Every finding on record at Grace Nursing Home

Based on observations, interviews, and record review, the facility failed to ensure a resident who required assistance with ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#23) of 2 residents reviewed for ADL's. The facility failed to trim and clean Resident #23's fingernails. Review of the facility's policy dated 02/2025 and titled, Fingernails/Toenails, Care of, revealed the following, in part:Policy: To promote cleanlinessPurpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines1. Nail care includes daily cleaning and regular trimming.Review of the Resident #23's Medical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, and Depression. Review of Resident #23's Quarterly MDS with ARD of 10/07/2025 revealed BIMS of 15, which indicated he was cognitively intact. Review of Resident #23's current Care Plan revealed the following in part:Problem: self-care deficit r/t needs assistance with ADLs, decreased mobility Intervention: Assist with ADLs as needed, bathe and shampoo hair, call light in reach, Personal hygiene-assist On 12/08/2025 at 1:29 p.m., an observation was made of Resident #23's fingernails. Fingernails were observed to be long and dirty. On 12/09/2025 8:13 a.m., an observation was made of Resident #23's fingernails. Fingernails were noted to be long with a black substance under 6 of his fingernails. Further observation revealed his fingernails were approximately 0.5 cm past the finger tip of all 10 fingers. On 12/09/2025 at 8:13 a.m., an interview was conducted with Resident #23. Resident #23 stated he had asked more than once for nails to be cleaned and trimmed. He further stated he would like for his nails to be cleaned and trimmed. On 12/09/2025 9:29 a.m., an observation was made of Resident #23's nails with S6LPN. She observed and confirmed Resident #23's nails were long and dirty and should have been cleaned and trimmed.On 12/10/2025 at 1:37 p.m., an interview was conducted with S2DON. He stated nursing staff were responsible for keeping the nails of non-diabetic residents cleaned and trimmed. He stated he expected all staff to keep each resident's nails cleaned and trimmed.

Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 (#102) residents reviewed for tube feeding. The facility failed to ensure:1. The enteral feeding flush bag was appropriately labeled with an opened date and time; and2. The enteral feeding pump was on and running continuously in accordance with physician orders.Review of Resident #102's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy, Dysphagia, Disturbances of Salivary Secretion, and Gastro-Esophageal Reflux Disease. Review of Resident #102's current Physician Orders revealed, in part, the following: Order date: 08/19/2025 - Enteral Feed Order: Peptamin 1.5 @ 60 mL/hr continuous every 24 hours, flush peg with 40 mL/hr via auto flush system. On 12/08/2025 at 10:01 a.m., an observation was made of Resident #102 in his room, sitting upright in his wheel chair, asleep. Resident #102's enteral feeding pump was noted to be off and not running. Further inspection revealed the feeding flush bag was not labeled with an opened date and time. On 12/08/2025 at 10:31 a.m., an observation was made of Resident #102's enteral feeding pump, formula and flush bags with S4LPN. On 12/08/2025 at 10:32 a.m., an interview was conducted with S4LPN. She stated she was responsible for Resident #102's care. She confirmed the Enteral feeding pump was not on or running and should have been. She further confirmed the feeding flush bag was not labeled with an opened date and time and should have been. On 12/09/2025 at 1:47 p.m., an interview was conducted with S2DON. He stated he expected his nursing staff to label all feeding flush bags with an opened date and time. He further confirmed Resident #102's feedings were to be administered continuously as physician ordered and Resident #102's pump should not have been off.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident received necessary respiratory care consistent with professional standards of practice for 2 (#39 and #68) of 3 residents reviewed for respiratory care. The facility failed to ensure:1. Resident #39's Oxygen tubing was labeled with the date last changed on her portable oxygen tank.2. Resident #39's portable oxygen tank administered the appropriate amount of oxygen in accordance with physician orders.3. Resident #68's pre-filled water reservoir was labeled with the date last changed. Review of the facility's policy with a revision date of 03/2025 and titled Departmental (Respiratory Therapy) revealed the following in part: General Guidelines 1. Pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every thirty (30) days, or when the water level becomes low. Steps in the procedure Infection Control Considerations Related to Oxygen Administration: 2. [NAME] the bottle along with the tubing with the current date upon opening. 1. Review of Resident #39's Clinical Record revealed she was recently re-admitted to the facility on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit. Review of Resident #39's current Physician Orders revealed the following, in part: Order Date: 12/08/2025-Change O2 tubing/mask weekly and PRN, every day shift, every Sunday. On 12/08/2025 at 10:14 a.m., an observation was made of Resident #39 sitting upright in her wheelchair in the dining room. Resident #39 was observed utilizing a portable oxygen tank and nasal cannula for oxygen administration. Further observation revealed the oxygen tubing was not labeled with the date last changed. On 12/08/2025 at 10:32 a.m., an observation was made of the Resident #39's portable oxygen tank and tubing with S4LPN. On 12/08/2025 at 10:33 a.m., an interview was conducted with S4LPN. S4LPN confirmed Resident #39's oxygen tubing was not labeled with the date last changed and should have been. 2. Review of Resident #39's Clinical Record revealed she was recently re-admitted to the facility on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit. Review of Resident #39's current Physician Orders revealed the following, in part: Order Date: 12/06/2025- Oxygen 2L/min per nasal cannula or mask PRN. On 12/08/2025 at 10:14 a.m., an observation was made of Resident #39 sitting upright in her wheelchair in the dining room. Resident #39 was noted utilizing a portable oxygen tank and nasal cannula for oxygen administration. Further observation revealed oxygen was being administered at a rate of 3L/min. On 12/08/2025 at 10:32 a.m., an observation was made of Resident #39's portable oxygen tank and tubing with S4LPN. On 12/08/2025 at 10:33 am, an interview was conducted with S4LPN. S4LPN confirmed Resident #39's oxygen was being administered at a rate of 3L/min and should have been at a rate of 2L/min. 3. Review of Resident #68's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included the following in part: Pulmonary Fibrosis, Interstitial Pulmonary Disease, Emphysema, Chronic Obstructive Pulmonary Disease, and Sleep Apnea. Review of the most recent MDS with an ARD of 10/01/2025 revealed a BIMS of 13, which indicated Resident #68 was cognitively intact. Review of Resident #68's current Physician Orders revealed the following, in part: Start date 08/27/2025 - Oxygen at 2 Liters per Nasal Cannula, as needed. On 12/08/2025 at 10:30 a.m., an observation was made of Resident #68's pre-filled water reservoir connected to her oxygen concentrator. Further observation revealed the water reservoir was not labeled with the open date. On 12/08/2025 at 10:45 a.m., an observation was made with S3LPN of Resident #68's pre-filled water reservoir connected to the oxygen concentrator. She confirmed the bottle was not labeled with the open date and should have been On 12/10/2025 at 1:37 p.m., an interview was conducted with S2DON. He stated he expected all nursing staff to ensure they were accurately carrying out physician orders. He confirmed nursing staff should have checked Resident #39's physician orders prior to setting the flow rate on the portable tank to ensure the appropriate amount of oxygen was administered. He further confirmed staff should label all oxygen tubing and oxygen humidifier water bottles with an open date.

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication rooms were free of expired medications / supplements for 1 (MR2) of 2 medication rooms reviewed. There were 119 residents residing in the facility.Findings: On 12/08/2025 at 9:22 a.m., an observation was made of MR2 with S3LPN. The following items were found:1 Bottle of Senna Liquid 8.8 mg / 5 ml Chocolate Flavor with an expiration date of 04/2025;1 Bottle of Adult Vitamin Tablets with an expiration date of 05/2025;1 Bottle of Adult Vitamin Tablets with an expiration date of 07/2025;2 Bottles of Adult Vitamin Tablets with an expiration date of 09/2025; and1 Bottle of Adult Vitamin Tablets with an expiration date 10/2025. On 12/08/2025 at 9:22 a.m., an interview was conducted with S3LPN. S3LPN confirmed the aforementioned medications /supplements were expired. S3LPN confirmed expired medications / supplements should not be kept in the medication storage room. On 12/09/2025 at 1:26 p.m., an interview was conducted with S2DON. S2DON stated nurses are responsible for checking the expiration dates on medications. S2DON confirmed there should be no expired medications / supplements in the medication room.

Based on observation, interviews and record reviews, the facility failed to ensure each resident had the right to be free from neglect for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for neglect. S3CNA and S4CNA neglected Resident #1 when they failed to verify Resident #1's transfer status prior to transferring Resident #1, who required mechanical lift for transfer. This deficient practice resulted in actual physical harm on 05/13/2025 at approximately 12:30 p.m., when S3CNA and S4CNA transferred Resident #1, who required a mechanical lift, by using a draw sheet without verifying what type of transfer assistance Resident #1 required. Following the transfer, Resident #1 yelled out in pain and an x-ray of the left shoulder was ordered. Resident #1 was diagnosed with a Closed Displaced Fracture of Proximal End of Left Humerus and was sent to the local emergency room for evaluation and treatment. After returning to the facility, Resident #1 continued to have pain and required her left arm to remain in a sling. Findings: Review of the facility's policy titled Identifying Neglect with a revision date of 09/2022, revealed the following in part: Policy Interpretation and Implementation: 4. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, mental anguish or emotional distress. 7. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as: d. staff lack of knowledge of the needs of the resident. 9. Examples of failures to provide care and services to the resident that result in neglect include: f. Failure of staff to implement resident interventions, even when residents are assessed and interventions are identified in the care plan. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired and her cognitive skills for daily decision making were severely impaired. Further review revealed in Section GG that the resident was dependent on staff for chair/bed transfers. Review of Resident #1's current care plan revealed a focus problem of self-care deficit related to needs assistance with ADLs, decreased mobility, diagnosis of Parkinsons, and right BKA (below knee amputation). Interventions included the following in part, requires Hoyer lift with 2 staff assistance for transfers. Review of the nurse's notes dated 05/13/2025 revealed the following in part: 05/13/2025 at 1:46 p.m.: Resident #1 screaming in pain regarding left shoulder. Resident unable to move shoulder without significant pain. Notified Nurse Practitioner, x-ray ordered. Tylenol given. Resident states nothing happened to shoulder, that it just hurts. Resident did get up into chair today and sat up for a few hours. No falls noted. Signed by S5LPN. 05/13/2025 at 4:51 p.m.: See x-ray results. Nurse practitioner notified. Ordered to be sent to emergency room for evaluation and pain management. Signed by S5LPN. Review of the facility's investigation report revealed in part the following: 05/13/2025 Resident #1 was brought to her room by S3CNA and S4CNA around 12:30 p.m. At this time, she was being transferred to the bed by S3CNA and S4CNA. She began to yell after the transfer. The CNAs reported to nurse the resident was yelling after she was put in bed. The nurse then assessed her and gave her some Tylenol. She notified the Nurse Practitioner who ordered an x-ray. X-ray showed fracture to left humerus. She was sent out acute to emergency room and later returned that night. 05/14/2025 DON and Administrator interviewed S3CNA and S4CNA. It was determined by administration after interviewing both CNAs the fracture happened after lunch when being put to bed. After interviewing both employees, it was determined that they did not transfer her using the Hoyer lift. Review of the hospital after visit summary dated 05/13/2025, revealed the resident was seen in the emergency department for left arm pain where she was diagnosed with a closed displaced fracture of proximal end of left humerus. Further review revealed she received the following treatment x-ray left Humerus and x-ray of left shoulder. Prescribed Hydrocodone-acetaminophen for pain. She was seen by orthopedic surgery who recommended a sling and follow-up outpatient. Resident is to wear sling until able to follow-up with orthopedic surgery. On 06/11/2025 at 1:00 p.m., a telephone interview was conducted with S5LPN. She stated she was the nurse assigned to Resident #1 on 05/13/2025 and confirmed Resident #1 had obtained a fracture to her left arm that day after being transferred. She stated she had taken care of the resident since then and Resident #1 complained of pain to her arm periodically. S5LPN said when the resident complained of pain, she administered PRN pain medication as ordered. On 06/11/2025 at 3:10 p.m., an observation and interview was conducted with Resident #1. The resident was observed lying in bed with a sling to her left arm. Resident #1 stated she hurt her arm but, did not know how. The resident said her arm hurt sometimes, but not right now. When asked if she received any pain medication when her arm hurt she answered yes. Resident #1 was unable to provide any more information due to being cognitively impaired. On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated that morning she and S3CNA went into Resident #1's room and transferred her from her bed to her wheelchair using a draw sheet. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for transfers. She stated normally, when she was unsure of what type of assistance a resident required with transferring, she would ask the nurse, another CNA, or look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA bought Resident #1 back into her room and used the same draw sheet to transfer her back to the bed. She stated when they moved her back into bed, the resident yelled out in pain. She stated at that time the nurse practitioner was walking down the hall, heard the resident yell, went in the room to assess the resident, and came out saying that the resident complained of left arm pain. S4CNA stated she told Resident #1's nurse about the resident complaining her arm was in pain. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her from the bed to her wheelchair and from her wheelchair back to bed with the draw sheet, and should have. On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet from the bed to her wheelchair and she remained in her wheelchair until after lunch. She stated after lunch she and S4CNA brought Resident #1 back to her room and transferred her back into bed from her wheelchair using the draw sheet. She stated when they transferred Resident #1 back to bed, she yelled out in pain. S3CNA stated she reported it to the nurse practitioner, who was in the hallway, and S5LPN. She stated the resident had not complained of pain prior to being transferred back to bed after lunch. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day. On 06/11/2025 at 3:33 p.m., an interview was conducted with S6LPN. She stated she was responsible for completing resident care plans. She reviewed Resident #1's care plan and confirmed the resident required a hoyer lift with 2 staff assistance for transfers. She stated if a resident was care planned for Hoyer lift transfers then she expected staff to transfer the resident using a Hoyer lift with 2 staff assistance. On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed and when they did, she yelled out and stated she was in pain. He stated once the results of the x-ray showed Resident #1's left arm was fractured he began to further investigate the situation. He stated after speaking with both S3CNA and S4CNA, it was determined Resident #1's fracture occurred after lunch when S3CNA and S4CNA transferred Resident #1 from her wheelchair back to bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated if a resident was care planned for Hoyer lift transfers then he expected staff to transfer the resident using a Hoyer lift with 2 staff assist. He stated if staff did not know what type of assistance a resident required he expected staff to look in the kiosk and verify what type of assistance is required and provide care according to the resident's plan of care. He stated he had not considered what occurred with Resident #1 to be neglect. He stated only S3CNA and S4CNA received in-service training on the proper way to use a hoyer lift and ensuring to look in the kiosk to verify transfer assistance required for residents prior to transfer. He confirmed no monitoring of staff was done after the in-service training was completed. On 06/12/2025 at 1:50 p.m., an interview was conducted with S1ADM. He stated he did not consider staff failing to transfer Resident #1 according to her care plan and sustaining an injury during improper transfer as neglect. He stated he considered it to be a mistake and stated S3CNA and S4CNA were in-serviced afterwards. He confirmed no monitoring of staff was done after in-service training was completed.

Based on record review and interviews, the facility failed to ensure an allegation involving neglect was reported to the State Survey Agency in the required timeframe for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for neglect. Findings: Review of the facility's policy titled Abuse Investigation and Reporting with a revision date of 06/2022, revealed the following in part: Reporting: 1. All alleged violations involving neglect will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of neglect will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Review of the facility's policy titled Identifying Neglect with a revision date of 09/2022, revealed the following in part: Policy Interpretation and Implementation: 4. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, mental anguish or emotional distress. 7. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as: d. staff lack of knowledge of the needs of the resident. 9. Examples of failures to provide care and services to the resident that result in neglect include: f. Failure of staff to implement resident interventions, even when residents are assessed and interventions are identified in the care plan. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired. Further review revealed in Section GG that the resident was dependent on staff for chair/bed transfers. Review of the facility's investigation report revealed in part the following: 05/13/2025 Resident #1 was brought to her room by S3CNA and S4CNA around 12:30 p.m. At this time, she was being transferred to the bed by S3CNA and S4CNA. She began to yell after the transfer. The CNAs reported to nurse the resident was yelling after she was put in bed. The nurse then assessed her and gave her some Tylenol. She notified the Nurse Practitioner who ordered an x-ray. X-ray showed fracture to left humerus. She was sent out acute to emergency room and later returned that night. 05/14/2025 DON and Administrator interviewed S3CNA and S4CNA. It was determined by administration after interviewing both CNAs the fracture happened after lunch when being put to bed. After interviewing both employees, it was determined that they did not transfer her using the Hoyer lift. Review of the facility's self-reported incidents to the state agency revealed no entries related to Resident #1's incident on 05/13/2025. Review of the hospital after visit summary dated 05/13/2025, revealed the resident was seen in the emergency department for left arm pain where she was diagnosed with a closed displaced fracture of proximal end of left humerus. On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for ADLs or transfers. She stated normally, when she was unsure of what type of assistance a resident required with transferring, she would ask the nurse, another CNA or look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA brought Resident #1 back into her room and used a draw sheet to transfer her back to the bed. She stated when they moved her back into bed, she yelled out in pain. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her and should have. On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet after lunch. She stated when they transferred Resident #1 back to bed, she yelled out in pain. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day. She confirmed failing to look up the correct way to transfer the Resident and the resident sustaining an injury at transfer was considered neglect. On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed and when they did, she yelled out and stated she was in pain. He stated once the results of the x-ray showed Resident #1's left arm was fractured he began to further investigate the situation and had notified S1ADM. He stated after speaking with both S3CNA and S4CNA, it was determined Resident #1's fracture occurred after lunch when S3CNA and S4CNA transferred Resident #1 from her wheelchair back to bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated he had not considered what occurred with Resident #1 to be neglect. He stated the Administrator was responsible for reporting incidents of alleged neglect to the state survey agency. On 06/12/2025 at 1:50 p.m., an interview was conducted with S1ADM. He stated he was responsible for reporting any allegations of neglect, to the State Survey Agency within 2 hours. He stated S2DON had notified him of the incident that occurred on 05/13/2025 the day it occurred. He stated he did not consider staff failing to transfer Resident #1 properly according to her care plan and sustaining an injury during improper transfer as neglect. He stated he considered it to be a mistake. He confirmed he had not reported the incident that occurred with Resident #1 to the State Survey Agency.

Based on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) residents reviewed in the sample. The facility failed to ensure Resident #1 was transferred properly using the mechanical lift with two person assistance. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired and her cognitive skills for daily decision making were severely impaired. Further review revealed in Section GG that the resident was dependent in chair/bed transfers. Review of Resident #1's current care plan revealed a focus problem of self-care deficit related to needs assistance with ADLs, decreased mobility, diagnosis of Parkinsons, and right BKA (below knee amputation). Interventions included the following in part, requires Hoyer lift with 2 staff assistance for transfers. On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated that morning she and S3CNA went into Resident #1's room and transferred her from her bed to her wheelchair using a draw sheet. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for ADLs or transfers. She stated normally, when she was unsure of what type of assistance a resident require with transferring, she would ask the nurse, another CNA or she would look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA bought Resident #1 back into her room and used the same draw sheet to transfer her back to the bed. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her from the bed to her wheelchair and from her wheelchair back to bed with the draw sheet, and should have. On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet from the bed to her wheelchair and she remained in her wheelchair until after lunch. She stated after lunch she and S4CNA brought Resident #1 back to her room and transferred her back into bed from her wheelchair using the draw sheet. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day. On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated if a resident was care planned for Hoyer lift transfers then he expected staff to transfer the resident using a Hoyer lift with 2 staff assist. He stated if staff did not know what type of assistance a resident required he expected staff to look in the kiosk and verify what type of assistance is required and provide care according to the resident's plan of care.

Based on interviews and record review, the facility failed to develop a Comprehensive Person-Centered Care Plan for 1 (#2) of 3 (#1, #2, #3) sampled residents reviewed. This was evidenced by the facility failing to ensure Resident #2's Comprehensive Person-Centered Care Plan was accurately updated to reflect his current Physician's Orders. Findings: Review of Resident #2's Clinical Record revealed he was admitted on [DATE] with diagnoses including, in part, the following: Dysphagia following Cerebral Infarction and Gastrostomy. Review of Resident #2's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/04/2025 revealed the provider assessed the resident as having a Brief Interview for Mental Status (BIMS) of 2, which indicated the resident had severe cognitive impairment. Review of Resident #2's current active Physician's Orders revealed the following, in part: Enteral feeds - every shift related to Hyperglycemia, Glucerna 1.5 @ 60 cc/hr continuous per Percutaneous Endoscopic Gastrostomy (PEG) with 40ml/hr flush (Start date 12/29/2024) NPO Diet, NPO texture (Start date 04/20/2024) Review of Resident #2's current Care Plan revealed the following, in part: Focus: Potential for alteration in nutrition related to PEG tube - at risk for aspiration: NPO: Formula changed to Glucerna 1.5 @ 60 ml/hr with 60 m/hr water flush. Intervention: Administer medications as ordered Focus: Preference for customary routines Interventions: Allow resident to have snacks between meals. On 04/01/2025 at 12:56 p.m., an interview was conducted with S2LPN. She stated she and one other nurse were responsible for resident care plans. She reviewed Resident #2's Physician's Orders and current Care Plan and confirmed the order for 60 ml/hr water flush did not reflect the current care plans 40ml/hr water flush and Resident #2's Care Plan Intervention of allowing snacks between meals did not reflect his current NPO Physician's Order. She confirmed Resident #2's care plan should accurately reflect his Physician's Orders and did not. On 04/01/2025 at 2:06 p.m., an interview was conducted with S1DON. He reviewed Resident #2's current Physician's Orders and current Care Plan. S1DON confirmed the Care Plan did not accurately reflect the Physician's Orders and should have.

Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure expired medications were not available for administration to residents on 1 (Med Cart 1) of 4 (Med Cart 1, 2, 3, and 4) medication carts observed. Findings: Review of the facility's policy titled Medication Labeling and Storage dated 02/2023 revealed the following: Medication Storage: 2. Nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. An observation was made on 10/14/2024 at 2:37 p.m. with S4LPN of Cart 1. The following was observed: 1 bottle of lubricant eye drops dated 08/21/2024, no expiration date; 1 bottle of eye drops dated 08/10/2024, no expiration date; 1 nasal inhaler with an expiration date of 08/17/2024. An interview was conducted with S4LPN on 10/14/2024 at 2:40 p.m. She reviewed the aforementioned two bottles of eye drops and stated eye drop medications were only used for 30 days. S4LPN confirmed expired nasal inhaler should have been removed from Med Cart 1 and was not. She confirmed medications were in use. An interview was conducted with S2DON on 10/14/2024 at 3:00 p.m. He stated staff nurses were responsible for checking medication carts for expired medications. He further stated nurses who administered medications were responsible for checking expiration dates before administering medications. S2DON confirmed the aforementioned two bottles of eye drops were beyond the 30 day use and nasal inhaler was expired, should have been discarded, and had not been.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 3 (#35, #107, and #271) of 3 (#35, #107, and #271) residents reviewed for infection control. The facility failed to ensure: 1. Staff implemented appropriate EBP (Enhanced Barrier Precautions) for Resident #107 and #271); and 2. Staff used proper hand hygiene during wound care for Resident #107, 3. Staff used proper infection control technique when providing catheter care for Resident #35. Findings: Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, revealed the following, in part: Policy Interpretation and Implementation: 1. EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms MDRO (Multi-Drug Resistant Organism) to residents. 3. Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include: c.) transferring. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. Effective implementation of EBR requires the availability of PPE supplies at the point of care. 1. Resident #107 Review of Resident #107's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer to Left Heel, Pressure Ulcer to Right Heel Unstageable, Osteomyelitis, and Need for Assistance With Personal Care. On 10/15/2024 at 12:35 p.m., an observation was conducted of S7CNA's transfer of Resident #107 from a stretcher back into his bed. Resident #107 had an EBP sign and PPE in a caddy on his door. S7CNA failed to don gloves or gown prior to transferring Resident #107. On 10/15/2024 at 12:40 p.m., an interview was conducted with S7CNA. She confirmed Resident #107 was under Enhanced Barrier Precautions for having wounds, and she transferred Resident #107 without donning gloves or a gown, but should have. On 10/16/2024 at 3:06 p.m., an interview was conducted with S2DON. S2DON confirmed transferring a resident who was on EBP was considered high-contact patient care and staff should have worn gown and gloves when transferring a resident on Enhanced Barrier Precautions. Resident #271 Review of Resident #271's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis of Stable Burst Fracture and Urinary Retention. On 10/14/2024 at 2:00 p.m., an observation was made of Resident #271 with an indwelling urinary catheter. Resident #271's door had no sign notifying staff or visitors EBP were in place and no PPE supplies were at his door. On 10/14/2024 at 2:10 p.m., an interview was conducted with S4LPN. S4LPN confirmed there was no EBP Precaution Sign or PPE supplies present for Resident #271, and should have been. On 10/14/2024 at 2:40 p.m., an interview was conducted with S2DON. S2DON stated residents with urinary catheters should have EBP measures implemented. S2DON further confirmed nursing staff should have implemented EBP on admission, and did not. 2. Review of facilities policy titled Handwashing/Hand Hygiene, dated August 2019, revealed, in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 6. Use of Alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water for the following situations: g. before handling clean dressings, gauze pads etc. k. after handling used dressings m. after removing gloves Resident#107 On 10/15/2024 at 3:10 p.m., an observation was conducted of S6LPN performing wound care for Resident #107. S6LPN applied clean gloves removed soiled dressings to bilateral lower extremities. S6LPN removed soiled gloves and applied clean gloves without performing proper hand hygiene. She then cleansed the right heel with wound cleanser, removed soiled gloves and applied clean gloves without performing proper hand hygiene. S6LPN dressed the right heel with a clean dressing, removed soiled gloves and applied clean gloves without performing hand hygiene. S6LPN cleansed left heel with wound cleanser, removed soiled gloves and applied clean gloves without performing proper hand hygiene. S6LPN dressed left heel with a clean dressing, removed soiled gloves and gown, washed hands with soap and water, and left Resident #107's room. On 10/15/2024 at 3:35 p.m., an interview was conducted with S6LPN. S6LPN confirmed she did not have hand sanitizer in resident's room and did not perform appropriate hand hygiene in between glove changes during Resident #107's wound care. S6LPN confirmed she should have used hand sanitizer or washed her hands with soap and water between glove changes. On 10/16/2024 at 3:06 p.m., an interview was conducted with S2DON. S2DON confirmed proper hand hygiene was using hand sanitizer or washing hands with soap and water. S2DON confirmed all staff should be performing proper hand hygiene between glove changes. 3. Review of the facility's policy titled Perineal Care, with a revision date of 02/2018, revealed the following, in part: Steps in the Procedure For a male resident: c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Resident #35 Review of Resident #35's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, Urinary Tract Infections, Chronic Kidney Disease Stage 3, Acute Cystitis with Hematuria, and Neuromuscular Dysfunction of Bladder. Review of Resident #35's Physician's Orders revealed the following in part: Clean indwelling catheter with soap and water daily and as needed. On 10/16/2024 at 10:32 a.m., an observation was made of S15CNA performing catheter care on Resident #35. [NAME] residue was observed on Resident #35's catheter tubing where the catheter tubing connects to the catheter bag near the resident's knees. S15CNA cleaned Resident #35's catheter tubing, starting at the brown residue near the resident's knees and wiped up the tubing going toward his urethra. On 10/16/2024 at 10:39 a.m., immediately following the above observation, an interview was conducted with S15CNA. She confirmed she performed Resident #35's catheter care incorrectly using improper technique, and stated she should have cleaned the catheter tubing starting at the catheter insertion site then away from the resident. On 10/16/2024 at 3:55 p.m., an interview was conducted with S2DON. He stated when performing catheter care on a resident, staff should clean catheter tubing starting at the insertion site then away from the resident, and it is not appropriate to clean the tubing going towards the insertion site. 47732 48333 49343

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1(#50) of 24 residents reviewed in the final sample. The facility failed to ensure Resident #50's urinal was emptied in a timely manner prior to meals being served in the resident's room. Findings: Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, Acquired Absence of Right and Left Leg Above the Knee, Anxiety, and Post Traumatic Stress Disorder. Review of Resident #50's most recent MDS (Minimum Data Set), with an ARD of 09/24/2024, revealed a BIMS (Brief interview for Mental Status) of 15, indicating Resident #50 was cognitively intact. Review of Resident #50's Progress Notes revealed, in part: Nutritional Note dated 09/24/24 at 3:00 p.m. - Resident eats all of his meals in his room. On 10/15/2024 at 9:00 a.m., an observation and interview was made of Resident #50. His urinal was present at his bedside and contained 400 cc of urine. Resident #50 stated the urinal had been there since 6:00 a.m., and staff have not routinely emptied it when they entered his room. He confirmed he had breakfast in his room this morning, with the urinal containing urine present during his meal. On 10/15/2024 at 11: 15 a.m., an observation was made of Resident #50. His urinal remained at his bedside with 400 cc of urine noted. Resident #50 confirmed it has not been emptied or used since 9:00 a.m. Resident #50 stated he asked for the urinal to be emptied. Resident #50 stated he feels leaving urine during meals is not respectful of his feelings. On 10/15/2024 at 12:30 p.m., an observation was made of Resident #50 as he was served his lunch tray in his room. His urinal remained at the bedside, in plain sight from the door and to the resident in his bed, with 400 cc of urine noted. On 10/15/2024 at 12:35 p.m., an interview was conducted with S17CNA. She confirmed she was caring for Resident #50. She stated his urinal with 400 cc of urine had not been emptied on her shift, and should have been. She further confirmed she had served Resident #50 his breakfast and lunch in his room, with the urinal containing urine present at bedside. On 10/15/2024 at 12:38 p.m., an observation and interview was conducted with S2DON. S2DON confirmed the Resident #50's urinal was hanging on the garbage can at bedside, with 400 cc of urine noted. He further confirmed staff had not emptied the urinal during their shift and should have. S2DON confirmed serving meals to residents with a urinal at the bedside was disrespectful.

Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 1(#28) of 1 sampled resident reviewed for abuse. The facility failed to ensure Resident #28 was free from physical abuse by Resident #100. Findings: The undated facility policy, reviewed on 10/16/2024, titled Abuse Prevention Program revealed, Policy Statement: Our residents have the right to be free from abuse. This includes freedom from Resident to Resident Abuse. Policy Interpretation: As part of the resident abuse prevention, the administration will: 1. Protect residents from abuse by anyone including other residents. Resident #28 Review of the Clinical Record revealed Resident #28 was admitted to the facility on [DATE]. Review of the Current MDS (Minimum Data Set) revealed Resident #28 had a BIMS (Brief Interview of Mental Status) score of 15, which indicated he was cognitively intact. On 10/16/2024 at 3:10 p.m., an interview was conducted with Resident #28. He stated on 09/01/2024, his roommate, Resident #100 was sitting by his bed punching and elbowing him. He stated he felt aggravated and scared the incident would happen again. He said he reported this to S3LPN. Review of S3LPN's Nurses Progress Note for Resident #28 revealed on 09/01/2024 at 10:47 a.m., Resident #28 informed S3LPN that he was awakened during the night to Resident #100 sitting next to his bed punching and elbowing him. Writer spoke to Resident #100 who stated yes I punched him. Resident #100 Review of the Clinical Record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses, which included Dementia. Review of the Current MDS revealed Resident #100 had a BIMS of 8, which indicated he was cognitively intact. Review of the Health Status Note completed by facility staff for Resident #100 dated 09/01/2024 revealed the resident was transferred to the emergency room for evaluation due to aggressive behaviors at 11:00 a.m., and returned to the facility at 1:13 p.m. He was still confused. Resident #100 was educated on physical abuse and staying in his room. On 10/15/2024 at 1:45 p.m., an interview was conducted with S4LPN. She stated Resident #100 had a history of issues including aggressive behaviors, delusional behaviors, and hallucinations. On 10/16/2024 at 4:20 p.m., an observation and interview was conducted with Resident #100. He was unable to be interviewed, due to refusal to talk to me. On 10/16/2024 at 2:40 p.m., an interview was conducted S3LPN. S3LPN stated she was informed on 09/01/2024 by Resident #28 of an incident during the night. S3LPN stated Resident#28 said he woke up to find Resident #100 sitting at his bedside punching and elbowing him. She stated Resident #28 said he was afraid. She stated she spoke to Resident #100 who confirmed the incident. S3LPN stated the incident was reported to S1ADM. She stated Resident #28 was moved to another room. She confirmed there was no additional staff training or other interventions implemented after the incident. On 10/16/2024 at 3:15 p.m., an interview was conducted with S2DON. S2DON stated on 09/01/2024 Resident #28 and Resident #100 were involved in an altercation. He stated Resident #100 was at the bedside of Resident #28 punching and elbowing him. S2DON confirmed no staff in-service was provided related to this incident. S2DON stated Resident #100 was sent to the hospital for evaluation and Resident #28 was moved to another room. S2DON confirmed Resident#100 punching and elbowing Resident #28 was abuse. S2DON did not report any further interventions. On 10/16/2024 at 3:30 p.m., an interview was conducted with S1ADM. S1ADM confirmed that he was made aware Resident # 28 was hit by Resident #100 while asleep in his bed. S1ADM stated Resident #28 was moved to another room, and Resident #100 was sent to the emergency room for evaluation. S1ADM did not report any further interventions. He further confirmed that the incident was Resident/Resident abuse.

Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#11) of 3 (#6, #11, and #92) residents reviewed for PASRR. Findings: A review of Resident #11's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression. Further review revealed additional medical diagnoses of Brief Psychotic Disorder (onset date of 09/28/2023). A review of Resident #11's Level 1 PASSR dated 10/24/2022, revealed Resident #11's diagnosis of Brief Psychotic Disorder was not included. Further review revealed no documented evidence a review had been resubmitted for a Level II evaluation and determination after Resident #11 received a diagnosis of Brief Psychotic Disorder on 09/28/2023. On 10/15/2024 at 10:45 a.m., an interview was conducted with S16SW. He stated he was responsible for submitting PASRR's for residents in the facility. He stated when a resident acquired a new mental health diagnosis he submits a request to the state agency for a PASRR Level II referral. He reviewed the Level I PASRR on file for Resident #11 dated 10/24/2022. He confirmed Resident #11 had acquired a diagnosis of Brief Psychotic Disorder since the last Resident Review submission. He confirmed a Resident Review form should have been resubmitted for evaluation and determination for Level II services for Resident #11, after the diagnosis of Brief Psychotic Disorder on 09/28/2023 and was not. On 10/15/2024 at 4:17 p.m., an interview was conducted with S2DON. He was notified of the above findings. He stated he did not know if Resident #11 required a Resident Review form resubmitted for a PASRR Level II referral, following the diagnosis of Brief Psychotic Disorder on 09/28/2023.

Based on observation, interviews, and record review, the facility failed to ensure services provided by the facility met professional standards of quality by failing to ensure nursing staff did not leave medications at bedside for 1 (#82) of 24 residents reviewed in final sample. Findings: Review of Resident #82's Clinical Record revealed she was admitted to the facility on [DATE]. Further review of Resident #82's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/13/2024 revealed she had a BIMS (Brief Interview of Mental Status) of 13, indicating she was cognitively intact. On 10/14/2024 at 8:55 a.m., an observation and interview was conducted with Resident #82 in her room. She had seven pills in a medication cup on her bedside table as well as a 4 ounce cup of liquid supplement. She stated S5LPN gave her medications at the bedside and left her room. On 10/14/2024 at 9:07 a.m., an interview was conducted with S5LPN in Resident #82's room. She confirmed there were 7 pills in the medication cup and 4 ounces of liquid supplement at resident's bedside. She confirmed she gave Resident #82 her morning medications, but did not observe Resident #82 swallow the medications prior to leaving the room. She further confirmed Resident #82 did not have Physician Orders to self-administer medications, and medications should not have been left at the bedside. On 10/16/2024 at 3:09 p.m., an interview was conducted with S2DON. He confirmed S5LPN should not have left mediations at the resident's bedside. He further confirmed no medications should be left at the bedside of a resident who is unable to self-administer medications.

Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were labeled for 1 (#2) of 2 (#2 and #75) residents reviewed for oxygen therapy. Findings: Review of the facility's policy titled Departmental (Respiratory Therapy), with a revision date of 11/2011, revealed in part: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks, and equipment among residents and staff. General Guidelines: 1. Pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every (7) days, or when the water level becomes low. Steps in the Procedure: Infection Control Considerations Related to Oxygen Administration: 2. [NAME] bottle with date upon opening. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. Review of Resident #2's Physician's Orders revealed the following, in part: Start date: 01/03/2024: Oxygen at 4 liters per minute via nasal cannula continuously. On 10/14/2024 at 10:30 a.m., an observation what made of Resident #2 lying in bed wearing her oxygen via nasal cannula. The oxygen tubing nor the humidifier bottle were labeled with date last changed. On 10/14/2024 at 10:36 a.m., an observation and interview was conducted with S14LPN. She stated resident oxygen tubing and humidification was changed every Sunday. She stated all oxygen tubing and humidifier bottles should be labeled with the date it was changed. S14LPN confirmed Resident #2's oxygen tubing and humidifier bottle was not dated and should have been. On 10/15/2024 at 4:15 p.m., an interview was conducted with S2DON. He was notified of the observation of Resident #2's oxygen tubing and humidifier bottle not being labeled with a date. He stated the facility's policy was to change all oxygen tubing and humidifier bottles every 7 days on Sunday. He stated oxygen tubing and humidifier bottles should be labeled with the date it was changed. S2DON confirmed Resident #2's oxygen tubing and humidifier bottle should have been labeled with the date it was changed.

Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. This deficient practice had the potential to affect 121 residents who were served meals from the facility's kitchen. Findings: Review of the facility's policy titled Food Receiving and Storage dated November 2022, revealed in part, the following: 1. All foods stored in the refrigerator or freezer are covered, labeled and dated. 7. Refrigerated foods are labeled and dated so they are used prior to expiration, frozen, or discarded. During the initial tour of the facility's kitchen with S11DM on 10/14/2024 at 9:00 a.m., the following observation was made: Walk-In Cooler: 1 package of block cheese, wrapped in plastic wrap, opened, dated 08/24/2024. An interview was conducted on 10/14/2024 at 9:30 a.m. with S11DM. She verified the above observation and confirmed the facility failed to store foods under sanitary conditions. She confirmed opened food products should be labeled with date it was opened and an expiration/discard date. She further stated she was responsible for ensuring staff complied with policy. An interview was conducted on 10/15/2024 at 11:57 a.m. with S12CD. She confirmed opened cheese should have a discard date. She stated the cheese should have had a use-by date of 7 days from opening and it did not. An interview was conducted on 10/14/2024 at 9:40 a.m. with S1ADM. He confirmed all food storage items should be labeled and dated.

Based on observation, record review, and interview, the facility failed to ensure all surveys during the 3 preceding years, including complaint surveys since the last annual survey, were accessible for residents, family members, legal representatives, and the public's review. Findings: An observation was made on 10/14/2024 at 8:35 a.m. of the facility's entrance. There was no facility binder available with Survey results located near the entrance of the facility. An observation was made on 10/14/2024 at 12:55 p.m. of dining area information display section. There were no previous surveys posted within the facility for residents, family members, legal representatives, or the public to review. An interview was conducted on 10/14/2024 at 1:15 p.m. with S1ADM. S1ADM verified the facility's survey results binder was not present for public view, and stated it was in his office. He reviewed the facility's Survey results binder and confirmed survey results from preceding annual recertification surveys dated 10/2023, 10/2022, 10/2021 should have been available for public review. S1ADM further confirmed the complaint surveys since the annual recertification survey, dated 08/27/2024 and 09/05/2024, should have been available for public review, and were not.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from neglect for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for neglect. The facility failed to ensure an effective system was in place for staff to identify whether a resident was out of the facility on pass or missing, which resulted in Resident #1 being left outside overnight without required care. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/26/2024 at 5:44 p.m., when Resident #1, a severely cognitively impaired resident who required extensive assistance, self-propelled outside the facility without staff knowledge. From 5:44 p.m. until the next morning at 8:15 a.m., staff assumed the resident was out of the facility on pass with family. When Resident #1 was found, she was lethargic, wet with urine, and her vital signs were pulse 119, blood pressure 155/54, and blood glucose of 287. Resident #1 was transferred to the hospital and admitted for Hypertensive Urgency, Hyponatremia, Dehydration and Mild AKI (Acute Kidney Injury). S1ADM was notified of the Immediate Jeopardy situation on 08/30/2024 at 5:39 p.m. The Immediate Jeopardy situation was removed on 08/30/2024 at 8:37 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more than minimal harm for the remaining 123 residents residing in the facility. Findings: Review of the facility policy titled Identifying Neglect, with a revision date of 09/2022, revealed the following, in part: 5. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's Clinical Record revealed Resident #1 was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Paroxysmal Atrial Fibrillation, Need For Assistance With Personal Care, and Acquired Absence of Left Leg Below Knee. Further review revealed Resident #1 was transferred to a local hospital on 08/27/2024 and had not returned to the facility. Review of Resident #1's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/09/2024, revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 07, which indicated severe cognitive impairment. Further review revealed Resident #1 was always incontinent of bladder and bowel, and required extensive two person assistance with bed mobility, transfers, and toilet use. Review of Resident #1's Care Plan revealed the following, in part: Focus: Alteration in elimination related to incontinent of bowel and bladder Interventions/Tasks: Assist with personal hygiene and perineal care as needed; Check every 2 hours for dryness. Focus: Diagnoses Diabetes Mellitus: Potential for hypoglycemia/hyperglycemia Interventions: Insulin as ordered; Medication as ordered. Focus: Diagnoses Atrial Fibrillation: At risk for decreased cardiac output. Interventions: Medications as ordered. Focus: Diagnosis Hypertension: at risk for fluctuations in blood pressure. Interventions: Medications as ordered. Focus: Potential for skin breakdown related to decreased mobility, incontinence. Interventions: Check for incontinent episode every 2 hours; Encourage frequent position changes. Review of Resident #1's August 2024 Medication Administration record revealed Resident #1 was not administered Atorvastatin Calcium Oral 40 mg, Insulin Glargine 15 units, Apixaban Oral Tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 50 mg as ordered on 08/26/2024 at 8:00 p.m. Further review revealed Resident #1 was not administered Diltiazem HCI ER Beads Capsule Extended Release 24 Hour 300 mg, Lisinopril Oral Tablet 5 mg, Synthroid Oral Tablet 25 mcg, Apixaban Oral Tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 50 mg as ordered on 08/27/2024 at 7:00 a.m. Review of Resident #1's Incident Report dated 08/27/2024 at 9:00 a.m. revealed Resident #1 was found outside by staff around 8:30 a.m. and sent to the hospital to be evaluated. The incident investigation revealed the LPN and CNA thought Resident #1 was out of the facility on pass with family. Review of Resident #1's Nursing Progress Notes revealed the following, in part: 08/27/2024 at 6:30 a.m., Upon S6LPN making rounds, she observed Resident #1's bed was empty and continued to make rounds. 08/27/2024 7:50 a.m., S6LPN attempted to locate Resident #1 for morning medications. CNAs nor other staff were aware of Resident #1's location. S6LPN along with other facility staff members began to look for Resident #1. Resident #1 was located outside sitting in the wheelchair along the enclosed fence line. S6LPN observed Resident #1 was easily aroused per staff. Staff members rolled the resident into the facility to her room. Resident #1's clothes were wet with urine. The treatment nurse stated her bottom is red, but I don't see anything else. S6LPN questioned how did she get outside? Along with how long had she been outside? The resident stated I don't know. Assessment performed per S6LPN vital signs as follows: B/P 155/54; P=119, R=22, Oral Temp =97.8, Blood Glucose=287. Fluids offered and encouraged, resident drinking without difficulty. Resident stated I am tired and sleepy. Review of the facility's document titled Resident Sign-Out Roster revealed Resident #1 was not signed out of the facility by family on 08/26/2024. On 08/30/2024 at 2:43 p.m., video footage of Resident #1's incident was reviewed and confirmed with S1ADM, which revealed following: On 08/26/2024 at 5:44 p.m., another resident opened the door and Resident #1 self-wheeled herself out on the patio. At 6:24 p.m., Resident #1 was observed wheeling her chair down the sidewalk, turned right where the sidewalk intersected, and got her left wheelchair leg stuck in the grass between the fence and side walk. Resident #1 was observed attempting to get her wheelchair unstuck. At around 8:30 p.m., Resident #1 was no longer visible due to darkness. On 08/27/2024 at 6:12 a.m., Resident #1 was observed asleep in her wheelchair and slightly leaned forward. At 8:12 a.m., S9AA came into the footage and at 8:15 a.m., facility staff were attending to Resident #1. Review of the Prehospital Care Record from a local ambulance company dated 08/27/2024 revealed the following, in part: On Scene: 9:37 a.m. Vitals: 9:47 a.m. Blood Pressure 157/46, Pulse: 49, Respirations 18, Blood Sugar 326. HPI (History of Present Illness) Some time yesterday Resident #1 was left outside and not found until this morning between 8-9 a.m. Resident #1 is very lethargic but arouses easily. Review of the local hospital records for Resident #1's dated 08/27/2024 revealed the following, in part: Vitals: 08/27/2024 10:24 a.m., Blood Pressure: 176/74; Pulse: 59 Chief Complaint: Hyponatremia, Acute Kidney Injury (AKI) History of Present Illness: Resident #1 is a [AGE] year old female with a past medical history of Hypertension, Hyperlipidemia, Dementia, BKA (Below Knee Amputation), Diabetes Mellitus, Atrial Fibrillation, and Rheumatoid Arthritis, who presents to this hospital from a local nursing home after being found outside sitting in her wheelchair unattended by a fence. Here in the Emergency Department, labs reveled patient has an AKI with Creatinine of 1.18, Hyponatremia with Sodium 131. She has an elevated blood glucose of 319. Blood pressure was 186/62. Hospital Medicine was called to admit for Hypertensive Urgency, Hyponatremia, Dehydration and Mild AKI. On 08/30/2024 at 12:30 p.m., an interview was conducted with S12CNA. S12CNA confirmed she worked on 08/26/2024 from 6:00 a.m. to 6:00 p.m. S12CNA stated the last time she saw Resident #1 was around 6:00 p.m. when she was leaving the facility and Resident #1 was visiting with her family. On 08/30/2024 at 12:06 p.m., an interview was conducted with S5CNA. S5CNA stated staff should check on the residents every 2 hours. S5CNA stated if a resident was not in their room, she would ask the previous shift where the resident was or ask their roommate. S5CNA confirmed she worked the night shift from 6:00 p.m. to 6:00 a.m. on 08/26/2024, and she did not see Resident #1 during her shift. S5CNA stated she started her rounds at 6:00 p.m. and rounded on Resident #1's room around 7:20 p.m. S5CNA stated at that time the resident was not in her room and she asked Resident #1's roommate where Resident #1 was. The roommate told her Resident #1 left the facility with her family. S5CNA stated she reported Resident #1 was with her family to S7LPN. S5CNA stated she thought Resident #1's family had taken her out of the facility for a day when Resident #1 was not in bed the next morning. S5CNA stated she did not know there was a binder for the residents to sign out on pass, and to check if the resident had been signed out. S5CNA confirmed Resident #1 required incontinence care, assistance with dressing, and bed transfers, and confirmed she had not provided care for Resident #1 at any time during her 08/26/2024 shift. On 08/30/2024 at 11:45 a.m., an interview was conducted S4LPN. S4LPN confirmed she worked on 08/26/2024 from 6:00 a.m. to 10:00 p.m. S4LPN stated on 08/26/2024 she went to Resident #1's room to administer medications around 8:00 p.m. and Resident #1 was not in her room. S4LPN stated she asked S5CNA where Resident #1 was and S5CNA stated Resident #1 was out on pass with her daughter. S4LPN stated Resident #1's daughters were at the facility between lunch and dinner on 08/26/2024. S4LPN stated there was a log book for signing residents out, and she did not check the book to see if Resident #1 had been signed out. S4LPN stated she reviewed the notes in the computer from the previous shift and did not see where Resident #1 had been signed out. S4LPN stated most families will notify staff if the residents will be out all night. S4LPN stated she assumed Resident #1 would return. On 08/30/2024 at 10:53 a.m., an interview was conducted with S6LPN. S6LPN stated Resident #1 used a wheelchair and could propel it with her arms and upper body. S6LPN stated Resident #1 was forgetful at times, but knew who she was and could tell time with a watch. She stated she worked the morning of 08/27/2024. S6LPN stated Resident #1 was not in her room at 7:00 a.m. and she thought the resident could be in the whirlpool or the dining room. S6LPN confirmed at 7:50 a.m., she realized Resident #1 was missing and staff found Resident #1 outside by the fence in her wheelchair. S6LPN stated Resident #1 she was lethargic, sleepy, and wet with urine. S6LPN stated she did not know how long Resident #1 was outside. S6LPN confirmed she did not administer Resident #1's morning medications on 08/27/2024 at 7:00 a.m. prior to the resident being transferred to the hospital. On 08/30/2024 at 11:08 a.m., an interview was conducted S9AA. S9AA stated on 08/27/2024 she saw Resident #1 asleep, outside in her wheelchair by the fence. S9AA stated Resident #1's wheelchair wheel had dropped off the sidewalk into a rut between the sidewalk and the grass. S9AA stated Resident #1's pants were soaked with urine from her knees up. On 08/30/2024 at 12:34 p.m., an interview was conducted with S13WC. S13WC confirmed she worked on 08/27/2024. S13WC stated after the resident was found outside, she and S6LPN brought Resident #1 to her room and conducted a body audit. S13WC stated Resident #1's amputation stump and right leg were swollen, she had redness to her sacrum, and her pants were wet with urine. S13WC stated Resident #1 stated she was tired and could not remember how she got outside or how long she had been out there. On 08/30/2024 at 2:11 p.m., an interview was conducted with S2DON. S2DON stated on the night of 08/26/2024, S5CNA asked Resident #1's roommate where the resident was. The roommate said Resident #1 was out of the facility on pass with family. S2DON reported S5CNA then reported this to S4LPN. S2DON confirmed neither staff verified if the resident was actually out on pass by checking the sign out log or calling the family. S2DON said he was not sure how long Resident #1 was outside for before being found. On 08/30/2024 at 2:11 p.m., an interview was conducted with S3ADON. S3ADON stated Resident #1's family had visited the resident on 08/26/2024. S3ADON explained the evening staff presumed the resident was out of the building with family on the evening of 08/26/2024. S3ADON stated staff should have investigated and verified if Resident #1 was actually out on pass. S3ADON stated the situation could have been avoided had staff verified the resident was out of the facility on pass. S3ADON stated the nurse should have checked the sign out log book and/or called the family to verify the resident's location when they could not find a resident. S3ADON stated he did not know how long Resident #1 was outside. S3ADON stated there was a system breakdown when the staff did not verify if Resident #1 was out of the facility which resulted in the resident not receiving the required ADL (Activities of Daily Living) care or medications. On 08/30/2024 at 2:50 p.m., and interview was conducted with S1ADM. S1ADM stated he became aware Resident #1 had been outside all night around 8:30 a.m. on 08/27/2024. S1ADM stated the CNA reported information to the nurse which was relayed by Resident #1's roommate. He explained the roommate said Resident #1 was out of the facility on pass with family. S1ADM stated the nurse should have checked the sign out binder, called the family, looked for the resident, and notified S3ADON, S2DON and S1ADM. S1ADM confirmed Resident #1 did not receive medications or incontinence care while she was outside. On 09/03/2024 at 3:15 p.m., an interview was conducted with S7LPN. S7LPN confirmed she came in to work at 10:00 p.m. on 08/26/2024. S7LPN stated when she arrived she was notified by S4LPN and S5CNA that Resident #1 was out of the facility on pass with her family. S7LPN confirmed she did not check the log book to see if Resident #1 was signed out on pass. On 09/04/2024 at 9:59 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #1's medication administration record and confirmed Resident #1 had not received her 8:00 p.m. medications on 08/26/2024 or her 7:00 a.m. medications on 08/27/2024. S2DON stated the hospital reported the resident to be dehydrated and hypertensive with a low sodium level upon admission. On 09/03/2024 9:38 a.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #1 was neglected by nursing staff for over 14 hours when the resident was outside.

Based on observations and interviews, the facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, such as the State Survey Agency and a statement as to how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. This deficient practice had the potential to affect any of the 123 residents residing in the facility. Findings: On 09/03/2024 at 2:00 p.m., a brief tour of the facility revealed no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency. On 09/04/2024 at 11:36 a.m., a brief tour of the facility was conducted with S8SS. S8SS confirmed there were no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency. On 09/04/2024 at 11:43 a.m., an interview was conducted with S1ADM. S1ADM confirmed there were no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency.

Based on observation of video surveillance, interviews and record review, the facility failed to ensure alleged violations involving neglect were reported to the state survey agency within twenty four hours after the allegations were made for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for neglect. Findings: Review of the facility policy titled Identifying Neglect, with a revision date of 09/2022, revealed the following, in part: 5. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress. Review of the facility policy titled Abuse Investigation and Reporting with a revision date of 06/2022, revealed the following, in part: All reports of resident neglect shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Reporting 1. All alleged violations involving neglect will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of neglect will be reported immediately, but no later than: b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Review of Resident #1's Incident Report dated 08/27/2024 at 9:00 a.m. revealed Resident #1 was found outside by staff around 8:30 a.m. and sent to the hospital to be evaluated. The incident investigation revealed the LPN and CNA thought Resident #1 was out of the facility on pass with family. Review of Resident #1's Nursing Progress Notes revealed the following, in part: 08/27/2024 at 6:30 a.m., Upon S6LPN making rounds, she observed Resident #1's bed was empty and continued to make rounds. 08/27/2024 7:50 a.m., S6LPN attempted to locate Resident #1 for morning medications. CNAs nor other staff were aware of Resident #1's location. S6LPN along with other facility staff members began to look for Resident #1. Resident #1 was located outside sitting in the wheelchair along the enclosed fence line. S6LPN observed Resident #1 was easily aroused per staff. Staff members rolled the resident into the facility to her room. Resident #1's clothes were wet with urine. The treatment nurse stated her bottom is red, but I don't see anything else. S6LPN questioned how did she get outside? Along with how long had she been outside? The resident stated I don't know. Assessment performed per S6LPN vital signs as follows: B/P 155/54; P=119, R=22, Oral Temp =97.8, Blood Glucose=287. Fluids offered and encouraged, resident drinking without difficulty. Resident stated I am tired and sleepy. On 08/30/2024 at 9:47 a.m., an interview was conducted with S1ADM. S1ADM stated there have been no incidents reported to the state agency since last year. On 08/30/2024 at 2:43 p.m., video footage of Resident #1's incident was reviewed and confirmed with S1ADM, which revealed following: On 08/26/2024 at 5:44 p.m., another resident opened the door and Resident #1 self-wheeled herself out on the patio. At 6:24 p.m., Resident #1 was observed wheeling her chair down the sidewalk, turned right where the sidewalk intersected, and got her left wheelchair leg stuck in the grass between the fence and side walk. Resident #1 was observed attempting to get her wheelchair unstuck. At around 8:30 p.m., Resident #1 was no longer visible due to darkness. On 08/27/2024 at 6:12 a.m., Resident #1 was observed asleep in her wheelchair and slightly leaned forward. At 8:12 a.m., S9AA came into the footage and at 8:15 a.m., facility staff were attending to Resident #1. On 08/30/2024 at 2:50 p.m., and interview was conducted S1ADM. S1ADM stated he became aware of the situation with Resident #1 around 8:30 a.m. on 08/27/2024. S1ADM stated staff reported Resident #1 was found outside. On 09/03/2024 9:38 a.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #1 was neglected by nursing staff for over 14 hours when the resident was outside. S1ADM confirmed he did not report the incident to the state agency. S1ADM confirmed the incident with Resident #1 should have been reported to the state agency.

Based on record review and interviews, the facility failed to ensure 1 (#4) of 5 (#1-#5) sampled residents reviewed were free of significant medication errors as evidenced by a nurse failing to identify a resident before administering medications. This resulted in a resident (#4) receiving another resident's medications (#1). This failed practice resulted in an actual harm for Resident #4 on June 8, 2016 at approximately 7:40 a.m. when the resident received her morning medications and another residents morning medications Resident #4 received [MEDICATION NAME] 10 mg (milligrams), 2 doses of Aspirin 81 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 0.4 mg, 2 Multivitamins, [MEDICATION NAME] 6.25 mg, [MEDICATION NAME] 15 mg, 2 doses of [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10-100 mg, Baclophen 10 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] HCL 0.2 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] Calcium 240 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 324 mg, [MEDICATION NAME] 0.125 mg, [MEDICATION NAME] 25 mg, Eye Drops, Tums, [MEDICATION NAME] 20 mg and [MEDICATION NAME] 4 mg. Resident #4 was admitted to a local hospital that morning with Altered Mental Status (AMS), a blood pressure of 68/32 and a heart rate of 52. The resident was given a 1 liter fluid bolus and placed on a [MEDICATION NAME] drip (a medicine to maintain blood pressure) at 5 mcg/kg/min in the emergency room and admitted to the ICU (Intensive Care Unit). Findings: Review of the facility's policy for administering medications revealed the following in part: Purpose- The purpose of this provider is to provide guidelines for the safe administration of oral medications. . Steps in procedure .10. Confirm the identity of the resident . Review of the clinical record for Resident #4 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set for Resident #4 with an Assessment Reference Date of 5/17/16 revealed the resident had a BIMS (Brief Interview for Mental Status) of 3 which indicated the resident was cognitively impaired. Review of the current MAR (Medication Administration Record) for Resident #4 revealed the following medications to be administered for 8:00 a.m.: [MEDICATION NAME] Calcium (Stools Softener) 240 mg (milligrams), Multivitamin, [MEDICATION NAME] 20 mg (heartburn,[MEDICAL CONDITION]), [MEDICATION NAME] 324 mg (iron supplement), Aspirin 81 mg, [MEDICATION NAME] 0.125 mg(Antiarrhythmic and blood pressure medication), [MEDICATION NAME] 25 mg (blood pressure medication), [MEDICATION NAME] 0.15% eye drops, Calcium [MEDICATION NAME] 1 tablet, [MEDICATION NAME] 50 mg(blood pressure medication), [MEDICATION NAME] 20 mg (blood pressure medication), [MEDICATION NAME] 4 mg ([MEDICATION NAME]) and [MEDICATION NAME] 25 mg (antidepressant). Review of the current MAR for Resident #1 revealed the following medications to be administered for 7:00 a.m.: [MEDICATION NAME] 10 mg (blood pressure medication), Aspirin 81 mg, [MEDICATION NAME] 20 mg (GERD medication), [MEDICATION NAME] 0.4 mg (prostate medication), Multivitamin, [MEDICATION NAME] 0.25 m (blood pressure medication), [MEDICATION NAME] 15 mg (anxiety medication), [MEDICATION NAME] 50 m (blood pressure medication), [MEDICATION NAME] 10-100 mg ([MEDICAL CONDITION] medication), [MEDICATION NAME] 10 mg (muscle relaxer), [MEDICATION NAME] 25 mg (blood pressure medication), [MEDICATION NAME] 0.2 mg (blood pressure medication) and [MEDICATION NAME] 20 mg (antidepressant). Review of the nursing notes documented by S3LPN revealed the following: 6/8/16- 7:20 am- Resident #4 up in wheelchair, propelling herself to the dining room for breakfast. The resident stopped where nurse was to get her morning meds. Blood pressure and pulse taken at that time, B/P 175/86 and P 70. While doing this, another resident from another hall came to nurse and started asking some questions. The nurse told the other resident she needed to talk to her nurse about what the resident was asking so she could let her doctor know what she needed. The other resident kept on asking questions distracting nurse to the point that before the nurse realized that she had already given Resident #4 her medicine, she gave her someone else's (Resident #1's) medicine. Nurse checked resident's blood pressure at that time. It was currently 7:40 a.m. The blood pressure was 93/39 and the pulse was 67. Nurse spoke with S2ADON and immediately notified S1DON who notified the doctor. Orders were given to send Resident #4 to the emergency room (ER) for evaluation. At 8:00 a.m., ambulance was notified to transfer. Blood pressures were taken before resident left to go to ER. 8:00 a.m. - B/P- 96/45, P-59, 8:05 a.m. - B/P - 97/44, P- 60, 8:10 a.m. - B/P - 98/45, P - 60, Respirations- 14. At 8:12 a.m., nurse called report to ER, Ambulance here at this time. Nurse also tried to get in touch with nephew but unable to get in touch with him, a little later nurse tried again and was able to speak with him and let him know that resident was sent to the ER because her blood pressure was low at 8:17 a.m. At 9:00 a.m., nurse at ER called back and requested MAR (Medication Administration Record) with medications from other resident (#1) and was notified that Resident #4 was given [MEDICATION NAME] and that she was going to be admitted . Nurse tried to call resident's nephew again to let him know that she was going to be admitted but was unable to get in touch with the nephew again. At 3:54 p.m., nurse tried to call resident's nephew again but not able to get in touch with him. Review of the hospital record for Resident #4 revealed the following: Admission: 6/8/16 Chief Complaint- Accidental Overdose, AMS (Altered Mental Status) Present Illness- Resident is a [AGE] year old female that presented to the ER this morning from nursing home with altered level of consciousness. Patient was given multiple medications this morning including another resident's medications. The nursing home reported to the ER that she was given the following medications: [REDACTED]. Resident was somnolent during the exam, she is oriented to name only. No vomiting, denies pain, she follows verbal commands. Poison control has been contacted, recommendations have been provided. Upon arrival to the ER, she was given 1 L (liter) Bolus of fluids secondary to blood pressure 60/30. She is now on [MEDICATION NAME] 5 mcg/kg/min and her most recent BP is systolic 94. Poison control recommends close monitoring for a minimum of 8 hours. They have alternative recommendations if vasopressors do not maintain her SBP (Systolic Blood Pressure) > (greater than) 80. Patient will be admitted to ICU. Review of the hospital discharge record revealed Resident #4 returned to the nursing facility on 6/10/16. Discharge [DIAGNOSES REDACTED]. Review of the Medication Error Report form for Resident #4 revealed the resident received Resident #1's morning medications in error on 6/8/16. The reason for making the error was the nurse was distracted by another resident. The actual effect of the error made was the resident was sent to the ER to monitor blood pressure. An interview was held with S3LPN on 6/13/16 at 9:30 a.m. She stated Resident #4 preferred to wake up early in the morning. She said on 6/8/16, she was passing medications in the dining room when Resident #4 wheeled up to her to receive her morning medications. She explained she prepared Resident #4's medications and gave them to her. She stated at that time, a resident she was not assigned to came up to her and asked her some questions. She said she did not want to be rude so she spoke with that resident. She stated while she was talking to that resident, she noticed Resident #1 was wheeling into the dining room. She stated she began to prepare Resident #1 ' s medications. She stated Resident #4 was still sitting next to her medications cart. She said without thinking about it, she handed Resident #1's medications to Resident #4 and she took them. She stated once Resident #4 swallowed, she immediately realized she gave the wrong medications to her. She stated she instructed Resident #4 to go eat breakfast and proceeded to attempt to contact the Nurse Practitioner for Resident #4's Physician. She stated she then notified the ADON (Assistant Director of Nursing). She stated the DON (Director of Nursing) was made aware by the ADON. She said the DON notified the physician and they called an ambulance to transfer her to the emergency room . She stated after Resident #4 ate, they brought her to her room and monitored her blood pressure every 5 minutes until the ambulance arrived. She stated the resident started to appear lethargic about 20 minutes after she took the medications. She stated the ambulance was quick to arrive. She stated the resident was readmitted to the facility on [DATE]. An interview was held with S2ADON on 6/13/16 at 12:59 p.m. She stated S3LPN came straight to her when she discovered she had administered Resident #1 ' s medications to Resident #4. She stated she attempted to contact the resident ' s PCP (Primary Care Physician) Nurse Practitioner but she was unable to get in touch with her. She stated she immediately notified S1DON and she contacted the doctor. She stated while S1DON spoke to the doctor, she never left Resident #4 ' s side and they obtained blood pressures every 5 minutes. She stated the ambulance was very quick to arrive and they sent the resident to the ER to be evaluated for low blood pressure. An interview was held with S1DON on 6/13/16 at 1:15 p.m. She confirmed Resident #4 received Resident #1 ' s medications in error. She stated it was an isolated incident. She explained she had initiated a plan of correction to ensure all nurses were educated to identify residents prior to administering medications. She stated she passed out the medication administration policy to the day nurses to pass on to the nurses on other shifts. She stated she had not in-serviced all nursing staff yet but planned to hold an in-service with all nursing staff on 6/13/16.