20 minutes residents awake and responsive to verbal commands. Resident drinking fluids recognizing family. Charge nurse aware to continue to monitor and report recurrence of somnolence to DON and physician. - DON 1/11/18 at 6:14 p.m.: Repositioned in bed. HOB elevated. Skin pink, warm, dry. Drank few sips of Ensure Vanilla. Few bites of food for CNA. Pushing staff hands away. Makes eye contact with nurse when name is called. Report given to night shift nurse. - LVN B 1/11/18 at 8:00 p.m.: Family requested resident goes to hospital as they feel she has increased right sided weakness and facial drooping. Resident has history of right sided weakness and facial drooping but family feels it is more pronounced. Resident voices I am fine. BP 127/83, HR 78, resp 16, SPO2 94% on O2 at 3LPM. FNP notified of family request to send resident to ER. Ambulance called and report called to ER. - DON During an interview on 1/30/18 at 9:03 a.m., LVN A confirmed she was the nurse that committed the medication errors while caring for Resident #1. When asked how the error occurred, she stated, There is such crunch time because the medications (from pharmacy) are delivered about that time now too so she was in a hurry, and there was no name on the door. I had Resident #1's chart pulled up, and I gave her the wrong medication. They (Resident #1 and Resident #5) were 2 new residents, and I had never seen them before. She confirmed the medication errors were Resident #1 received another Resident's [MEDICATION NAME] and [MEDICATION NAME] ER. LVN A stated she did not remember the doses, but she stated the doses would be on the MAR and Individual Control Drug Record. She stated she did not notify the DON or ADM of the medication error on 1/10/18. She confirmed all residents on Hall C receive oral medications. During a confidential interview on 1/25/18 at 11:31 a.m., Individual D stated she was the nurse caring for Resident #1 at the hospital on [DATE]. She stated Resident #1 was sent to the emergency room to rule out a stroke. She stated Resident #1 was very lethargic and unable to maintain her oxygen saturation without a high concentration mask (an oxygen mask that delivers around 90% oxygen). She stated Resident #1's oxygen level would drop to 70%, if she was changed to a nasal cannula. She stated the CAT scan did not reveal a stroke. She confirmed the admission [DIAGNOSES REDACTED].#1 was given 10 mg [MEDICATION NAME] on 1/10/18 about 8:00 p.m., and Resident #1 was not given [MEDICATION NAME] until 1/11/18 about 2:00 p.m. She stated when she spoke with Resident #1's family, she was informed Resident #1 was transferred to the ER because she was acting different. During a confidential interview on 1/25/18 at 3:09 p.m., Individual C stated Resident #1 received another Resident's medication on 1/10/18 about 8:00 p.m. She stated Resident #1 was not transferred for almost 24 hours after the medication errors. She stated the family was not notified of medication errors until 1/11/18. She stated Resident remained very sleepy and unable to eat or drink without falling asleep before she finished one bite or drink. She stated Resident #1 had virtually no oral intake of fluids for 24 hours, and she stated, they kept trying to drip water into her mouth, but nothing was working. She stated Resident #1 could barely stay awake and would fall asleep mid-conversation. She stated Resident #1 required oxygen via a mask or her oxygen level would drop. She confirmed Resident admitted for several days for a [MEDICATION NAME] Overdose. During an interview on 1/29/18 at 9:13 a.m., Resident #1 was unable to recall any of the events from the evening of 1/10/18 and 1/11/18. She stated the first thing she remembers was being at the hospital a day or so after I was admitted . She stated, They told me I got the wrong medicine, but I don't remember much. I was pretty wiped out. During an interview on 1/29/18 at 10:25 a.m., DON stated she was notified the morning of 1/11/18 that LVN A made the medication errors on the evening of 1/10/18. She stated LVN A stated she gave Resident #1 another Resident's [MEDICATION NAME] 10mg [MEDICATION NAME] about 8:00 p.m. She stated LVN A notified the on-call provider, but failed to notify administration or family. When DON arrived the morning of 1/11/18 and was informed of the medication error, she immediately went to assess Resident #1. She stated Resident #1 was responsive to verbal stimuli and lethargic. She stated the half-life of [MEDICATION NAME] was 4-6 hours. She stated had Resident #1 received [MEDICATION NAME] only, she should have been more awake, and even back to her normal state by the morning of 1/11/18. She stated, something just didn't add up; she shouldn't been that sedated that long. She stated was concerned, and she contacted the provider and obtained a one-time order for [MEDICATION NAME] (a short-term opioid, narcotic reversal agent). DON stated Resident #1 awoke after the [MEDICATION NAME] administration, and she ate a little dinner. DON stated she offered to send (Resident #1) to the ER earlier in the day, but the family refused. That evening someone new in the family came in, and they felt she needed to be evaluated. Resident #1 was sent to the ER due to facial drooping. DON stated Resident #1 was transferred to the hospital about 8:00 p.m. on 1/11/18. She stated that after the medication error, LVN A received 1:1 in-service training and computer based training on 1/11/18. DON stated, during the facility's investigation on 1/11/18, it was discovered LVN A failed to report that Resident #1 received [MEDICATION NAME] 80mg PO Extended Release, in addition to the [MEDICATION NAME] 10mg. DON stated LVN A did not report the [MEDICATION NAME] medication error or do any charting regarding the medication error. When asked how the knowledge of Resident #1 receiving [MEDICATION NAME] 80mg ER, in addition to the [MEDICATION NAME], would have changed her care, she stated, I would have called 911 then, or we could have prevented the transfer by giving her [MEDICATION NAME] every 4 hours. NOTE: DON interview regarding the doses of [MEDICATION NAME] and [MEDICATION NAME] conflicts with the Individual Control Drug Record that indicates [MEDICATION NAME] 160mg ER was given and [MEDICATION NAME] 25mg. During an interview on 1/29/18 at 10:55 a.m., MD confirmed the on-call provider was notified of the [MEDICATION NAME] medication error on 1/10/18. However, he stated he was not notified of the medication error of the [MEDICATION NAME] administration until 1/11/18. He stated [MEDICATION NAME] alone would not have caused the long-acting lethargy and altered level of consciousness experienced by Resident #1. He confirmed [MEDICATION NAME] Extended Release would have caused the lethargy and altered level of consciousness. He stated had he known of the [MEDICATION NAME] medication error on 1/10/18, he would have started the [MEDICATION NAME] much sooner and would have given her several doses. He confirmed the hospital admission ruled out a possible stroke, and confirmed Resident #1 had a Narcotic Overdose. During an interview on 1/29/18 at 2:30 p.m., ADM, DON, and RCN were informed the significant medication errors placed Resident #1 in an Immediate Jeopardy situation from 1/10/18 to 1/11/18. They were informed the sample would be expanded, and the survey would be extended. During an interview on 1/29/18 at 3:46 p.m., DON was asked How do you think this incident (Immediate Jeopardy) in area of neglect and Quality of Care related to Significant Medication Errors came about? She stated, LVN A failed to use the tools and resources that were available. She added, if you don't know the resident, go ask someone. She acted directly outside of our policies, and everything I teach them. During an interview on 1/29/18 at 10:02 a.m., ADM was asked How do you think this incident (Immediate Jeopardy) in area of neglect and Quality of Care related to Significant Medication Errors came about? She stated, Unfortunately, human error by a nurse .She got in a hurry, and she made a human error. She confirmed the incident was not reported to her until 1/11/18, right before morning meeting. Record Review of the Medication Error Form (first report generated after being informed of the [MEDICATION NAME] medication error) for Resident #1, dated 1/11/18, stated: Date of Occurrence: 1/10/18 at 7:30 p.m. Description of Incident: went into the wrong resident's room. Administered wrong medication. [MEDICATION NAME] 25mg sublingual. Remarks by person committing the violation: had 2 new residents. Got them confused. Didn't realize until later in the medication pass. Record Review of the Medication Error Form (second report generated after being informed of the [MEDICATION NAME] ER medication error) for Resident #1, dated 1/12/18, stated: Date of Occurrence: 1/10/18 at 7:30 p.m. Description of Incident: It was discovered during the investigation of another error that nurse also administered [MEDICATION NAME] 80mg extended release to the wrong resident. Remarks by person committing the violation: When asked why she did not disclose terror immediately she reports she was nervous and forgot to tell DON when she asked if other medications were given. Record review of the Hospital's History and Physical, dated 1/12/18, for Resident #1, stated: Chief Complaint EMS stated that Patient was given 10mg of [MEDICATION NAME] at the nursing home accidentally given someone else's medication. History of Present Illness This is an [AGE] year old woman ., apparently it was discovered the patient was given someone else's [MEDICATION NAME] at the nursing home last night which was 10mg of [MEDICATION NAME]. When she arrived to the ER she had altered mentation, somnolence and difficulty speaking. In the ER she responded well to [MEDICATION NAME]. Diagnoses 1. Medication Overdose. Due to the nursing home giving her someone else's medication which was 10 mg of [MEDICATION NAME] apparently. Record Review of the Hospital Medication Orders, dated 1/11/18, for Resident #1, stated: [MEDICATION NAME] ([MEDICATION NAME], a medication used to temporarily reverse opioid, narcotic overdose) 0.4mg Intravenous Push given 1/11/18 at 10:21 p.m. [MEDICATION NAME] ([MEDICATION NAME]) continuous infusion 2mg in [MEDICATION NAME] 5% in Water 500 ml to be run at 5 ml/hr. Oxygen via non-rebreather mask (delivers 100% oxygen). Record Review of the Employee/Peer Review Report Form reporting LVN A to the Texas Board of Nursing completed by the facility, stated: Incident/Conduct On 1/10/18 at 7:30 p.m., (LVN A) administered [MEDICATION NAME] liquid 25mg and [MEDICATION NAME] 80mg (Extended Release) tab to the wrong Resident. She failed to disclose the [MEDICATION NAME] administration to Director of Nursing. Resident remained somnolent for greater than 24 hours requiring hospitalization with a [MEDICATION NAME] drip . Record Review of the facility's policy for Medication Incident Report Procedure, dated 2003, stated: Policy: All medication incidents will be documented. Medication administration errors will be reported to the resident's attending physician and family member. Procedure: 4. The resident's clinical record will include documentation as follows: a. The medication error. b. Name of attending physician, and date and time notified of error. c. Physician subsequent orders. d. Resident's reaction/response/condition. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from 1/10/18 to 1/11/18. The facility took the following actions to correct the non-compliance on 1/11/18: LVN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 5 rights of medication administration was provided to LVN A, training for all staff administering medications was begun covering the 5 rights of medication administration, the Resident Identification while administering medication, policy training for medication errors, and all nursing staff administering medications were audited and observed on the medication cart on three separate occasions by the Director of Nursing, Assistant Director of Nursing, and Regional Corporate Nurse. After discovering LVN A failed to disclose all the incorrect medication administered to Resident #1, she was terminated prior to any further Resident contact. The training for all staff administering medication was conducted over several days and completed by the beginning of the survey on 1/29/18. This surveyor confirmed that the facility's plan of removal was implemented as evidenced by: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the LVN A had not worked since 1/11/18. 3) Interviews with all available licensed nurses and medication aides to confirm they had been audited and observed passing medications on three different occasions by the RCN, DON and ADON. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 1/29/18, documented a census of 12 residents on Hall C with 12 residents receiving oral medications (LVN A interview).

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors. The facility failed to ensure nursing staff administered the correct dose of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. Staff administered 250mg of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment instead of the prescribed 25mg, which was 10 times the prescribed dosage of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment, to Resident #1 on 5 separate occasions over a 34 hour period. This failure resulted in Resident #1 receiving an overdose of [MEDICATION NAME] ([MEDICATION NAME]) which caused Resident #1 to experience stomach pain, dizziness, low heart rate and blood pressure and decreased oxygen saturation level. Resident #1 required emergency medical treatment. This failure resulted in identification of an IJ (Immediate Jeopardy) on 8/1/15. While the immediacy of the IJ was removed on 8/2/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to ensure staff administer correct doses of medication has the potential to affect 1resident in the facility by placing the resident at risk of overdosing on medications, having adverse reactions and having a decline in health due to complications from not administering medications as ordered. Findings include: Record review of Resident #1's clinical record revealed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS quarterly assessment completed 4/22/15 documented a BIMS score of 15, cognitively intact. MDS indicated Resident #1 required limited 1 person physical assists with ADLs. Record review of the pharmacy packing slip dated 7/29/15 documented 3 - 1ml syringes of [MEDICATION NAME] 25mg/0.lml were delivered to the facility on [DATE] at 3:28 p.m. Each 1ml syringe contained 10 doses of [MEDICATION NAME] ([MEDICATION NAME]) topical gel. There were 2 additional unused 1ml syringes of [MEDICATION NAME] ([MEDICATION NAME]) topical gel present in the C Hall medication cart. Record review of Resident #1's July 2015 Medication Administration Record (MAR) documents: [MEDICATION NAME] Gel ([MEDICATION NAME]) [MEDICATION NAME] Dose: 25mg = (0.1ml) topical Q6H PRN nausea with vomiting. According to the July 2015 MAR, Resident #1 received [MEDICATION NAME] Gel topical on the following dates and times administered by: 7/30/15 at 3:10 a.m. administered by LVN F 7/30/15 at 9:30 a.m. administered by MA H 7/30/15 at 4:30 p.m. administered by MA H 7/31/15 at 3:10 a.m. administered by LVN F 7/31/15 at 1:00 p.m. administered by MA H. Record review of the facility's Resident Transfer Form completed 7/31/15 at 1:45 p.m. by LVN B documents Resident #1 was transferred from the facility to the emergency room due to lethal dose [MEDICATION NAME]. Record review of MA H's Witness Statement completed 7/31/15 documents: On Friday 7/31/15 (Resident #1) ask me for medicine and I said what kind of medicine and she said for vomiting but I don't want the pill. I want the topical [MEDICATION NAME]. (sic) And I don't read right how much I have to put on her and I put the whole syringe on both wrist. (This would equal 250mg of [MEDICATION NAME] topical ointment). During an interview on 8/1/15 at 11:27 a.m., MA H stated on 7/30/15 Resident #1 asked for a lot of meds because she didn't feel well. She was throwing up. She would not take [MEDICATION NAME]. She wanted the topical [MEDICATION NAME]. When I went to give the [MEDICATION NAME], there was 3 syringes in the baggie. I used a whole syringe (1ml=250mg) - half on one wrist, half on the other. I used a whole syringe each time I gave the [MEDICATION NAME]. MA H stated she did not look at the specific order. I watched the night nurse (LVN F) do it and I gave it just like she did, the whole syringe. When asked about the three administration times on 7/30/15 and 7/31/15 that she administered the medication, MA H stated she gave the whole syringe all three times (7/30/15 at 9:30 a.m. and 4:30 p.m. and 7/31/15 at 1:00 p.m.). MA H stated LVN F didn't train or explain it to me. I just watched her. MA H stated ADON stated she (MA H) had been giving the medication wrong because MA H had been administering the entire contents of the 1ml syringe (250mg) each time MA H administered the medication and Hospice staff caught it when LVN B called for a refill. MA H stated they used all three syringes that were delivered on 7/29/15 and there aren't any left in the facility. MA H stated she was currently suspended for giving the wrong dose of [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 8/1/15 at 10:50 a.m., DON stated the topical [MEDICATION NAME] should be in the top drawer of the medication cart. When asked about the medication error, DON stated, I guess they couldn't read the syringe. During an interview on 8/1/15 at 12:00pm, DON stated she was notified of the situation on 7/31/15 about 1:00 p.m. or 2:00 p.m. but she could not come to the facility immediately as she was out of town. DON stated MA H was suspended immediately but staff were unable to contact LVN F. During an interview on 8/1/15 at 12:50 p.m., NP stated topical [MEDICATION NAME] should not be administered more often that every four hours with a maximum dose per administration not to exceed 25mg. NP stated the dose that Resident #1 received was too much and adverse reactions could include sedation and decreased respirations. NP stated the facility's DON needed to address the situation. During an interview on 8/1/15 at 1:19pm, DON stated we should have initiated inservices immediately. The facility DON was notified on 8/1/15 at 1:19 p.m. that an IJ situation had been identified due to the above failures. During an interview on 8/1/15 at 1:55 p.m., Resident #1 stated, They gave me too much [MEDICATION NAME] in 36 hours - 750mg. I feel I am owed an apology. Yesterday I kept feeling worse and worse. I had severe stomach pains. Resident #1 expressed she is afraid of the long term effects of the [MEDICATION NAME]. During an interview on 8/1/15 at 2:50pm, ADO agreed that the mistakes in the administration of Resident #1's topical [MEDICATION NAME] constituted an IJ situation, stating, that was negligent and this is an IJ. During an interview on 8/2/15 at 2:45pm, LVN F stated when she is administering topical medications, she will determine the dose by looking at the resident's MAR prior to administering the dose. LVN F stated she works on C hall and Resident #1 is the only resident receiving a topical medication. LVN F stated Resident #1's topical [MEDICATION NAME] goes on the wrist/inner arm. I'd administer half of the syringe to each of her wrists. LVN F demonstrated with a 1ml syringe, saying I put half on one arm, half on the other. I did it this way every time. When asked to read the drug dosage directions on Resident #1's MAR, LVN F stated, I gave her way too much medication. Record review of the facility's undated Medication Administration Policy documents: Staff should follow the 5 Rights of Medication Administration - right resident, right medication, right dose, right route and right time. Never administer a medication based on your judgment of the dose. Check the drug card against your MAR. Verify you are administering the right drug at the right time to the right person. The facility's Plan of Removal was provided by the Administrator on 8/1/15 at 5:44 p.m. The Plan of Removal was accepted at 12:10 p.m. on 8/2/15. The facility took the following actions to remove the IJ: Problem: Medication Errors. Resident #1 received a dose of [MEDICATION NAME] topical gel that exceeded the physician ordered dosage on 5 different occasions. Goal: All residents are to receive medication dosages as ordered by the physician. All residents who receive medication are at risk as being affected by this practice. Interventions: -Resident #1's physician was notified of a change in condition and was sent to the hospital on [DATE]. -A medication error report was completed on 7/31/15 for the 5 administrations of the wrong dose of [MEDICATION NAME] gel. -The medication aide and nurse who administered the wrong dosages of [MEDICATION NAME] were suspended pending investigation and will be terminated. -The physician orders [REDACTED]. -Licensed nurses and medication aides were in-serviced by the DON and/or ADON starting on 8/1/15. All will be in-serviced by 8/4/15. Until then, no medication aide nor charge nurse will be allowed to assume their duties of patient care until they have been inserviced on the following: -The 5 rights of medication administration. Right patient, right route, right medication, right time and right dose. -How to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration. -To verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR. -To notify the ADON or DON if they had any question related to the medication administration. -Medication aides were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. -Charge nurses were in-serviced to notify the physician for an needed clarifications or questions. -MD medical director of the facility was notified of the immediate jeopardy on 8/1/15. -Incident was self-reported to DADS on 8/1/15. -All staff will be in-serviced on Abuse and Neglect by 8/4/15. Monitoring: The DON and/or ADON will observe a portion of a medication pass at least 5 times per week to ensure compliance and to ensure that the 5 rights of medication administration are being followed. The DON and/or ADON will have at least 5 nurses or medication aides demonstrate how to administer a dose of a topical medication from a syringe. At this time, no resident has this type of order, so this will be a mock med administration. Findings will be reviewed in the facility QA committee and changes to the plan will be made as required. Verification of the facility's Plan of Removal: Interviews with 10 different staff members (3 RNs, 3 LVNs and 4 MAs) on 8/2/15 from 12:22 p.m. to 2:42 p.m. revealed all had been inserviced on the 5 rights of medication administration, how to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration, to verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR and to notify the ADON or DON if they had any question related to the medication administration. The Medication Aides interviewed stated they were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. LVNs and RNs interviewed stated they were in-serviced to notify the physician for any needed clarifications or questions. Observations of two Medication Aides using 2 medication carts completing medication pass on 8/2/15 from 12:30 p.m. to 2:00 p.m. revealed the Medication Aides consistently followed facility procedure when administering medications to residents. On 8 /2/15 at 3:08 p.m., the ADM was notified the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of harm and scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. The DON stated on 8/1/15 there was one resident in the facility with topical medications prescribed.

Based on interview and record review, the administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being for 1 of 5 residents (Resident #1) reviewed for neglect, in that: The Administrator failed to ensure the facility's policies and procedures to prohibit neglect were implemented, causing Resident #1 to receive an overdose of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. The Administrator and DON failed to supervise nursing staff to ensure significant medication errors did not occur. The DON failed to effectively train and monitor staff to ensure medications were administered in the correct dosage. The Administrator and DON failed to ensure nursing staff administered the correct dose of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. Staff administered 10 times the prescribed dosage of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment to Resident #1 on 5 separate occasions over a 34 hour period. As a result of the overdose of [MEDICATION NAME] ([MEDICATION NAME]), Resident #1 experienced stomach pain, dizziness, low heart rate and blood pressure and decreased oxygen saturation level and required emergency medical treatment. This failure resulted in identification of an IJ (Immediate Jeopardy) on 8/1/15. While the immediacy of the IJ was removed on 8/2/15, the facility remained out of compliance at a severity level harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to ensure staff administer correct doses of medication has the potential to affect 1 resident in the facility by placing the resident at risk of overdosing on medications, having adverse reactions and having a decline in health due to complications from not administering medications as ordered. Findings include: During an interview on 8/1/15 at 12:00pm, DON stated she was notified of the situation on 7/31/15 about 1:00 p.m. or 2:00 p.m. but she could not come to the facility immediately as she was out of town. DON stated MA H was suspended immediately but staff were unable to contact LVN F. During an interview on 8/1/15 at 1:19pm, DON stated we should have initiated inservices immediately. During an interview on 8/2/15 at 1:01pm, DON stated she did not think the situation would be an immediate jeopardy because it was only one person. Because her life was in danger, it was probable cause it should be an IJ. During an interview on 8/2/15 at 3:40pm, ADM stated the immediate jeopardy was a result of human error on their part. Employees were lax in carrying out their duties. Record review of staff inservices completed April 2015 to August 2015 revealed no inservices were completed on the proper administration of topical ointments, specifically [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. Record review of Resident #1's clinical record revealed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS quarterly assessment completed 4/22/15 documented a BIMS score of 15, cognitively intact. MDS indicated Resident #1 required limited 1 person physical assists with ADLs. Record review of the pharmacy packing slip dated 7/29/15 documented 3 - 1ml syringes of [MEDICATION NAME] 25mg/0.lml were delivered to the facility on [DATE] at 3:28 p.m. Each 1ml syringe contained 10 doses of [MEDICATION NAME] ([MEDICATION NAME]) topical gel. There were 2 additional unused 1ml syringes of [MEDICATION NAME] topical gel present in the C Hall medication cart. Record review of Resident #1's July 2015 Medication Administration Record (MAR) documents: [MEDICATION NAME] Gel ([MEDICATION NAME]) [MEDICATION NAME] Dose: 25mg = (0.1ml) topical Q6H PRN nausea with vomiting. According to the July 2015 MAR, Resident #1 received [MEDICATION NAME] Gel topical on the following dates and times administered by: 7/30/15 at 3:10 a.m. administered by LVN F 7/30/15 at 9:30 a.m. administered by MA H 7/30/15 at 4:30 p.m. administered by MA H 7/31/15 at 3:10 a.m. administered by LVN F 7/31/15 at 1:00 p.m. administered by MA H. Record review of the facility's Resident Transfer Form completed 7/31/15 at 1:45 p.m. by LVN B documents Resident #1 was transferred from the facility to the emergency room due to lethal dose [MEDICATION NAME]. Record review of MA H's Witness Statement completed 7/31/15 documents: On Friday 7/31/15 (Resident #1) ask me for medicine and I said what kind of medicine and she said for vomiting but I don't want the pill. I want the topical [MEDICATION NAME]. (sic)And I don't read right how much I have to put on her and I put the whole syringe on both wrist. (This would equal 250mg of [MEDICATION NAME] topical ointment). During an interview on 8/1/15 at 11:27 a.m., MA H stated on 7/30/15 Resident #1 asked for a lot of meds because she didn't feel well. She was throwing up. She would not take [MEDICATION NAME]. She wanted the topical [MEDICATION NAME]. When I went to give the [MEDICATION NAME], there was 3 syringes in the baggie. I used a whole syringe (1ml=250mg) - half on one wrist, half on the other. I used a whole syringe each time I gave the [MEDICATION NAME]. MA H stated she did not look at the specific order. I watched the night nurse (LVN F) do it and I gave it just like she did, the whole syringe. When asked about the three administration times on 7/30/15 and 7/31/15 that she administered the medication, MA H stated she gave the whole syringe all three times (7/30/15 at 9:30 a.m. and 4:30 p.m. and 7/31/15 at 1:00 p.m.) MA H stated LVN F didn't train or explain it to me. I just watched her. MA H stated ADON told her she (MA H) had been giving the medication wrong because MA H had been administering the entire contents of the 1ml syringe (250mg) each time MA H administered the medication and Hospice staff caught it when LVN B called for a refill. MA H stated they used all three syringes that were delivered on 7/29/15 and there aren't any left in the facility. MA H stated she was currently suspended for giving the wrong dose of [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 8/1/15 at 10:50 a.m., DON stated the topical [MEDICATION NAME] should be in the top drawer of the medication cart. When asked about the medication error, DON stated, I guess they couldn t read the syringe. During an interview on 8/1/15 at 12:50 p.m., NP stated topical [MEDICATION NAME] should not be administered more often that every four hours with a maximum dose per administration not to exceed 25mg. NP stated the dose that Resident #1 received was too much and adverse reactions could include sedation and decreased respirations. NP stated the facility's DON needed to address the situation. The facility DON was notified on 8/1/15 at 1:19 p.m. that an IJ situation had been identified due to the above failures. During an interview on 8/1/15 at 1:55 p.m., Resident #1 stated, They gave me too much [MEDICATION NAME] in 36 hours - 750mg. I feel I am owed an apology. Yesterday I kept feeling worse and worse. I had severe stomach pains. Resident #1 expressed she is afraid of the long term effects of the [MEDICATION NAME]. During an interview on 8/1/15 at 2:50pm, ADO agreed that the mistakes in the administration of Resident #1's topical [MEDICATION NAME] constituted an IJ situation, stating, that was negligent and this is an IJ. During an interview on 8/2/15 at 2:45pm, LVN F stated when she is administering topical medications, she will determine the dose by looking at the resident's MAR prior to administering the dose. LVN F stated she works on C hall and Resident #1 is the only resident receiving a topical medication. LVN F stated Resident #1's topical [MEDICATION NAME] goes on the wrist/inner arm. I'd administer half of the syringe to each of her wrists. LVN F demonstrated with a 1ml syringe, saying, I put half on one arm, half on the other. I did it this way every time. When asked to read the drug dosage directions on Resident #1's MAR, LVN F stated, I gave her way too much medication. Record review of the facility's Abuse/Neglect Policy dated 1/8/03 documented: Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or others. Record review of the facility's undated Medication Administration Policy documents: Staff should follow the 5 Rights of Medication Administration - right resident, right medication, right dose, right route and right time. Never administer a medication based on your judgment of the dose. Check the drug card against your MAR. Verify you are administering the right drug at the right time to the right person. The facility's Plan of Removal was provided by the Administrator on 8/1/15 at 5:44 p.m. The Plan of Removal was accepted at 12:10 p.m. on 8/2/15. The facility took the following actions to remove the IJ: Problem: Medication Errors. Resident #1 received a dose of [MEDICATION NAME] topical gel that exceeded the physician ordered dosage on 5 different occasions. Goal: All residents are to receive medication dosages as ordered by the physician. All residents who receive medication are at risk as being affected by this practice. Interventions: -Resident #1's physician was notified of a change in condition and was sent to the hospital on [DATE]. -A medication error report was completed on 7/31/15 for the 5 administrations of the wrong dose of [MEDICATION NAME] gel. -The medication aide and nurse who administered the wrong dosages of [MEDICATION NAME] were suspended pending investigation and will be terminated. -The physician orders [REDACTED]. -Licensed nurses and medication aides were in-serviced by the DON and/or ADON starting on 8/1/15. All will be in-serviced by 8/4/15. Until then, no medication aide nor charge nurse will be allowed to assume their duties of patient care until they have been inserviced on the following: -The 5 rights of medication administration. Right patient, right route, right medication, right time and right dose. -How to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration. -To verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR. -To notify the ADON or DON if they had any question related to the medication administration. -Medication aides were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. -Charge nurses were in-serviced to notify the physician for an needed clarifications or questions. -MD, medical director of the facility was notified of the immediate jeopardy on 8/1/15. -Incident was self-reported to DADS on 8/1/15. -All staff will be in-serviced on Abuse and Neglect by 8/4/15. Monitoring: The DON and/or ADON will observe a portion of a medication pass at least 5 times per week to ensure compliance and to ensure that the 5 rights of medication administration are being followed. The DON and/or ADON will have at least 5 nurses or medication aides demonstrate how to administer a dose of a topical medication from a syringe. At this time, no resident has this type of order, so this will be a mock med administration. Findings will be reviewed in the facility QA committee and changes to the plan will be made as required. Verification of facility's Plan of Removal: Interviews with 10 different staff members (3 RNs, 3 LVNs and 4 MAs) on 8/2/15 from 12:22 p.m. to 2:42 p.m. revealed all had been inserviced on the 5 rights of medication administration, how to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration, to verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR and to notify the ADON or DON if they had any question related to the medication administration. The Medication Aides interviewed stated they were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. LVNs and RNs interviewed stated they were in-serviced to notify the physician for any needed clarifications or questions. Observations of two Medication Aides using 2 medication carts completing medication pass on 8/2/15 from 12:30 p.m. to 2:00 p.m. revealed the Medication Aides consistently followed facility procedure when administering medications to residents. On 8/2/15 at 3:08 p.m., the ADM was notified the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. On 8/1/15, the DON stated there was one resident in the facility with topical medications prescribed.

Based on observation, interview and record review, the facility failed to implement their policies and procedures that prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect. The facility failed to ensure nursing staff administered the correct dose of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. Staff administered 10 times the prescribed dosage of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment to Resident #1 on 5 separate occasions over a 34 hour period. As a result of the overdose of [MEDICATION NAME] ([MEDICATION NAME]), Resident #1 experienced stomach pain, dizziness, low heart rate and blood pressure and decreased oxygen saturation level and required emergency medical treatment. This failure resulted in identification of an IJ (Immediate Jeopardy) on 8/1/15. While the immediacy of the IJ was removed on 8/2/15, the facility remained out of compliance at a severity level harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to ensure staff administer correct doses of medication has the potential to affect 1 resident in the facility by placing the resident at risk of overdosing on medications, having adverse reactions and having a decline in health due to complications from not administering medications as ordered. Findings include: Record review of Resident #1's clinical record revealed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS quarterly assessment completed 4/22/15 documented a BIMS score of 15, cognitively intact. MDS indicated Resident #1 required limited 1 person physical assists with ADLs. Record review of the pharmacy packing slip dated 7/29/15 documented 3 - 1ml syringes of [MEDICATION NAME] 25mg/0.lml were delivered to the facility on [DATE] at 3:28 p.m. Each 1ml syringe contained 10 doses of [MEDICATION NAME] ([MEDICATION NAME]) topical gel. There were 2 additional unused1ml syringes of [MEDICATION NAME] topical gel present in the C Hall medication cart. Record review of Resident #1's July 2015 Medication Administration Record (MAR) documents: [MEDICATION NAME] Gel ([MEDICATION NAME]) [MEDICATION NAME] Dose: 25mg = (0.1ml) topical Q6H PRN nausea with vomiting. According to the July 2015 MAR, Resident #1 received [MEDICATION NAME] Gel topical on the following dates and times administered by: 7/30/15 at 3:10 a.m. administered by LVN F 7/30/15 at 9:30 a.m. administered by MA H 7/30/15 at 4:30 p.m. administered by MA H 7/31/15 at 3:10 a.m. administered by LVN F 7/31/15 at 1:00 p.m. administered by MA H. Record review of the facility's Resident Transfer Form completed 7/31/15 at 1:45 p.m. by LVN B documents Resident #1 was transferred from the facility to the emergency room due to lethal dose [MEDICATION NAME]. Record review of MA H's Witness Statement completed 7/31/15 documents: On Friday 7/31/15 (Resident #1) ask me for medicine and I said what kind of medicine and she said for vomiting but I don't want the pill. I want the topical [MEDICATION NAME]. (sic) And I don't read right how much I have to put on her and I put the whole syringe on both wrist. (This would equal 250mg of [MEDICATION NAME] topical ointment). During an interview on 8/1/15 at 11:27 a.m., MA H stated on 7/30/15 Resident #1 asked for a lot of meds because she didn't feel well. She was throwing up. She would not take [MEDICATION NAME]. She wanted the topical [MEDICATION NAME]. When I went to give the [MEDICATION NAME], there was 3 syringes in the baggie. I used a whole syringe (1ml=250mg) - half on one wrist, half on the other. I used a whole syringe each time I gave the [MEDICATION NAME]. MA H stated she did not look at the specific order. I watched the night nurse (LVN F) do it and I gave it just like she did, the whole syringe. When asked about the three administration times on 7/30/15 and 7/31/15 that she administered the medication, MA H stated she gave the whole syringe (1ml=250mg) all three times (7/30/15 at 9:30 a.m. and 4:30 p.m and 7/31/15 at 1:00 p.m.) MA H stated LVN F didn't train or explain it to me. I just watched her. MA H stated ADON stated she (MA H) had been giving the medication wrong because MA H had been administering the entire contents of the 1ml syringe (250mg) each time MA H administered the medication and Hospice staff caught it when LVN B called for a refill. MA H stated they used all three syringes that were delivered on 7/29/15 and there aren't any left in the facility. MA H stated she was currently suspended for giving the wrong dose of [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 8/1/15 at 10:50 a.m., DON stated the topical [MEDICATION NAME] should be in the top drawer of the medication cart. When asked about the medication error, DON stated, I guess they couldn't read the syringe. During an interview on 8/1/15 at 12:00pm, DON stated she was notified of the situation on 7/31/15 about 1:00 p.m. or 2:00 p.m. but she could not come to the facility immediately as she was out of town. DON stated MA H was suspended immediately but staff were unable to contact LVN F. During an interview on 8/1/15 at 12:50 p.m., NP stated topical [MEDICATION NAME] should not be administered more often than every four hours with a maximum dose per administration not to exceed 25mg. NP stated the dose that Resident #1 received was too much and adverse reactions could include sedation and decreased respirations. NP stated the facility's DON needed to address the situation. During an interview on 8/1/15 at 1:19pm, DON stated we should have initiated inservices immediately. The facility DON was notified on 8/1/15 at 1:19 p.m. that an IJ situation had been identified due to the above failures. During an interview on 8/1/15 at 1:55 p.m., Resident #1 stated, They gave me too much [MEDICATION NAME] in 36 hours - 750mg. I feel I am owed an apology. Yesterday I kept feeling worse and worse. I had severe stomach pains. Resident #1 expressed she is afraid of the long term effects of the [MEDICATION NAME]. During an interview on 8/1/15 at 2:50pm, ADO agreed that the mistakes in the administration of Resident #1's topical [MEDICATION NAME] constituted an IJ situation, stating that was negligent and this is an IJ. During an interview on 8/2/15 at 2:45pm, LVN F stated when she is administering topical medications, she will determine the dose by looking at the resident's MAR prior to administering the dose. LVN F stated she works on C hall and Resident #1 is the only resident receiving a topical medication. LVN F stated Resident #1's topical [MEDICATION NAME] goes on the wrist/inner arm. I'd administer half of the syringe (0.5ml=125mg) to each of her wrists. LVN F demonstrated with a 1ml syringe, saying I put half on one arm, half on the other. I did it this way every time. When asked to read the drug dosage directions on Resident #1's MAR, LVN F stated, I gave her way too much medication. Record review of the facility's Abuse/Neglect Policy dated 1/8/03 documented: Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or others. Record review of the facility's undated Medication Administration Policy documents: Staff should follow the 5 Rights of Medication Administration - right resident, right medication, right dose, right route and right time. Never administer a medication based on your judgment of the dose. Check the drug card against your MAR. Verify you are administering the right drug at the right time to the right person. The facility's Plan of Removal was provided by the Administrator on 8/1/15 at 5:44 p.m. The Plan of Removal was accepted at 12:10 p.m. on 8/2/15. The facility took the following actions to remove the IJ: Problem: Medication Errors. Resident #1 received a dose of [MEDICATION NAME] topical gel that exceeded the physician ordered dosage on 5 different occasions. Goal: All residents are to receive medication dosages as ordered by the physician. All residents who receive medication are at risk as being affected by this practice. Interventions: -Resident #1's physician was notified of a change in condition and was sent to the hospital on [DATE]. -A medication error report was completed on 7/31/15 for the 5 administrations of the wrong dose of [MEDICATION NAME] gel. -The medication aide and nurse who administered the wrong dosages of [MEDICATION NAME] were suspended pending investigation and will be terminated. -The physician orders [REDACTED]. -Licensed nurses and medication aides were in-serviced by the DON and/or ADON starting on 8/1/15. All will be in-serviced by 8/4/15. Until then, no medication aide nor charge nurse will be allowed to assume their duties of patient care until they have been inserviced on the following: -The 5 rights of medication administration. Right patient, right route, right medication, right time and right dose. -How to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration. -To verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR. -To notify the ADON or DON if they had any question related to the medication administration. -Medication aides were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. -Charge nurses were in-serviced to notify the physician for an needed clarifications or questions. -MD, medical director of the facility was notified of the immediate jeopardy on 8/1/15. -Incident was self-reported to DADS on 8/1/15. -All staff will be in-serviced on Abuse and Neglect by 8/4/15. Monitoring: The DON and/or ADON will observe a portion of a medication pass at least 5 times per week to ensure compliance and to ensure that the 5 rights of medication administration are being followed. The DON and/or ADON will have at least 5 nurses or medication aides demonstrate how to administer a dose of a topical medication from a syringe. At this time, no resident has this type of order, so this will be a mock med administration. Findings will be reviewed in the facility QA committee and changes to the plan will be made as required. Verification of the facility's Plan of Removal: Interviews with 10 different staff members (3 RNs, 3 LVNs and 4 MAs) on 8/2/15 from 12:22 p.m. to 2:42 p.m. revealed all had been inserviced on the 5 rights of medication administration, how to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration, to verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR and to notify the ADON or DON if they had any question related to the medication administration. The Medication Aides interviewed stated they were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. LVNs and RNs interviewed stated they were in-serviced to notify the physician for any needed clarifications or questions. Observations of two Medication Aides using 2 medication carts completing medication pass on 8/2/15 from 12:30 p.m. to 2:00 p.m. revealed the Medication Aides consistently followed facility procedure when administering medications to residents. On 8 /2/15 at 3:08 p.m., the ADM was notified the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. On 8/1/15. the DON stated there was one resident in the facility with topical medications prescribed.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures that prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect. The facility failed to ensure nursing staff administered the correct dose of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment. Staff administered 10 times the prescribed dosage of [MEDICATION NAME] ([MEDICATION NAME]) topical ointment to Resident #1 on 5 separate occasions over a 34 hour period. As a result of the overdose of [MEDICATION NAME] ([MEDICATION NAME]), Resident #1 experienced stomach pain, dizziness, low heart rate and blood pressure and decreased oxygen saturation level and required emergency medical treatment. This failure resulted in identification of an IJ (Immediate Jeopardy) on 8/1/15. While the immediacy of the IJ was removed on 8/2/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to ensure staff administer correct doses of medication has the potential to affect 1 resident in the facility by placing the resident at risk of overdosing on medications, having adverse reactions and having a decline in health due to complications from not administering medications as ordered. Findings include: Record review of the facility's Abuse/Neglect Policy dated 1/8/03 documented: Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or others. Record review of the facility's undated Medication Administration Policy documents: Staff should follow the 5 Rights of Medication Administration - right resident, right medication, right dose, right route and right time. Never administer a medication based on your judgment of the dose. Check the drug card against your MAR. Verify you are administering the right drug at the right time to the right person. Record review of Resident #1's clinical record revealed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS quarterly assessment completed 4/22/15 documented a BIMS score of 15, cognitively intact. MDS indicated Resident #1 required limited 1 person physical assists with ADLs. Record review of the pharmacy packing slip dated 7/29/15 documented 3 - 1ml syringes of [MEDICATION NAME] 25mg/0.lml were delivered to the facility on [DATE] at 3:28 p.m. Each 1ml syringe contained 10 doses of [MEDICATION NAME] ([MEDICATION NAME]) topical gel. There were 2 additional unused 1ml syringes of [MEDICATION NAME] topical get present in C Hall medication cart. Record review of Resident #1's July 2015 Medication Administration Record (MAR) documents: [MEDICATION NAME] Gel ([MEDICATION NAME]) [MEDICATION NAME] Dose: 25mg = (0.1ml) topical Q6H PRN nausea with vomiting. According to the July 2015 MAR, Resident #1 received [MEDICATION NAME] Gel topical on the following dates and times administered by: 7/30/15 at 3:10 a.m. administered by LVN F 7/30/15 at 9:30 a.m. administered by MA H 7/30/15 at 4:30 p.m. administered by MA H 7/31/15 at 3:10 a.m. administered by LVN F 7/31/15 at 1:00 p.m. administered by MA H. Record review of the facility's Resident Transfer Form completed 7/31/15 at 1:45 p.m. by LVN B documents Resident #1 was transferred from the facility to the emergency room due to lethal dose [MEDICATION NAME]. Record review of MA H's Witness Statement completed 7/31/15 documents: On Friday 7/31/15 (Resident #1) ask me for medicine and I said what kind of medicine and she said for vomiting but I don't want the pill. I want the topical [MEDICATION NAME]. (sic) And I don ' t read right how much I have to put on her and I put the whole syringe on both wrist. (This would equal 250mg of [MEDICATION NAME] topical ointment). During an interview on 8/1/15 at 11:27 a.m., MA H stated on 7/30/15 Resident #1 asked for a lot of meds because she didn't feel well. She was throwing up. She would not take [MEDICATION NAME]. She wanted the topical [MEDICATION NAME]. When I went to give the [MEDICATION NAME], there was 3 syringes in the baggie. I used a whole syringe (1ml=250mg) - half on one wrist, half on the other. I used a whole syringe each time I gave the [MEDICATION NAME]. MA H stated she did not look at the specific order. I watched the night nurse (LVNF) do it and I gave it just like she did, the whole syringe. When asked about the three administration times on 7/30/15 and 7/31/15 that she administered the medication, MA H stated she gave the whole syringe all three times (7/30/15 at 9:30 a.m. and 4:30 p.m. and 7/31/15 at 1:00pm). MA H stated LVN F didn't train or explain it to me. I just watched her. MA H stated ADON stated she (MA H) had been giving the medication wrong because MA H had been administering the entire contents of the 1ml syringe (250mg) each time MA H administered the medication and Hospice staff caught it when LVN B called for a refill. MA H stated they used all three syringes that were delivered on 7/29/15 and there aren't any left in the facility. MA H stated she was currently suspended for giving the wrong dose of [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 8/1/15 at 10:50 a.m., DON stated the topical [MEDICATION NAME] should be in the top drawer of the medication cart. When asked about the medication error, DON stated, I guess they couldn't read the syringe. During an interview on 8/1/15 at 12:00pm, DON stated she was notified of the situation on 7/31/15 about 1:00 p.m. or 2:00 p.m. but she could not come to the facility immediately as she was out of town. DON stated MA H was suspended immediately but staff were unable to contact LVN F. During an interview on 8/1/15 at 12:50 p.m., NP stated topical [MEDICATION NAME] should not be administered more often that every four hours with a maximum dose per administration not to exceed 25mg. NP stated the dose that Resident #1 received was too much and adverse reactions could include sedation and decreased respirations. NP stated the facility's DON needed to address the situation. During an interview on 8/1/15 at 1:19pm, DON stated we should have initiated inservices immediately. The facility DON was notified on 8/1/15 at 1:19 p.m. that an IJ situation had been identified due to the above failures. During an interview on 8/1/15 at 1:55 p.m., Resident #1 stated, They gave me too much [MEDICATION NAME] in 36 hours - 750mg. I feel I am owed an apology. Yesterday I kept feeling worse and worse. I had severe stomach pains. Resident #1 expressed she is afraid of the long term effects of the [MEDICATION NAME]. During an interview on 8/1/15 at 2:50pm, ADO agreed that the mistakes in the administration of Resident #1's topical [MEDICATION NAME] constituted an IJ situation, stating that was negligent and this is an IJ. During an interview on 8/2/15 at 2:45pm, LVN F stated when she is administering topical medications, she will determine the dose by looking at the resident's MAR prior to administering the dose. LVN F stated she works on C hall and Resident #1 is the only resident receiving a topical medication. LVN F stated Resident #1's topical [MEDICATION NAME] goes on the wrist/inner arm. I'd administer half of the syringe to each of her wrists. LVN F demonstrated with a 1ml syringe, saying I put half on one arm, half on the other. I did it this way every time. When asked to read the drug dosage directions on Resident #1's MAR, LVN F stated, I gave her way too much medication. The facility's Plan of Removal was provided by the Administrator on 8/1/15 at 5:44 p.m. The Plan of Removal was accepted at 12:10 p.m. on 8/2/15. The facility took the following actions to remove the IJ: Problem: Medication Errors. Resident #1 received a dose of [MEDICATION NAME] topical gel that exceeded the physician ordered dosage on 5 different occasions. Goal: All residents are to receive medication dosages as ordered by the physician. All residents who receive medication are at risk as being affected by this practice. Interventions: -Resident #1's physician was notified of a change in condition and was sent to the hospital on [DATE]. -A medication error report was completed on 7/31/15 for the 5 administrations of the wrong dose of [MEDICATION NAME] gel. -The medication aide and nurse who administered the wrong dosages of [MEDICATION NAME] were suspended pending investigation and will be terminated. -The physician orders [REDACTED]. -Licensed nurses and medication aides were in-serviced by the DON and/or ADON starting on 8/1/15. All will be in-serviced by 8/4/15. Until then, no medication aide nor charge nurse will be allowed to assume their duties of patient care until they have been inserviced on the following: -The 5 rights of medication administration. Right patient, right route, right medication, right time and right dose. -How to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration. -To verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR. -To notify the ADON or DON if they had any question related to the medication administration. -Medication aides were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. -Charge nurses were in-serviced to notify the physician for an needed clarifications or questions. -MD, medical director of the facility was notified of the immediate jeopardy on 8/1/15. -Incident was self-reported to DADS on 8/1/15. -All staff will be in-serviced on Abuse and Neglect by 8/4/15. Monitoring: The DON and/or ADON will observe a portion of a medication pass at least 5 times per week to ensure compliance and to ensure that the 5 rights of medication administration are being followed. The DON and/or ADON will have at least 5 nurses or medication aides demonstrate how to administer a dose of a topical medication from a syringe. At this time, no resident has this type of order, so this will be a mock med administration. Findings will be reviewed in the facility QA committee and changes to the plan will be made as required. Verification of facility's Plan of Removal: Interviews with 10 different staff members (3 RNs, 3 LVNs and 4 MAs) on 8/2/15 from 12:22 p.m. to 2:42 p.m. revealed all had been inserviced on the 5 rights of medication administration, how to administer [MEDICATION NAME] gel and how to measure the correct ordered dose for administration, to verify the medication label against the MAR for each medication administration to help ensure the 5 rights and at no time should they administer a medication without verifying with the MAR and to notify the ADON or DON if they had any question related to the medication administration. The Medication Aides interviewed stated they were in-serviced to notify the licensed nurse for any potential discrepancies or questions related to the med administration. LVNs and RNs interviewed stated they were in-serviced to notify the physician for any needed clarifications or questions. Observations of two Medication Aides using 2 medication carts completing medication pass on 8/2/15 from 12:30 p.m. to 2:00 p.m. revealed the Medication Aides consistently followed facility procedure when administering medications to residents. On 8 /2/15 at 3:08 p.m., the ADM was notified the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of harm and a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. On 8/1/15, the DON stated there was one resident in the facility with topical medications prescribed.