Every finding on record at Grapevine Medical Lodge

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety in the facility's only kitchen in that: The facility failed to ensure food items that were placed in the refrigerator were sealed, dated, and labeled appropriately.The facility failed to ensure food items with expired use by dates were disposed of properly.The facility failed to ensure refrigerators meet standard temperature guidelines. These failures could place residents at risk for food-borne illnesses.Findings included: Observation on 6/16/2026 at 5:40 a.m., revealed walk in cooler temperature was at 49.5 degrees Fahrenheit. In the cooler there were two trays of individual cups of what appeared to be pudding-like substances that were not labeled. In the walk-in cooler there was a gallon of Worcestershire that had an expired used by date of 6/13/26. There was a small sandwich bag of lettuce labeled with an expired use by date of 6/13/26. The area where dishes are placed for washing there were two containers labeled as beef stew and mix veggies with a used by date of 6/16/26 sitting out next to where dish washing water with soap was being prepared. There were five racks of bread observed labeled and dated. The top rack was labeled wheat bread had an expired used by date of 6/15/26. Observation on 6/16/26 at 6:45 a.m., revealed the two containers labeled with beef stew and mixed veggies were still sitting next to the prepared dish washing water. The two trays that appeared to be pudding were still in the reach in cooler unlabeled. The reach in cooler temperature was at 53 degrees Fahrenheit. The hand-washing sink had continuously dripping water and did not appear to have been cleaned as there was a buildup that did not appear sterilized. In an interview and record review with the Dietary Manager on 6/16/26 at 6:50 a.m. she stated the facility cooler had broken on 06/15/26 and the kitchen was utilizing the reach in refrigerator to store items. The Dietary Manager stated all kitchen staff were responsible for checking temperatures and she stated the reach in cooler is normally at standard temperature of 41 degrees or below. She stated the temperature was higher because they were going in and out while preparing breakfast. A review of the temperature checks on the reach in cooler showed there were multiple dates of the temperature checks showing the reach cooler temperature read at 43 degrees and 42 degrees previously. Observation on 6/16/26 at 7:30 a.m., revealed breakfast trays dropped on the 200 hall. Hall staff were informed and acknowledged trays were received. Last breakfast tray was delivered at 8:00 a.m. Observation on 6/16/26 at 8:10 a.m., revealed the reach in cooler temperature was at 54 degrees. Interview of Dietary Manager on 6/17/26 at 9:00 a.m., requested lunch test tray. Interview of Resident 27 on 6/17/26 at 10:30 a.m., stated her food is always cold during the resident counsel meeting. She stated it does not matter if it is breakfast, lunch, or dinner, the food is always cold. She stated she does not like the taste of the food. Observation on 6/17/26 at 1:30 p.m., test tray received. Test tray included gumbo, string bean salad, fruit, and mechanic soft gumbo. Alternative lunch item was chicken tenders and fries. Food items were warm and palatable. Interview of Dietary Aide A on 6/18/26 at 1:00 p.m., stated she had worked at the facility for 17 years. She stated the facility's policy was to label and date everything except plastic wear. She stated temperature standards were 40 degrees or below for the coolers and 35 degrees or below for the freezer. She stated maintenance had been made aware the reach in cooler was not properly keeping temperature. She stated temperatures are checked every day. She stated when she arrives at work in the mornings she checked the temperatures. She stated she was not aware the wheat bread had expired and used by date because the dishwasher is responsible for putting the bread away. She stated the unlabeled individual cups were pudding used to give medicine to residents. She stated a corporate nurse had told them they did not have to label them if they had a date. She stated residents can get sick or the milk would be spoiled if temperature guidelines are not met. She stated all kitchen staff are responsible for ensuring temperatures are correct. Interview of Dietary Aide B on 6/18/26 at 1:10 p.m., she stated she had worked at the facility for 7 years. She stated the facility's policy was to label and date all foods received from their vendor. She stated they had a binder they use to determine how long food items could be kept. She stated all items received an open date and a used by date. She stated refrigerator temperature should be at 40 degrees or below and freezer temperature should be at 10 degrees or below. She stated all kitchen staff were responsible for checking temperatures and temperatures were checked twice a day. She stated the individual unlabeled cups was pudding. She stated they were told by corporate they only had to put a date on top of each cup. She stated she was aware of the expired used by date wheat bread. She stated she found it yesterday and got rid of it. She stated temperatures not being met can cause food to go bad and it can be harmful to residence. Interview of Dietary Manager on 6/18/26 at 1:16 p.m., she stated she had worked at the facility for 6 years. She stated the facility's policy requires all food to be labeled and dated. She stated all food items received an open date and a used by date. She stated there was a binder they used to determine how long they could keep each item. She stated she was unaware there were multiple items that had an open date but not a used by date. She stated refrigerator temperatures were required to be 35 degrees, and the freezer temperature should be 10 degrees or below. She stated if there are issues with temperatures dietary staff will let her know. She stated if she was at work, she would let maintenance know, if she is not at work dietary staff would let maintenance know. She stated all kitchen staff are responsible for checking refrigerator and freezer temperatures. She stated the dietary staff that cooks is responsible for checking food temperatures. She stated residents can get salmonella or E. coli if they consume food that is not stored or prepared at the proper temperature. She was informed of the unlabeled pudding in the reach in cooler. She stated a corporate nurse had come in and told them they only had to put a date on them. She stated she had let dietary staff know they had to take the extra step and label the puddings going forward. She stated she is not aware of any complaints regarding the food or food temperatures. She stated she goes to grievance meetings, and she had never had any complaint about the food. She stated there were two residents that complained about the food being cold, but it was breakfast. She was informed of breakfast tray distribution taking 30 minutes to be completed and multiple residents complaining about food being cold. She stated no one had brought a delay of trays being given out to her attention. She stated once they drop the trays off the kitchen staff doesn't have anything to do with the food. Record review of the facility's policy titled: Food Receiving and Storage dated July 2014 stated: Policy: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:All food stored in the refrigerator or freezer will be covered, labeled and dated ( use by date.)Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law.Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements. Refrigerator and Freezer Policy: Facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitations, and will observe food expiration guidelines. Policy Interpretation and Implementation:Acceptable temperature ranges are 35 degrees to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit.Monthly tracking sheets will include time, temperatures, initials, and action taken. The last column will be completed only if temperatures are not acceptable. The supervisor will take immediate actions if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on observations, interviews, and record reviews, 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, the residents' goals and preferences for 1 of 3 residents (Resident #152029) reviewed for oxygen treatment. The facility failed to follow Resident #152029's physician orders for PRN oxygen treatment if the resident's oxygen level fell below 90. The failure could place residents at risk of hypoxia or respiratory compensation. Findings included: Record review of Resident # 152029 MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident # 152029 Care Plan dated 06/17/2026 revealed a primary diagnosis of other specified disorders of muscle and secondary diagnoses that included dysphagia following cerebral infarction, chronic diastolic (congestive) heart failure, pleural effusion, not elsewhere classified, acute respiratory failure with hypoxia, focus: The resident has oxygen therapy r/t Goal; The resident will have no s/sx of poor oxygen absorption through the review date. Interventions: observe for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased Heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusions, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin Color. Oxygen Settings: O2 via (SPECIFY; nasal prongs/mask) L (Specify Freq) Humidified. Record review of Resident #152029 Active Orders dated 06/16/2026 revealed; Oxygen PRN: Administer oxygen at 1 liters per NC related to SOB if Sat <90% as needed. Oxygen: Administer continuous oxygen at [1 LPM] Liters per NASAL CANNULA; may remove for ADLS; Keep HOB Elevated for SOB while lying flat every shift for desat. Oxygen: Administer oxygen at 1 Liters per NC r/t SOB as needed. During an observation and interview on 06/16/2026 at 8:37 AM, Resident #152029 was observed sitting up in a chair eating breakfast without her nasal cannula. Observed O2 tubing on the nightstand next to the bed. Resident stated her O2 was removed the previous night when she received ADL care and was not replaced by the night nurse. She stated she did not realize she did not have it on until the nurse never came back. Durning an interview on 06/16/2026 at 8:56 AM, LVN C stated she got held up down the hall and she was making her way down the hall. She was observed to use the pulse oximeter to assess Resident #152029 oxygen level at room air and the reading was 80. Observed LVN C replace O2 water and tubing prior to placing nasal cannula on Resident #152029. During a re-interview on 06/18/2026 at 1:53 PM, LVN C stated Resident #152029 room air level (checked while she was breathing the regular air in the room was check with pulse oxygen and the reading was 80. She stated because the room air reading was low she was going to apply PRN O2. She changed out the tubing and added new water. She said the outgoing nurse reported that Resident #152029 was doing well. She said the risk to the resident could be hypoxia and shortness of breath. Durning an interview on 06/18/2026 at 2:27 PM, the DON revealed Resident #15029's oxygen was removed for ADL care; the nurse is supposed to return and replace the oxygen after ADL care. The risk to the residents was it could cause confusion. Record review of the facility's Oxygen Administration policy, revised February 2025, reflected: .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.

Based on observation, interview, and record review, the facility failed to keep garbage storage receptacle in a sanitary condition according to professional standards: 1. The facility failed to keep the outside garbage storage area clean.2. The facility failed to ensure the garbage receptacle outside lid was closed. These failures could place residents at risk of attracting rodents, insects, and contracting food-borne illnesses.Findings included: Observation of the outside of the facility on 6/18/26 at 10:30 a.m., revealed there was a disposable cup, white plastic bag, and an empty box with what appeared to be water damage observed on the grass on the right side of the building. In front of the building a black trash bag was observed in the grass close to the bushes in front of resident windows. Observation on 6/18/26 at 10:35 a.m., revealed the facility's only dumpster was half full, with two sliding doors that were open. The double lids at the top of the dumpster were open. Various trash items was found on the ground on the left side of the dumpster area that included: water damaged boxes, garbage bags with items in it, used plastic saran wrap, disposable plastic cups, lids plastic dessert cups, and plastic gloves. In an interview on 6/18/26 at 10:45 a.m., the Maintenance Director stated he was responsible for maintaining the facility grounds with housekeeping. He stated he completed a walkthrough throughout the week. A walkthrough outside was completed with the maintenance director. He observed the black trash bag at the front of the facility. He opened the bag and said the bag must have been left by the landscapers on Monday 6/15/26. He stated the bag could have been there since Monday. We walked around the side of the building where the water damaged empty box was sitting in the grass near the parking lot. He stated he was not aware of the box, nor the other items observed in the grass. He stated the facility used the area on the left side of the dumpster when the dumpster was full. He stated once receptacle is empty or has room for garbage, they take the garbage left on the ground and place it in the dumpster. He stated they would place items that could not fit in the dumpster in that area. He stated there were businesses that would come with a trailer to pick up the items the facility leaves out such as toilets and wheelchairs. He stated he did not know the name of the businesses that would drive by and there was not a schedule. He stated the businesses will come sporadically. He stated the potential harm of items being left on the ground can attract bugs or pests. He observed the lid of the dumpster opened and stated the lids were supposed to be always closed. He stated their dumpster would fill up quickly and trash picked up six times a week, except on Sunday's. He stated it used to be four times a week, but it has been six times a week for over a year. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #107) of 8 residents reviewed for infection control. The facility failed to ensure Resident #107's foley catheter's tubing remained off the floor when he was sitting in his wheelchair and being pushed by staff. This failure could affect residents by placing them at risk of illness and exposure to diseases. Findings included: Record review of Resident #107's admission record reflected an [AGE] year-old-male who admitted to the facility on [DATE] with a primary diagnosis of Parkinson's disease with dyskinesia with fluctuations (a progressive disorder of the nervous system that affects movement with involuntary erratic jerking movements), and secondary diagnoses of wedge compression fracture of the third lumbar vertebra (a spinal injury where the front portion of the L3 bone in your lower back collapses while the back portion stays intact), vascular dementia with other behavioral disturbance (restricted blood flow to the brain causing cognitive and personality changes such as hallucinations), and prostatic hyperplasia with lower urinary tract symptoms (an enlargement of the prostate gland causing various urinary tract symptoms). A record review of Resident #107's Quarterly MDS dated [DATE] revealed he had a BIMS score of 10 which indicated he was mildly cognitively impaired. The H Section - Bladder and Bowel indicated he had an indwelling catheter. The active diagnoses revealed he had a traumatic brain injury. A record review of Resident #107's care plan with a revision date of 1-6-2026 stated he had a catheter which required enhanced barrier precautions. In an observation and attempted interview on 6-16-2026 at 10:50 AM, Resident #107 was observed sitting in his wheelchair, in the TV dayroom, with his foley catheter hose touching the floor. An attempted interview revealed Resident #107 was not responsive to questions. A staff member was observed to roll Resident #107 away from the TV area while his foley catheter hose touched the floor. In an observation and interview on 6-16-2026 at 11:00 AM, RN R stated she had seen Resident #107's catheter hose touching the floor and said it was an infection control issue. RN R said the risk to residents having a foley catheter hose touching the floor was that it could possibly cause an infection. RN R said it was the responsibility of the CNAs and nurses to ensure that catheters remain off floors when in use. RN R said the clip that held the hose onto the wheelchair had come loose. In an interview on 6-17-2026 at 4:19 PM, it was revealed that the DON expected catheter hoses to be kept from touching floors as it could cause a UTI. The DON said it was the responsibility of the CNAs and nurses who work with residents to make sure catheter parts remain off the floor. Record review of the facility's policy titled Infection Prevention and Control Program and revised in 2016 stated: Policy Statement 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety . 7. Prevention of Infectiona. important facets of infection prevention include .(3) educating staff and ensuring that they adhere to proper techniques and procedures .(7) following established general and disease-specific guidelines, such as those of the Centers for Disease Control (CDC). Record review of the facility's policy dated revised on 1-3-2023 titled Catheter Care, Urinary stated: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Catheters are still the primary cause of nosocomial infections . Preparation 1. Review the residents' care plan to assess any special needs of the resident . Infection Control 2. Maintain clean techniques when handling or manipulating the catheter, tubing, or drainage bag .Changing Catheters3. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Based on observation, interview, and record review, the facility failed to keep drugs and biologicals in locked compartments for 2 (medication cart A and medication cart B) of 4 carts reviewed for medication storage.The facility failed to lock nurse medication cart A and nurse medication cart B while the carts were unattended on 6/16/2026.This failure could affect residents' safety and privacy.Findings included:During an observation on 6/16/2026 at 5:34 AM, Medication Cart A was left unlocked and unattended at the nurse station. There was no nurse by the nurse station. There was 2 staff members in the hallway by the nurse station. During an observation on 6/16/2026 at 5:40 AM, Medication Cart B was unlocked and unattended. There was a resident sitting in her wheelchair by her room door, across from the medication cart. There was no nursing staff nearby. In an interview on 6/16/2026 at 5:45 AM, LVN A stated she had Medication Cart B. She stated there was a resident asking for help, so she rushed in to help the resident. She stated she forgot to lock Medication Cart B. She stated carts should be kept locked when not in use to prevent unauthorized access to the carts. She stated it's a safety risk when cart was not kept secured. She stated she has been in-serviced on medication cart safety.In an interview on 6/16/2026 at 6:00 AM, LVN B stated she was responsible for Medication Cart A. She stated she did not know why it was left unlocked. She stated medication carts should be kept locked when not in used to prevent residents from having access to medications in the cart. She stated the risk included breach of privacy due to resident information could be accessed by unauthorized personnel. She stated she had been in-service on cart safety. In an interview on 6/18/2026 at 11:26 AM, the DON stated she expected all medication and treatment carts to be kept locked when not in use. She stated it was for the safety of residents because residents could take medications that were not theirs, which could cause adverse effects. She stated in-service for cart safety was done annually or when there was an issue. Record review of facility's Security of Medication Cart, revised in April 2007, revealed the policy stated Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility must provide a safe, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #83) of 17 rooms reviewed for odors. The facility failed to ensure Resident #83's Restroom did not have a strong odor of gases from the sewer line. This failure could place residents at risk for a diminished quality of life. Findings included: Record review of Resident #83's admission record dated 6-17-2026, indicated a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of displaced comminuted fracture of shaft of right tibia, subsequent encounter for closed fracture (the right leg larger shine bone was broken in at least 3 places and out of alignment), displaced comminuted fracture of shaft of right fibula subsequent encounter for closed fracture (the right leg smaller shine bone was broken in at least 3 places and out of alignment), specified chronic obstructive pulmonary disease (COPD) (a progressive irreversible lung disease that restricts airflow caused by airborne irritants), type 2 diabetes mellitus with hyperglycemia (a chronic condition when the body cannot produce insulin properly causing blood sugar to build to unhealthy levels), and need for assistance with personal care. Record review of Resident #83's Nursing Home PPS (NP) Item Set MDS dated [DATE], reflected she had a BIMS score of 15 being cognitively intact. Section GG, in the functional abilities section indicated Resident #83 used a wheelchair to ambulate. A record review of Resident #83's care plan, dated 6-15-2026, revealed Resident #83 had shortness of breath and emphysema (a lung disease where the tiny air sacs in the lungs are gradually destroyed). In an observation and interview on 6-16-2026 at 10:15 AM, a sewer type odor was detected coming from Resident #83's room. Upon opening the restroom door in Resident #83's room the unpleasant odor increased dramatically to the point where it was hard to breathe. The restroom also had a shower in it where Resident #83 took a shower. Resident #83 was lying on her bed and said the smell coming from her restroom had been present since she admitted to her room. Resident #83 said the odor is so bad at times it causes her to feel ill and not want to take a shower. Resident #83 said she had not told anyone about the smell because it was impossible for the facility to not know about the problem. In an interview on 6-16-2026 at 10:30 AM, the Maintenance Director said he did not know about the odor coming from Resident #83's restroom but knew of another room, in the same hallway, that had a similar problem. The Maintenance Director said the facility would just run some water for a while and that usually solved the odor problem in the other room. The Maintenance Director said the odors could make residents not want to be around the odors. The Maintenance Director said he was responsible for ensuring resident's restrooms stay free of unpleasant odors coming from the sewer or plumbing lines. In an observation and interview on 6-16-2026 at 10:40 AM, Housekeeper C was observed cleaning Resident #83's restroom. Housekeeper C said she had worked at the facility for 1 year, cleans Resident #83's restroom daily, and the odor always comes back. Housekeeper C said she believed the smell was coming from the sewer line and had been continuously coming back since last year. Housekeeper C said this type of sewer line odor could cause residents to not want to use their restroom and not take a shower in it. In an interview on 6-16-2026 at 10:50 AM, CNA D said she had worked at the facility for 3 months and worked in the hallway where Resident #83 resided. CNA D said the cause of the bad smell was the sewer line. CNA D said, housekeeping cleans the restroom daily, but the smell stays. CNA D said the Administrator knew about the problem, but it was not fixed. In an interview on 6-16-2026 at 11:00 AM, LVN E said she worked in the hallway where Resident #83 lived. LVN E said the odor in Resident #83's bathroom has been there for over a year. LVN E said staff have to run water through the shower to lessen the odor but it does not get rid of it. LVN E said she thought the maintenance department knew about the problem. LVN E said the effect an odor of that kind could have on residents was it could cause them to not want to use that restroom. LVN E said the CNAs, nurses, and the maintenance department were responsible for ensuring restrooms stayed clean and free of intolerable odors. In an observation and interview on 6-17-2026 at 9:55 AM, the toilet was observed to be removed from the bathroom of Resident #83's bathroom and a contractor plumbing was working on it. The contractor plumber said the cause of the odor coming from Resident #83's bathroom was coming from the sewer line. The contractor plumber said the flange, the toilet sits on, was pushed down too far causing the wax ring to be too compressed, allowing the sewer gas smell into the restroom. The contractor plumber said he could repair it. A short time later, the contractor plumber was observed making the repairs to Resident #83's toilet. In an interview on 6-17-2026 at 5:00 PM, the Administrator said, in the hallway where Resident #83 resides, there have been occasional gas smells because a shower had not been used. The Administrator said the facility just runs water through the showers and the smell leaves. The Administrator said the plumber did fix a flange problem with Resident #83's toilet. The Administrator said he expected residents not to have to deal with unpleasant odors coming from their restrooms. The Administrator said no one reported a problem with Resident #83's restroom. The Administrator said the facility uses an electronic system TELS and almost any staff member can use it to report a problem with a restroom odor and it will be routed to the maintenance department. The Administrator said all staff members were responsible for reporting problems with odors in restrooms as this could make residents feel unpleasant. In an observation and interview on 6-18-2026 at approximately 11:00 AM, Resident #83's bathroom and bedroom were free of unpleasant odors. Resident #83 said her room was free of unpleasant odors and thank you for dealing with this problem. Record review of the facility's policy dated 2017 and titled: Quality of Life - Homelike Environment stated: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Clean, sanitary and orderly environment .f. Pleasant, neutral scents . 3. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include .b. Institutional odors .

Based on observation, interview, and record review, the facility failed to ensure medication was stored in locked compartments for 1 of 8 medication carts (Med Cart A) reviewed for drug security. The facility did not lock Med cart A when unattended and not in use on 04/13/25. This deficient practice could place residents at risk of medications loss, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings Include: In an observation on 04/13/25 at 08:58 AM and at 09:13 AM, it was revealed Med Cart A was unlocked and unattended with the lock mechanism out (indicating it was unlocked) by the main nursing station facing outwards to the entrance foyer. Residents, family, staff and four surveyors were walking by the unlocked medication cart. No facility staff was attending to or using Med Cart A; it was not in use and unlocked. Observation and Interview on 04/13/25 at 09:13 AM, revealed LVN D approached the surveyor who was standing by the unlocked Med Cart A. LVN D stated she was the charge nurse, and she did not know who Med Cart A belonged to. LVN D pulled the top drawer open and placed the empty medication packs inside Med cart A and locked it. Inside Med cart A was insulin, over the counter and prescription medication. LVN D stated Med cart A should have been locked when not in use. She stated she would address the issue in the morning shift huddle. She stated the cart should be locked so that the Residents and others without authority do not have access to the cart for accidental drug ingestion. In an interview with CNA A on 04/14/25 at 06:07 AM, she said she was trained to report to the nurse, charge nurse or DON when there was any medication that was not secured. She said even when medication is at the bedside such as prescribed creams, it needs to be reported immediately. She said all medications even over the counter need to be reported if not secured or at the bedside. Interview on 04/15/25 at 10:10 AM with DON revealed, the expectation was the medication cart should be locked when staff was not directly working with the cart. She stated she would not speculate on the risk however, the expectation was that the nursing staff would follow policy and procedure and lock and secure the medication cart when not in use. She said all nursing staff were responsible for securing medications when not in use. She stated an in-service was completed with the nursing staff. Interview on 04/15/25 at 3:49 PM with Administrator revealed, the medication cart should be locked if it was out of sight and staff were not actively working in the cart. The expectation was that all staff would follow company policies and procedures and to always use the best nursing judgement when taking care of the residents. Review of facility in-service dated 04/14/25, titled Infection control, pain medication, OTC medication at bed side, giving medications with meals and Locking Medication led by DON revealed eleven nursing staff had completed the in-service. Review of facility policy Storage of Medication revised in April 2019 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 9. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure that containers in the refrigerator were covered and labeled. 2. The facility failed to ensure that prepared food was tightly covered in the facility's only refrigerator. These failures could place residents at risk for food-borne illnesses. Findings include: Observation of the facility's only refrigerator on 04/13/2025 at 9:17 AM revealed a plastic container uncovered with breadcrumbs not labeled sitting on the bottom shelf of the refrigerator. Observation of the facility's only refrigerator on 04/13/2025 at 9:19 AM revealed a package of blueberries sitting on top of premade pies covered with parchment paper touching the crust of the pie. Interview with [NAME] A on 04/13/2025 at 9:18 AM revealed, she stated the food in the plastic container was breadcrumbs used for meatloaf. She stated that the item should not have been placed in the refrigerator without a cover and label. She stated that she does not know who placed the container in the refrigerator and removed the uncovered plastic container from the refrigerator. Interview on 04/15/2025 at 2:28 PMm with Dietary Manager revealed, she stated her expectation is that food in the refrigerator have a cover on it and be labeled and dated. The risk is potential harm to the resident in the form of bacteria or e coli. The pies were covered with wax paper and the item was placed on top of the wax paper to secure the paper in place because the vent fan in the refrigerator will cause the wax paper to lift. She stated each pie should have been individually wrapped. She stated that the risk of placing an item on top of the pies is that it could leak into the pies and contaminate the pies. Interview on 04/15/2025 at 3:;16 PM with DON revealed, she stated the expectation is dining staff follow the policy regarding food storage and handling to ensure that food is kept fresh. She stated that she could not speculate regarding the risk of not following the food policy. Interview on 04/15/2025 at 3:48 PM with Administrator revealed, the dining staff should follow food storage and handling procedure to ensure that food is not wasted. He stated that he could not speculate on the risk to the residents. Review of the facility's Food Storage policy, dated 12/01/2011, reflected: All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded. Review of the U.S. Public Health Service Food Code, dated 2017, reflected: .3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the food: (1) In a clean, dry location; . Review of the U.S. Public Health Service Food Code, dated 2017, reflected: .3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or package that does not bear a date or day; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . Review of the U.S. Public Health Service Food Code, dated 2017, reflected: .3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal foods during storage, preparation, holding, and display from: (a) Raw ready-to-eat food including other raw animal food such as fish for sushi or molluscan shellfish or other raw ready-to-eat food such as fruits and vegetables, (b) Cooked ready-to-eat, and (c) Fruits and vegetables before they are washed; (d) Frozen, commercially processed and packaged raw animal food may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. (2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display .

Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feedings for 1 (Resident # 75) of 1 residents reviewed for enteral feedings The facility failed to assess Resident #75 to self-administer her feeds via the g-tube three times a day since admission on 04/02/2025. This failure could place residents at risk of needs not being met and a decline in resident's health. Findings included: Review of Resident #75's admission record dated 04/13/25, revealed she was a [AGE] year-old female with an initial admitted [DATE] and readmitted [DATE]. Her primary diagnosis was lack of coordination. Her secondary diagnoses included progressive systemic sclerosis (this is an autoimmune disease that causes the body to produce too much collagen which causes the skin and internal organs to harden and tighten), dysphagia/oropharyngeal phase (difficulty swallowing), idiopathic nonspecific intestinal pneumonitis (this is an unknown cause of chronic lung diseases), unspecified severe protein calorie malnutrition, Reynaud's syndrome without gangrene (this is a condition in which some areas of the body feel numb and cool), idiopathic hypotension (low blood pressure upon standing with an unknown cause) and gastroparesis (a stomach condition affects stomach muscles). Resident #75 was her own responsible party. Review of Resident #75's quarterly MDS dated [DATE] reflected Resident #75 had a BIMS score of 15, indicating she was cognitively intact. She makes herself understood, and she understands others. The document reflected Resident #75 had a feeding tube and received 51% or more of her nutrition through the feeding tube. The document also reflected Resident #75 required supervision or touching assistant with eating ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of Resident#75's April 2025 physician orders reflected . - Enteral Feed Order every shift Enteral: Enteral Nutrition via Bolus: [Brand name] 1.5 calorie 120 ml TID per day via bolus via peg tube with meals.1.5kcal,17 grams protein, 50ml free water before and after bolus feeding to provide a total of 575ml free water/day from formula. - Enteral Feed Order every shift Enteral: Check tube placement via residual and tube visualization before initiation of formula, medication administration, and flushing tube - Regular/Enhanced diet, regular texture, Regular consistency, for diet - Enteral Feed Order every 4 hours Enteral: Flush feeding tube with 180 ml of free water per every four hours. - Torsemide Tablet 20 MG Give 4 tablet orally two times a day for edema -Physician orders did not reflect self-administration of enteral feeding by Resident #75 Review of Resident #75's care plan initiated on 04/10/25, revealed Resident #75 requires gastrostomy tube feeding related to swallowing problem. She also had an order to eat via mouth. The goal was Resident#75 would remain free of side effects or complications related to tube feeding through review date. The resident will maintain adequate nutritional and hydration status, as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. The interventions were to Check for tube placement and gastric contents/residual volume per facility protocol. and record, to observe/document/report PRN any s/sx of: Aspiration- fever, Shortness of breath, Tube dislodged, Infection at tube site, Self-extubation (pulling out g-tube), Tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Further review of care plan revealed Resident #75 has an ADL self-care performance deficit related to Disease Process, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment. The goal was for the resident to maintain the current level of function through the review date. Interventions for EATING: Resident requires assistance with eating. The care plan did not reflect Resident #75 was assessed and care planned to self-administer her own g-tube bolus feeding three times a day via the g-tube. Review of Resident #75's assessment for self-administration of bolus feeds reflected it was not completed on initial admission on 12/18/24 and on current admission on 04/02/25. Review of Resident #75's vitals and weights from 12/18/24 to 04/03/25 revealed no concerns with weight loss. Resident #75 maintained weight of 79.2 to 84 pounds. In an observation and interview with Resident #75 on 04/13/25 at 1:50 PM, Resident #75 was in her room. She stated she had eaten some lunch, but she had a very poor appetite. She said she was going to do her bolus feeding via her g-tube. Resident #75 had five cartons of formula, a clear cup with water, a syringe dated 04/13/25 on it and extra clear cups with measuring numbers printed on them. She stated she had been trained by two awesome nurses that were no longer working for the facility. She stated she was very comfortable doing her own formula feeding, but she gets tired of doing all 3 meals by herself. She stated it would be nice if the facility staff could help her with some tasks and not just assume she could do everything by herself. She said some nurses observed or supervised when she first admitted (12/18/24), but now they just bring her the formular cartons and set up a new syringe and change her dressing every night. She stated she had informed the nurses, but she could not remember the names of those who she had complained to. In an interview with LVN C on 04/14/25 at 09:13 AM, it was revealed that she was assigned to Resident #75, and she was going to monitor Resident #75 with her bolus feedings. She stated Resident #75 had been trained to self-administer her own feeding during her multiple stays at the facility. She said she was allowed to do it with us watching her and I make sure that I watch her when she is doing her own feedings. She said whenever Resident #75 had any questions about her g-tube use LVN C had educated her. LVN C stated she monitored Resident #75 as she did her own feeding, and she had no concerns with the procedure. LVN C stated she did not do an assessment for Resident #75 to self-feed, and she did not do the care plans for the residents. In an interview with ADON on 04/14/25 at 11:45 AM, she said she was aware of Resident #75 requesting more help with her bolus feeding. She said Resident #75 told her that she was getting tired of doing all her own feeds. ADON said she educated Resident #75 on Friday (04/11/25) that with the new order of increased fluid intake of 180 ml free water every 4 hours and decreases of Torsemide Tablet from 40 mg to 20 mg, the nurses were now going to be doing all of Resident #75's feedings and water flushes via g-tube. ADON said Resident #75 can be forgetful at times and may have forgotten that the nurses would be doing her feeds and water flushes now. ADON stated she had communicated with the nurses, and they were all aware that they were required to do the feedings and water flushes for Resident #75. ADON stated she is not sure who had brought into Resident #75's room the formula cartons because she took everything out of her room Friday after she had a conversation and an understanding that nursing would do all feeds and water. ADON said they are monitoring Resident #75's weight and that the G-tube was for supplemental due to poor oral intake. ADON said the expectation was that the nurses would give the feeding and water. ADON stated she believes that Resident #75 was care planned and assessed to self-administer. In an interview with MDS Nurse on 04/15/25 at 1:15 PM, it was revealed that MDS nurses with the IDT (nursing, dietary, ADON, MDS, DON) completed care plans and if a resident was able to self-administer then it should be care planned. She said Resident #75 had been admitted several times and she had been trained on g-tube self-administration because she was discharging home by herself, and she was also assessed that she could administer her own feeding without any issues. MDS nurse said nursing had notes stating that Resident #75 was receiving training for g-tube management before going back to the hospital on 3/24/25. She said she would not speculate the risk to the resident without confirming with the DON that the care plan and assessments for self-administration were not completed. In a phone interview with the dietician on 04/15/25 at 01:33 PM, it was revealed that Resident #75 was being monitored for weight loss. She said nursing was responsible for assessing and care planning for Resident #75's g-tube self-administration. She stated Resident #75 was admitted to the facility in December 2024 on tube feeding as a supplemental nutrition due to being underweight. She said it was important to assess the resident so that you can know volume being taken in, frequency of feeding, know that she will have water needed before and after each feeding, what to do if she is unable to tolerate the feeding. The Dietitian said she was not responsible for completing the care plans and assessment, and she cannot edit any of the documents, however she would tell nursing her recommendations to ensure the resident was meeting nutritional need and maintaining current weight. In an interview with LVN E on 04/15/25 at 02:53 PM, she said she had been at the facility for six months. She said she was in-serviced on removing all formula and feeding from Resident #75's room because the nurses will be doing all her bolus feeding and water flushes. She said the times that she has taken care of Resident #75 she always supervised her feedings. She said Resident #75 can check the residual by pulling the syringe back to check the amount and she knows how to do flushes before feeding and after. She said as long as the resident was trained in how to do her feeding correctly there was no harm. She said it was important to monitor her feeding so that they can record her input. LVN E said she did not investigate the g-tube assessments and care planning because it was not in her scope of practice to complete care plans as an LVN. She said the MDS, ADON or DON completed the care plans. In an interview with DON on 04/15/25 at 02:29 PM, she said training for g-tube use was provided for Resident #75 before she went home in a previous visit. She said Resident #75 was trained by nursing and NP to self-feed. She said she was responsible for making sure that all care areas of the residents were care planned. She said the expectation was that the nurse supervised the resident during feeding. She stated she would not speculate on the risk because the issue was that, it was just a paper trail that was missed and it did not impact the residents wellbeing. Review of facility Policy Enteral Nutrition revised November 2018 reflected in part: 8. The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and provider also monitor the resident for worsening of conditions that place the resident at risk for the above. 17.Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented, and any changes are made to the care plan. Input from the resident or legal representative is included in the assessment .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents, for two Residents (Res#24 and Res#196) of two residents reviewed for medication use, in that: MA administered Resident #24's Gabapentin (ordered for treatment of pain) and Resident #196's Creon Oral Capsule Delayed Release Particles 3000-9500 Unit (ordered for Exocrine Pancreatic Insufficiency) greater than one hour after the scheduled administration time. Resident #24 and Resident #196 did not receive their scheduled 8:00 am medications until after 9:30 am on 04/14/2025. MA was arriving on the Hall 4 with medication cart to begin the Med pass at 9:30 am. This failure could place Res #24 at risk for continued pain and Res #196 at risk for not being able to digest and absorb important nutrients with each meal. The findings were: Record review of Resident # 24's face sheet dated 04/15/2025, revealed a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included: Other Specified Disorders of the Muscle (specific types of muscle tightness, dysfunctions of individual muscles, and metabolic disorders affecting muscle function): Cellulitis of Right Lower Limb (a bacterial infection of the skin and underlying tissues, often affecting the lower leg); Non-pressure Chronic Ulcer of Other Part of Right Foot with Fat Layer Exposed (a long-lasting open sore that develops on a specific area of the foot); Charcot Joint, Unspecified Site (a progressive condition that causes the bones and joints in the foot to degenerate). Record review of Resident #24's admission MDS assessment, dated 03/22/2025, reflected Resident #24 had a BIMS of 15, indicating he was cognitively intact. Record review of Resident #24's care plan, dated 11/02/17, revealed Resident #24 has discomfort r/t Neuropathy (any nerve damage that causes pain, numbness, tingling, swelling, or weakness in different parts of the body), Arthritis Disease, and Planter Foot pain. The Approach was to administer medication as ordered per MD (Medical Doctor). Record review of Resident #24's April MAR revealed the following order: Gabapentin Tablet 600 MG, Give 1 tablet by mouth three times a day for neuropathy. Times: 8:00 am, 1400 pm, 2000 pm. Start date of 03/22/2025. In an interview on 04/14/2025 at 9:30 AM with Resident #24 he said he had not received his 8:00 AM pain medications. Medication had not been initialed as given at 8:00 am on 04/14/2025 on the April MAR. In an interview on 04/14/2025 with Resident #24 revealed that his feet were hurting at that time, and he was uncomfortable. Resident #24 should have gotten his pain medication at 8:00 am. In an interview on 04/14/2025 at 9:30 am the MA revealed that she was just arriving on Hall 4 to start passing the medications. The MA was responsible to give Resident #24's and Resident #196's medications to them. In an interview on 04/14/2025 at 9:40 am the ADON revealed that the MA was late because she had participated in Med Pass observation with the Nurse Surveyor at 6:30 AM. This was the reason for the Med Aide to be late passing her 8:00 AM medications. Record Review of Resident #196's face sheet dated 04/15/2025, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Bullous Pemphigoid (a rare condition causing large fluid-filled blisters); Exocrine Pancreatic Insufficiency (a digestive disorder that occurs when the pancreas doesn't produce enough digestive enzymes, or the enzymes it does produce do not function properly); Other Specified Diseases of Pancreas (Inflammation of the pancreas caused by its own digestive chemicals); Antineoplastic Chemotherapy Induced Pancytopenia (condition where patient undergoing chemotherapy experiences a significant decrease in all blood cell types: red blood cells (anemia), white blood cells (neutropenia), and platelets (thrombocytopenia). Record review of Resident #196's admission MDS assessment, dated 04/13/2025, reflected Resident #196 had a BIMS of 15, indicating he was cognitively intact. Record review of Resident #196's care plan, dated 04/14/2025, reflected Resident #196 has an alteration in gastrointestinal status r/t Bullous Pemphigoid, Exocrine Pancreatic Insufficiency, Gastroesophageal reflux (stomach acid or bile irritates the food pipe lining), Other Specific Disease of Pancreas. The approach was to administer medications as ordered with meals. Record review of Resident #196's April MAR revealed the following order: Creon Oral Capsule Delayed Release Particles 3000-9500 Unit (Pancrelipase Lipase-Protease-Amylase). Give 3 capsules by mouth with meals for Exocrine Pancreatic Insufficiency. Times: 8:00 am, 1200 pm, 1700 pm. Start date of 04/11/2025. Medication had not been initialed as given at 8:00 am on 04/14/2025 on the April MAR. Interview on 04/15/2025 at 9:15 am with Resident #196 revealed that he had not received his Creon medication that his physician ordered for him to take with each meal to help with his food digestion. Interview on 04/15/2025 at 03:15 pm with the DON revealed the MA was late in passing the morning medications on 04/14/2025 r/t she had completed the medication pass with the state surveyor at 6:30 am. For this reason, her schedule was behind. The MA passes the medications for Hall 1 and Hall 4. The DON revealed that the Medication Administration Policy includes the one hour before and one hour after times and follow a liberal medication pass according to resident's preferences. DON stated she would not speculate on risk of medications not being given to residents as ordered. The DON revealed that the medication for Resident #196 will be placed on the nurse's medication cart to ensure that he received his medication with each meal. Interview on 04/15/2025 at 3:30 pm with the ADM revealed that he expects the staff to follow the policy on medication administration. The ADM stated he would not speculate the risk of medications not being given to residents as ordered. Record review of the facility's policy on, Administering Medications, dated April 2019 revealed, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review the facility failed to develop and implement a person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs 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 1 (Resident #75) of 1 resident reviewed for Care plan in that: The facility failed to care plan Resident #75 self-feeding via the g-tube three times a day since admission on 04/02/2025. This failure could place residents at risk of needs not being met and a decline in resident's health. Findings included: Review of Resident #75's admission record dated 04/13/25, revealed she was a [AGE] year-old female with an initial admitted [DATE] and readmitted [DATE]. Her primary diagnosis was lack of coordination. Her secondary diagnoses included progressive systemic sclerosis (this is an autoimmune disease that causes the body to produce too much collagen which causes the skin and internal organs to harden and tighten), dysphagia/oropharyngeal phase (difficulty swallowing), idiopathic nonspecific intestinal pneumonitis (this is an unknown cause of chronic lung diseases), unspecified severe protein calorie malnutrition, Reynaud's syndrome without gangrene (this is a condition in which some areas of the body feel numb and cool), idiopathic hypotension (low blood pressure upon standing with an unknown cause) and gastroparesis (a stomach condition affects stomach muscles). Resident #75 was her own responsible party. Review of Resident #75's quarterly MDS dated [DATE] reflected Resident #75 had a BIMS score of 15, indicating she was cognitively intact. She makes herself understood, and she understands others. The document reflected Resident #75 had a feeding tube and received 51% or more of her nutrition through the feeding tube. The document also reflected Resident #75 required supervision or touching assistant with eating ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of Resident#75's April 2025 physician orders reflected . - Enteral Feed Order every shift Enteral: Enteral Nutrition via Bolus: [Brand name] 1.5 calorie 120 ml TID per day via bolus via peg tube with meals.1.5kcal,17 grams protein, 50ml free water before and after bolus feeding to provide a total of 575ml free water/day from formula. - Enteral Feed Order every shift Enteral: Check tube placement via residual and tube visualization before initiation of formula, medication administration, and flushing tube - Regular/Enhanced diet, regular texture, Regular consistency, for diet - Enteral Feed Order every 4 hours Enteral: Flush feeding tube with 180 ml of free water per every four hours. - Torsemide Tablet 20 MG Give 4 tablet orally two times a day for edema (swelling) -Physician orders did not reflect self-administration of enteral feeding by Resident #75 Review of Resident #75's care plan initiated on 04/10/25, revealed Resident #75 requires gastrostomy tube feeding related to swallowing problem. She also had an order to eat via mouth. The goal was Resident#75 would remain free of side effects or complications related to tube feeding through review date. The resident will maintain adequate nutritional and hydration status, as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. The interventions were to Check for tube placement and gastric contents/residual volume per facility protocol and to record, to observe/document/report PRN any s/sx of: Aspiration- fever, Shortness of breath, Tube dislodged, Infection at tube site, Self-extubation (pulling out g-tube), Tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Further review of care plan revealed Resident #75 has an ADL self-care performance deficit related to Disease Process, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment. The goal was for the resident to maintain the current level of function through the review date. Interventions for EATING: Resident requires assistance with eating. The care plan did not reflect Resident #75 was assessed and care planned to self-administer her own g-tube bolus feeding three times a day via the g-tube. Review of Resident #75's vitals and weights from 12/18/24 to 04/03/25 revealed no concerns with weight loss. Resident #75 maintained weight of 79.2 to 84 pounds. In an observation and interview with Resident #75 on 04/13/25 at 1:50 PM, Resident #75 was in her room. She stated she had eaten some lunch, but she had a very poor appetite. She said she was going to do her own bolus feeding via her g-tube. Resident #75 had five cartons of formula, a clear cup with water, a syringe dated 04/13/25 on it and extra clear cups with measuring numbers printed on them. She stated she had been trained by two awesome nurses that were no longer working for the facility. She stated she was very comfortable doing her own formula feeding, but she gets tired of doing all 3 meals by herself. She said some nurses observed or supervised when she first admitted (12/18/24), but now they just bring her the formular cartons and set up a new syringe and change her dressing every night. She stated it would be nice if the facility staff could help her with some tasks and not just assume she could do everything by herself. She stated she had informed the nurses, but she could not remember the names of those who she had complained to. In an interview with LVN C on 04/14/25 at 09:13 AM, it was revealed that she was assigned to Resident #75, and she was going to monitor Resident #75 with her bolus feedings. She stated Resident #75 had been trained to self-administer her own feeding during her multiple stays at the facility. She said she was allowed to do it with us watching her and I make sure that I watch her when she is doing her own feedings. She said whenever Resident #75 had any questions about her g-tube use LVN C had educated her. LVN C stated she monitored Resident #75 as she did her own feeding, and she had no concerns with the procedure. LVN C stated she did not do an assessment for Resident #75 to self-feed, and she did not do the care plans for the residents. In an interview with ADON on 04/14/25 at 11:45 AM, she said she was aware of Resident #75 requesting more help with her bolus feeding. She said Resident #75 told her that she was getting tired of doing all her own feeds. ADON said she educated Resident #75 on Friday (04/11/25) that with the new order of increased fluid intake of 180 ml free water every 4 hours and decreases of Torsemide Tablet from 40 mg to 20 mg, the nurses were now going to be doing all of Resident #75's feedings and water flushes via g-tube. ADON said Resident #75 can be forgetful at times and may have forgotten that the nurses would be doing her feeds and water flushes now. ADON stated she had communicated with the nurses, and they were all aware that they were required to do the feedings and water flushes for Resident #75. ADON stated she is not sure who had brought into Resident #75's room the formula cartons because she took everything out of her room Friday after she had a conversation and an understanding that nursing would do all feeds and water. ADON said they are monitoring Resident #75's weight and that the G-tube was for supplemental due to poor oral intake. ADON said the expectation was that the nurses would give the feeding and water. ADON stated she believes that Resident #75 was care planned and assessed to self-administer. In an interview with MDS Nurse on 04/15/25 at 1:15 PM, it was revealed that MDS nurses with the IDT (nursing, dietary, ADON, MDS, DON) completed care plans and if a resident was able to self-administer then it should be care planned. She said Resident #75 had been admitted several times and she had been trained on g-tube self-administration because she was discharging home by herself, and she was also assessed that she could administer her own feeding without any issues. MDS nurse said nursing had notes stating that Resident #75 was receiving training for g-tube management before going back to the hospital on 3/24/25. She said she would not speculate the risk to the resident without confirming with the DON that the care plan and assessments for self-administration were not completed. In a phone interview with the dietician on 04/15/25 at 01:33 PM, it was revealed that Resident #75 was being monitored for weight loss. She said nursing was responsible for assessing and care planning for Resident #75's g-tube self-administration. She stated Resident #75 was admitted to the facility in December 2024 on tube feeding as a supplemental nutrition due to being underweight. She said it was important to assess the resident so that you can know volume being taken in, frequency of feeding, know that she will have water needed before and after each feeding, what to do if she is unable to tolerate the feeding. The Dietitian said she had not input on the care plan and assessment, and she cannot edit any of the documents, however she would tell nursing her recommendations to ensure the resident is meeting nutritional need and maintaining current weight. In an interview with LVN E on 04/15/25 at 02:53 PM, she said she had been at the facility for six months. She said she was in-serviced on removing all formula and feeding from Resident #75's room because the nurses will be doing all her bolus feeding and water flushes. She said the times that she has taken care of Resident #75 she always supervised her feedings. She said Resident #75 can check the residual by pulling the syringe back to check the amount and she knows how to do flushes before feeding and after. She said as long as the resident was trained in how to do her feeding correctly there was no harm. She said it was important to monitor her feeding so that they can record her input. LVN E said she did not investigate the g-tube assessments and care planning because it was not in her scope of practice to complete care plans as an LVN. She said the MDS, ADON or DON completed the care plans. In an interview with DON on 04/15/25 at 02:29 PM, she said training for g-tube use was provided for Resident #75 before she went home in a previous visit. She said Resident #75 was trained by nursing and NP to self-feed. She said she was responsible for making sure that all care areas were care planned. She said the expectation was that nurse supervises the resident during feeding. She stated she would not speculate on the risk because the issue was that, it was just a paper trail miss and it did not impact the resident's wellbeing. Review of facility policy Care plans, comprehensive Person Centered revised January 2025 revealed . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and review, the facility failed to ensure Parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Resident #246) of four residents reviewed for intravenous fluids. The facility failed to change Resident #246's PICC line dressing which was loose, unsealed, and not intact before administering her antibiotic on 04/13/25. This failure could place residents at risk for catheter related blood stream infection. Findings included: Review of Resident #246's admission record dated 04/13/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnoses were osteoarthritis of right knee (pain and swelling of right knee) and osteomyelitis of the vertebra lumbar region (bone infection in the spine area). Secondary diagnoses were surgical aftercare following orthopedic surgery, reduced mobility (movement), mixed cholesterol, pain in right knee, idiopathic (unknown cause) peripheral automatic neuropathy (nerve damage). unspecified dementia (this is a brain disease that alters brain function and causes cognitive decline), and insomnia (trouble falling asleep). Review of Resident #246's April 2025 physician order on 04/13/25, reflected: -Monitor IV site for signs and symptoms of infection or infiltration (liquid/swelling across barrier of skin). If negative findings inform MD. Every shift for monitoring. -Piperacillin Sodium-Tazobactam Solution Reconstituted 3-0.375 Gram Use 3.375 gram intravenously every 8 hours for Lumbar 3-Lumbar 4 Abscess (pus)/osteomyelitis (bone infection)/Discitis (disc infection) for 6 Weeks. - Daptomycin-Sodium Chloride Intravenous Solution 350-0.9 Milligram/50 Milliliter-% (Daptomycin-Sodium Chloride). Use 350 Milligram intravenously one time a day for Complicated skin infection due to Enterococcus faecalis bacteria for 6 Weeks. -Change peripheral IV site and tubing every 72 hours or as needed Review of Resident #246's care plan initiated on 04/11/25 revealed she was on IV medication. The goal was that Resident #246 would have no complications related to IV therapy through the review date. The interventions were to Monitor IV site for signs and symptoms of infection or infiltration. If negative findings to notify MD, to change dressing as ordered, to change IV site and tubing as ordered, and to Flush IV as ordered. Review of Resident #246's admission MDS dated [DATE] did not reflect a BIMS score. In an observation and interview on 04/13/25 at 12:17 PM, Resident #246 was lying on her back in her bed with family at bedside. She was attached to an IV pole getting IV medication. The medication was an antibiotic Daptomycin350 mg in 0.9% Sodium Chloride set at 100 milters/hour on the IV line. She had a single lumen PICC (lumen is a part of the IV catheter port for access from vein to the outside of the skin) on her right upper arm. Her PICC line dressing was loose, lifted on the right side, unsealed, and the bio patch that secures the PICC line was intact but exposed to air on the right outer side. The PICC line dressing was coming off and appears to have been reinforced previously with paper tape that was hanging off the edge but not sealing the PICC line dressing. The PICC line entry site window was visible, and it did not appear red, no signs and symptoms of infection or infiltration were observed, and it was clean. The PICC line dressing was dated 4/6/25. Resident #246 was non interviewable. Resident #246's family stated Resident #246 was admitted five days ago due to an infection in her back after getting back surgery. Family said she was not sure if the PICC line was replaced when Resident #246 admitted to the facility, or it was the same one inserted while she was in the hospital. Family stated Resident #246 may have been itching and scratching and could have caused the tape to become loose. She said she did not know if the dressing was changed. An interview with LVN B on 04/13/25 at 12:38 PM revealed he was Resident #246's nurse and he was the one that started the antibiotics for Resident #246 today. LVN B said he saw the dressing was loose and not intact when he started the antibiotic [Daptomycin] which takes almost an hour to complete and after that, he would hang another antibiotic [Piperacillin] and, when he was finished with the two antibiotics, he was planning on changing the PICC line dressing. He stated, I wanted to finish the antibiotics first before I changed the dressing. He said he did not know how often Resident #246's PICC line dressing was scheduled to be changed without looking in the computer to see her orders for PICC line dressing. He said normally it was every 7 days on Wednesday. He stated that he knew how to perform a PICC line dressing change, and he had been trained, and he was going to change Resident #246's after he was done with the antibiotics. He stated he had not changed it yet even if it was loose and unsealed because he was planning on doing it later. He stated it was important to make sure that PICC line dressing was sealed and intact for infection control. LVN B stated that he would notify the surveyors to observe the PICC line dressing change. An interview with LVN C on 04/14/25 at 8:44 AM revealed Resident #246's PICC line dressing was changed yesterday (04/13/25). She said, PICC line dressing changes were to be completed whenever they were soiled, loose, or as ordered every Wednesday unless the date fell before Wednesday then it was changed on the due date. LVN C said PICC line dressing was to be changed using a sterile kit per policy and procedure and documentation of dressing changes were to be charted in the MAR . An interview with the DON on 04/14/25 at 07:12 AM revealed PICC line dressing changes were to be completed by the assigned nurses as needed and or every Wednesday. She said when dressing was loose and coming off it should be changed or reinforced so that it was sealed for infection control, to keep the site clean, and for protection. She said LVN B was in-serviced immediately. In an interview with LVN E on 04/15/25 at 02:53 PM, she said she had been at the facility for six months. She said she had been in-serviced about IV dressings and infection control. She said IV dressings are expected to be changed every Wednesday or unless the due date falls on a different day then they are changed on that day. She said the PICC line dressing should be clean, dry, and intact. She said it was important to protect the integrity on the line and to prevent infection. In an interview with the DON on 04/15/25 at 3:17 PM, DON stated she was not informed by LVN B that surveyor wanted to observe the PICC line dressing change for Resident #246. She stated she would not speculate on the risk to the resident, however, the expectation was that the nursing staff would follow policy and procedure for changing PICC line dressing as needed and every 7 days per policy. An interview with the ADM on 04/15/25 at 3:49 PM revealed that all nurses were responsible for following policy and procedures for assessing PICC line dressings and completing dressing changes as ordered. He stated he could not speculate on the risk of not doing a PICC line dressing change but the expectation was that all staff follow company policies and procedures and to always use the best nursing judgement when taking care of the residents. Review of Resident #75's MAR on 04/14/25 revealed Change PICC dressing every seven days or as indicated for soiled or damaged dressing. External length 0cm and arm circumference 7cm. Notify MD of negative findings. Change stabilization device and injection caps with each dressing change. Every shift every Wed for maintenance was completed on 04/13/2025 at 4:31 PM by ADON. Review of nurse competency, nurse check off and Midline (this is a type of IV, a soft, flexible catheter inserted into a vein used for short-term antibiotic therapy) and CVAD dressing change certificate dated 04/14/25 revealed LVN B had completed all training on 04/14/25. Review of facility in-service dated 04/14/25, titled Infection control, pain medication, OTC medication at bed side, giving medications with meals and Locking Medication led by DON revealed eleven nursing staff had completed the in-service. Record review of the facility's policy titled Midline dressing changes revision date April 2016, reflected: Policy: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way .

Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director Qualifications. The facility did not ensure the Activity Director completed the required training to serve as the director of the activities program. This failure could place residents at risk of not having an overall skilled and knowledgeable Activities Director to direct an effective activities program, which could result in the residents not receiving activities to meet their needs. Findings include: Record review of the Activity Director's Personnel record revealed her hire date was 01/03/22 and there was not any documentation of certification or Activity CEU's or therapist certification in her file. Interview on 12/12/22 at 10:15 am, the Administrator stated their Activity Director was currently working to get her Activity Director Certification and they had no other Certified AD who worked at this facility. Interview on 12/13/2022 at 4:32 pm, the Activity Director stated she started working at this facility in January 2022 and did not have her Activities Director certification. She stated the Administrator told her when she became the AD, she would have to complete a certification class. She stated the MEPAP course was a self-paced online program she started about six months ago. She stated she did not have a bachelor's degree and was not an Occupational Therapist and Occupational Assistant. She stated she knew what she was doing as an AD and talked to the SW or MDS nurse if she had any questions about anything. She stated she planned the resident's day to day activities such as cooking, coloring, baking and anything they could have potentially done in the past. She stated she graduated from high school last year and worked at a restaurant and as the receptionist at this facility before getting the AD position. She stated she had completed 85% of the MEPAP certification course. She stated not being a certified AD could cause her to be incapable of doing her job effectively and could also lose this job if she did not get certified. She stated if she had the opportunity to have completed the MEPAP course before she became the AD she would have done so. Interview on 12/14/22 at 3:25 pm, the Administrator stated the AD started working at this facility as a receptionist a year ago and she became the AD around February or March 2022. He stated he was aware the AD had to be certified and the facility's AD started her Activity Director Certification in April 2022. He stated the AD should complete her certification training around the end of January 2023 and stated she had no other qualifications to be the AD. He stated the AD was supervised by the Social Worker and the Occupational Therapist and the Occupational Therapiat was not directing the Activity program and completing the resident's Activity Assessments. He stated none of the residents were affected from not having a qualified AD, and the only negative outcome was that the facility would be getting a deficiency. He stated there was no harm or negative outcomes to the residents for not having a qualified AD. Record review of the Facility's Activity Director's Job Title undated revealed, Responsibilities: Work in planning, coordinating and providing an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest, and physical, mental and psychosocial well-being of each resident. Arrange for use of any community facilities. Recruits, orients, and supervises the volunteer program of the facility and provides all necessary documentation .Qualifications: Completed an activity director training course approved by any state. These courses must be approved by recognized body, such as the National Certification Council for Activity Professionals, the National Therapeutic Recreation Society, or the Consortium for Therapeutic/Activities Certification . Record review of the Facility's Activity Programs - Staffing policy dated 2001 and revised August 2006 revealed, Policy Statement: Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interest of each resident .Policy interpretation and Implementation: 1. Our activity programs are under the direct supervision of a qualified professional who: is a qualified therapeutic recreation specialist .has two (2) years of experience in a social or recreational program within the last five (5) years .is a qualified Occupational therapy or Occupational therapy assistant or has completed a training course approved by the state

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (LVN C and MA D) of 2 staff observed for infection control practices. While administering Resident #77's medications, LVN C did not change gloves or perform hand hygiene between touching the PEG tube, feeding pump tubing, syringe, and bed sheet and putting her hand in a cup of water to retrieve the medication stirrer. MA D failed to touch medication dose cups on exterior surfaces only. These failures could place residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Observation on 12/12/22 at 8:44 AM revealed LVN C donning gloves to administer crushed medications in individual dose cups to Resident #77 by placing 5 ML of water into crushed medication and stirring with a wooden spoon, then dropping the wooden spoon into a filled cup of water. LVN C poured the dose cup contents into a syringe connected to PEG tube, using gloved hands to touch PEG tube, feeding pump tubing, syringe and bed sheet. LVN C did not change/remove gloves after administering medications and before LVN C poured 5 ML of water from water cup containing wooden spoon and then use gloved fingers to reach into water and retrieve wooden spoon which LVN C again used to stir dose cup containing water and crushed medications. LVN C was observed to repeat same process for multiple medications given individually. LVN C was observed to use the same gloves throughout medication administration process. Observation of MA D during routine medication pass revealed MA D repeatedly using bare hand(s) to touch dose cup lips and carrying dose cups using thumb and forefinger with forefinger on inside of cup and thumb on outside of dose cup(s) containing medication. Interview on 12/12/22 at 10:00 AM with LVN C stated she had always dropped wooden spoon (used to stir medications when adding water to dose cup medications) into cup of water used for medications and PEG tube flush and then used fingers to retrieve spoon to stir next medication. LVN C stated she was followed by surveyor on last survey and was not cited for same action. LVN C stated she did not realize she had allowed syringe tip to touch bed sheets. LVN C stated allowing syringe to touch sheet was cross contamination and should not occur. LVN C stated she had not changed gloves after administering each medication. When surveyor asked LVN C why she had touched feeding pump tubing, PEG tube, syringe and bed sheets and then used same gloves to retrieve wooden spoon from water used for medications and PEG tube flushes, LVN C responded she had always administered PEG tube medications that way and no one had ever said anything. When surveyor asked if cross-contamination was an issue LVN C responded, Yes. Interview and Observation on 12/12/22 at 8:14 AM with MA D stated she knew she was not supposed to carry dose cups of medication by placing one finger on inside of cup and thumb in another dose cup (MA D made a pinching motion with thumb/index finger). MA D stated she had a tray, somewhere, for the purpose of carrying medication but failed to use tray because she was in a hurry and just didn't think of using tray. MA D stated she could have contaminated dose cups with germs and caused resident to become sick. MA D stated she had been in-serviced on Infection Control many times by various nurses. MA D stated only dose cup sides should be touched to prevent cross contamination. Interview on 12/13/22 at 10:15 AM with ADON A stated the inside of dose cups should not be touched, that it was cross contamination. ADON A stated all nursing staff was in-serviced to never touch inside of dose cups because that was contamination and had the potential to cause resident illness. Interview on 12/13/22 at 10:19 AM with ADON B stated medication cups should only be touched on outside of container, away from container lip; stated touching inside of container could cause resident illness. Interview on 12/13/22 at 1:43 PM with the Administrator of MA D picking up dose cups (containing medication) using thumb and forefinger, with one digit grasping inside of cup and 2nd digit grasping outside of cup. Administrator stated he did not know all of the nursing processes; that he left that part to the DON. The Administrator stated staff was being in-serviced on proper procedure. Interview on 12/13/22 at 3:00 PM with the DON stated all nurses/med-aides were in- serviced to only touch med cups on outside of cups. DON stated grasping dose cups with one digit on the inside of the pill cup was contamination and should not occur. The DON stated RN H in-serviced medication-aides and nurse aides on Infection Control. The DON stated RN L had in-serviced all nurses yesterday on Infection Control with return demonstration. Record review of the policy Infection Prevention and Control dated August 2016 revealed . 7. Prevention of Infection 3. educating staff and ensuring that they adhere to proper techniques and procedures. www.dhhs.ne.gov/schoolhealth Summary of 14 Areas of Competency for Medication Administration by Unlicensed Assistive Personnel 1. Recognize the recipient's right to personal privacy. 2. Recognize the recipient's right to refuse medication. 3. Maintain hygiene and standards of infection control. 4. Follow facility procedures regarding storage, handling, and disposal of medications. 5. Recognize general conditions when the medication should not be given. 6. Accurately document all medications: Student name, medication name, dose, route, time administered, or refusal. 7. Follow the Five Rights: a. Right Person b. Right Medication c. Right Time d. Right Dose e. Right Route f. A sixth right is documenting the five rights of medication administration

Based on interview and record review, the facility failed to ensure the Pre Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #60) of one residents reviewed for PASRR Screenings. The facility failed to recognize Resident #60 who had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Review of Resident #60's Face Sheet revealed, A [AGE] year-old male who readmitted to the facility 03/13/15 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Diagnosis/History revealed the onset of the major depressive disorder was 08/11/12 and the unspecified [CONDITION(S)] on 03/13/15. Review of Resident #60's Doctor Order Summary Report dated 10/07/21 revealed, Monitor for target behaviors every shift for use of anti-depressant medication. Medications included: [MEDICATION(S)], famotidine, [MEDICATION(S)], and [MEDICATION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 3 severely impaired, rejection of care happened 1-3 days, transfers extensive assist of one person, walking: did not occur, used a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 6 severely impaired., ADL's extensive assist of one person for dressing, toilet use, and personal hygiene, used of a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Review of Resident #60's Psychiatric Initial assessment dated [DATE] revealed the reason for the referral was Depression and Adjustment Disorder. Review of Resident #60's Care plans undated revealed, [CONDITION(S)], unspecified convulsions, unspecified [CONDITION(S)] ., major depressive disorder ., at risk for alteration in psycho-social well-being, cognitive impairment, at risk for falls . Review of Resident #60's PASRR Level 1 screen dated 03/03/15 revealed, Submitter information was the facility, Referring Entity: the facility .C. 100. Mental Illness: No . This was his only PASRR Level 1 Screen found in the SIMPLE LTC system. Observation and interview on 10/05/21 at 12:39 PM Resident #60 sat in a wheelchair in his room, dressed, well groomed, and watching TV. Resident # 60 shook his head yes when asked if he was treated well, shook his head yes when asked if he got the help he needed when he needed it, he giggled with each question and indicated he had no concerns. He said the food was [NAME] and this was the only negative thing he had to say. Interview on 10/07/21 at 12:54 PM the Administrator stated the SW was responsible for the PASARRs. Interview on 10/07/21 at 2:37 PM ADON A stated the MDS Coordinator and SW are responsible for PASRR. Interview on 10/07/21 at 3:20 PM the SW stated he had been here for 2 months. After surveyor explained about the PASRR for Resident #60 the SW said the PASRR records were in Medical Records and he would go and see if he could find Resident #60's PASARR Level One. On 10/07/21 at 3:40 PM the SW brought me the Level one screen from Resident #60'd admitted d 03/03/15. He did not know about Resident #60's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/07/21 at 3:55 PM the SW came and had Resident #60's Face Sheet with a re-admitted [DATE]. He stated maybe the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked the SW to look in the PASRR system and see if there were any other PASRR Screens or evaluations for Resident #60 the SW said Resident #60 had been in the facility since 2014 or 2015, and the only PASRR screen was from 2015 and he was not noted to have the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor showed him the face sheet on the computer which had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW agreed and stated he was going to email the MHMR PASARR Coordinator for this building and get Resident 60's status updated so they could come and evaluate him. Interview on 10/07/21 at 4:00 PM, requested Resident #60's Admission MDS and most recent annual MDS from the DON and explained about the PASARR problem. She stated Resident #60 was just admitted . When informed he had been here for a number of years, she said she would look into it. Interview on 10/07/21 at 4:05 PM, the MDS Coordinator brought Resident #60's most recent Annual MDS and then a quarterly. When asked to get the original admission MDS and the most recent annual, she stated he had come in 2015 and she did not have access to it as the facility had belonged to another company who used a different computer system. The surveyor requested Resident #60's 2020 annual MDS assessment. MDS Coordinator stated she would go and see. Asked her for the communication between the facility and Medicaid about when the facility had contacted them and what was documented. She did not know what we were talking about. SIMPLE LTC Medicaid portal (Long term care software company) she stated is the only place she goes to and she does not know what we were talking about. Interview on10/07/21 at 4:56 PM, the BOM stated she was responsible for checking the SIMPLE LTC Medicaid portal daily for Medicaid eligibility, 3618/3619 (Medicaid eligibility forms), issues/alerts and MDS Coordinator and SW are responsible for the PASRR and she would alert the MDS Coordinator about any (Medicaid eligibility) issues. Interview on 10/07/21 at 5:02 PM, the Admission Director had been working at the facility for three months and she got resident PASRRs from whoever agency (hospital, doctor office) sent the resident and the PASRR form was forwarded to them from the hospital, doctor office or wherever the resident came from. She said she does not really do much with PASRR, but she had access to epic (hyperspace healthcare system). Interview on 10/07/21 at 5:05 PM, the SW stated MDS Coordinator checked the simple ltc portal. If there was an alert for a resident, she would check their PASRR screen to make sure they were accurate. They had not had any issues, Resident 60's PASRR 1 was checked by someone else prior to him working at the facility. The SW also said he was kind of new to the PASRR and had not had any training, he was not able to access the PASRR system, for Resident #60, he had not had any alerts from MDS Coordinator. The SW said he had simple ltc portal and he would print them out from there for today but had not seen any alerts for Resident #60. The SW said they had 2 MDS nurses before but now they have one MDS Nurse who was responsible for checking the PASRR status in the SIMPLE LTC portal. Resident #60 did not have an evaluation because his PASRR screen did not show he had a mental illness. He stated on 10/07/21 he had emailed the MHMR PASRR Coordinator of the local authority as they would like to get him evaluated for PASRR service. He also said normally when a person was positive then they automatically got a referral to the Local Authority to do a PE (PASRR Evaluation). Interview on 10/07/21 at 5:12 PM, the MDS Coordinator had worked at the facility for 5 1/2 years. She said Resident #60 had not had a PASRR Evaluation because a no for MI would not trigger for a PASRR Evaluation. She said he had a stroke but was not getting medications for unspecified [CONDITION(S)]. After she reviewed his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator said SW was responsible for entering the PASRR 1 but they all had assess, BOM/business office manager, SW and her could check the simple ltc portal for any status updates from the LA, she checks the LTC/long term care Medicaid portal whenever she does MDS assessments and said the SW said he was going to refer Resident #60 to the local authority. She said Resident #60 was not getting PASRR because he had a negative PASRR 1 when he admitted and the reason why he had a negative was because [CONDITION(S)] and major depression were not eligible PASRR diagnoses. Interview on 10/07/21 at 5:22 PM, the Administrator stated the SW was responsible for PASRRs, they had positive residents in the facility. He stated the SW, MDS Coordinator, and rehab would check the simple LTC, but the SW was solely responsible to check the SIMPLE LTC portal. He stated the SW was trained prior to working here. He said he had to ask the SW if Resident #60 had been here for 6 1/2 years and if he was on any medications. The Administrator was not sure if they missed anything and not sure if the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He also said in theory not getting PASRR services could cause a decline in the functioning and his expectations was for the PASRR documentation to be accurate. Review of the facility's policy and procedure, Behavioral Assessment, Intervention and Monitoring dated revised March 2019 revealed: 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. It also stated: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognitive, altered behavior, substance use disorder, or mental disorder.2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of the medical record and general observations.

Based on interview and record review the facility failed to ensure residents identified with a newly evident or possible serious mental illness was referred, to determine if the resident required specialized services for one (Residents #60) of one resident reviewed for PASRR Coordination. The facility failed to submit Resident #60's PASARR 1012 (A form used to determine whether the individual has a primary dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents with a qualifying diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: Review of Resident #60's face sheet revealed, a [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Diagnosis/History revealed the onset of the major depressive disorder was 08/11/12 and the unspecified [CONDITION(S)] was on 03/13/15. Review of Resident #60's PASRR Level 1 screen dated 03/03/15 revealed, Submitter information was the facility, Referring Entity: the facility .C. 100. Mental Illness: No . This was his only PASRR Level 1 Screen found in the SIMPLE Ltc system. Review of Resident #60's doctor summary report dated 10/07/21 revealed, Monitor for target behaviors every shift for use of anti-depressant medication. Medications included: [MEDICATION(S)], famotidine, [MEDICATION(S)], and [MEDICATION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 3 severely impaired, rejection of care happened 1-3 days, transfers extensive assist of one person, walking: did not occur, used a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 6 severely impaired., ADL's extensive assist of one person for dressing, toilet use, and personal hygiene, used of a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Review of Resident #60's Psychiatric Initial assessment dated [DATE] revealed the reason for the referral was Depression and Adjustment Disorder. Review of Resident #60's Care plans undated revealed, [CONDITION(S)], unspecified convulsions, unspecified [CONDITION(S)] ., major depressive disorder ., at risk for alteration in psycho-social well-being, cognitive impairment, at risk for falls . Observation and interview on 10/05/21 at 12:39 PM Resident #60 sat in a wheelchair in his room, dressed, well groomed, and watching TV. Resident # 60 shook his head yes when asked if he was treated well, shook his head yes when asked if he got the help he needed when he needed it, he giggled with each question and indicated he had no concerns. Interview on 10/07/21 at 3:20 PM the SW stated he started working at the facility for 2 months. The SW said the PASRR records were in Medical Records and he would go and see if he could find Resident #60's PASRR Level One. Interview and record review on 10/07/21 at 3:40 PM the SW reviewed Resident #60's admission Level one screen dated 03/03/15. He did not know Resident #60's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/07/21 at 3:55 PM the SW stated after review of Resident #60's face sheet with a re-admitted [DATE]. He stated maybe the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW said Resident #60 had been in the facility since 2014 or 2015, and the only PASRR screen was from 2015 and he was not noted to have the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW agreed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/07/21 at 4:05 PM, the MDS Coordinator stated she was employed in 2015 and did not have access to Resident #60's admission MDS assessment because the facility had belonged to another company who used a different computer system. She stated SIMPLE LTC Medicaid portal (Long term care software company) was the only program she used and was not aware of any documentation of communication between the facility and Medicaid for Resident #60 . Interview on 10/07/21 at 4:56 PM, the BOM stated the MDS Coordinator and SW are responsible for the PASRRs. She was responsible for checking the simple LTC Medicaid portal daily for Medicaid eligibility forms 3618/3619 (Medicaid eligibility forms), any issues/alerts she would notify the MDS Coordinator about any (Medicaid eligibility) issues. Interview on 10/07/21 at 5:02 PM, the Admission Director had been working at the facility for three months and she got resident PASRRs from whoever agency (hospital, doctor office) sent the resident and the PASRR form was forwarded to them from the hospital, doctor office or wherever the resident came from. She said she does not really do much with PASRR, but she had access to epic (hyperspace healthcare system). Interview on 10/07/21 at 5:05 PM, the SW stated the MDS Coordinator checked the simple LTC portal. If there was an alert for a resident, she would check their PASRR screen to make sure they were accurate. They had not had any issues, Resident #60's PASRR 1 was checked by someone else prior to him working at the facility. The SW also said he was kind of new to the PASRR and had not had any training. He said was not able to access the PASRR system, and he had not received any alerts from MDS Coordinator. The SW said he had simple LTC portal and he would print them out today but had not seen any alerts for Resident #60. The SW said Resident #60 did not have an evaluation because his PASRR screen did not show he had a mental illness. He stated on 10/07/21 he had emailed the MHMR PASRR Coordinator of the local authority so they could get Resident #60 evaluated for PASRR services. He also said normally when a person was positive then they automatically got a referral to the Local Authority to do a PE (PASRR Evaluation). Interview on 10/07/21 at 5:12 PM, the MDS Coordinator had worked at the facility for 5 1/2 years. She said Resident #60 had not had a PASRR Evaluation because a no for MI would not trigger for a PASRR Evaluation. She said he had a stroke but was not getting medications for unspecified [CONDITION(S)]. After she reviewed his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator said the SW was responsible for entering the PASRR 1, and they all , BOM/business office manager, SW and herself could check the simple LTC portal for any status updates from the LA. She checks the LTC/long term care Medicaid portal whenever she does MDS assessments and said the SW said he was going to refer Resident #60 to the local authority. She said Resident #60 was not getting PASRR services because he had a negative PASRR 1 when he admitted , and the reason why he had a negative PASRR 1 was because [CONDITION(S)] and major depression were not eligible PASRR diagnoses. Interview on 10/07/21 at 5:22 PM, the Administrator stated the SW was responsible for PASRRs, they had positive residents in the facility. He stated the SW, MDS Coordinator, and rehab would check the simple LTC, but the SW was solely responsible to check the simple LTC portal. He stated the SW was trained prior to working here. He said he had to ask the SW if Resident #60 had been here for 6 1/2 years and if he was on any medications. The Administrator was not sure if they missed anything and not sure if the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He also said in theory not getting PASRR services could cause a decline in the functioning and his expectations was for the PASRR documentation to be accurate. Review of the facility's policy and procedure, Behavioral Assessment, Intervention and Monitoring dated revised March 2019 revealed: 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. It also stated: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognitive, altered behavior, substance use disorder, or mental disorder.2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of the medical record and general observations.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Residents #60) of 21 residents reviewed for Medical Records. The facility failed to identify Resident #60's inaccurate Hospital PASRR Level 1 screen and correct PASRR records, which indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place all residents at risk of inadequate care/treatment services and benefits, which could result in a decreased quality of life, physical functioning and psycho-social well-being. Findings included: Review of Resident #60's Face Sheet revealed, A [AGE] year-old male who readmitted to the facility 03/13/15 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's PASRR Level 1 screen dated 03/03/15 revealed, Submitter information was the facility, Referring Entity: the facility .C. 100. Mental Illness: No . Review of Resident #60's Diagnosis/History dated 10/07/21 revealed the onset of the major depressive disorder was 08/11/12 and the unspecified [CONDITION(S)] on 03/13/15. Review of Resident #60's doctor order summary report dated 10/07/21 revealed, Monitor for target behaviors every shift for use of anti-depressant medication. Medications included: [MEDICATION(S)], famotidine, [MEDICATION(S)], and [MEDICATION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 3 severely impaired, rejection of care happened 1-3 days, transfers extensive assist of one person, walking: did not occur, used a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Review of Resident #60's Annual MDS dated [DATE] revealed, he was not evaluated for PASRR, he had unclear speech, sometimes understood, sometimes understands, BIMS score 6 severely impaired., ADL's extensive assist of one person for dressing, toilet use, and personal hygiene, used of a wheelchair, frequently incontinent of bladder and always continent of bowel, psychiatric/mood disorder: depression (other than [CONDITION(S)]), psychotic disorder (other than [CONDITION(S)]), .[CONDITION(S)]. Interview on 10/07/21 at 4:05 PM, the MDS Coordinator stated the original admission MDS was completed when the company was under another ownership, she did not have access to it because they used a different computer system. Review of Resident #60's Psychiatric Initial assessment dated [DATE] revealed the reason for the referral was Depression and Adjustment Disorder. Review of Resident #60's Care plans undated revealed, [CONDITION(S)], unspecified convulsions, unspecified [CONDITION(S)] ., major depressive disorder ., at risk for alteration in psycho-social well-being, cognitive impairment, at risk for falls . Observation and interview on 10/05/21 at 12:39 PM Resident #60 sat in a wheelchair in his room, dressed, well groomed, and watching TV. Resident # 60 shook his head yes when asked if he was treated well, shook his head yes when asked if he got the help he needed when he needed it, he giggled with each question and indicated he had no concerns. Interview10/07/21 at 3:40 PM the SW brought me the Level one screen from Resident #60's admitted d 03/03/15. He did not know about Resident #60's diagnosis. Interview and record review on 10/07/21 at 3:55 PM the SW reviewed Resident #60's face sheet with a re-admitted [DATE] which had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW looked in the PASRR system and see if there were any other PASRR Screens or evaluations for Resident #60 the SW said the only PASRR screen the facility had was from 2015 and Resident #60 was not noted to have a mental illness. The SW stated he was going to email the MHMR PASARR Coordinator for this building and get Resident 60's status updated so they could come and evaluate him. Interview on 10/07/21 at 5:05 PM, the SW stated MDS Coordinator checked the SIMPLE LTC portal. If there was an alert for a resident, she would check their PASRR screen to make sure they were accurate. They had not had any issues, he said Resident 60's PASRR 1 was checked by someone else prior to him working at the facility. The SW also said Resident #60 did not have an evaluation because his PASRR screen did not show he had a mental illness. He stated he had sent emailed the MHMR PASRR Coordinator of the local authority as they would like to get him evaluated for PASRR service. Interview on 10/07/21 at 5:12 PM, the MDS Coordinator said Resident #60 had not had a PASRR Evaluation because a no for MI would not trigger for a PASRR Evaluation. After she reviewed his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator said Resident #60 was not getting PASRR services because he had a negative PASRR 1 when he admitted and the reason why he had a negative was because [CONDITION(S)] and major depression were not eligible PASRR diagnoses. Interview on 10/07/21 at 5:22 PM, the Administrator stated he was not sure if they missed anything and not sure if the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He had reached out to an expert. He said in theory not getting PASRR services could cause a decline in the functioning and his expectations was for the PASRR documentation to be accurate.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one (medication cart #1) of three treatment carts reviewed. The facility failed to ensure medication cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings include: An observation on 08/25/21 at 3:13 PM revealed medication cart #, on the 300 hall, was unlocked and unattended. All drawers of the medication cart could be opened, and medications were easily accessible. There was 1 resident within arm's reach of the medication cart. An observation and interview on 08/25/21 at 3:14 PM, revealed CMA A was walking out of a resident's room. He stated medication cart #1 was his. He stated he should not have left the cart unlocked and that he should have locked the medication cart. He stated it was important to ensure the cart was locked when not in use to prevent people from getting into his cart and taking medications. In an interview on 08/25/21 at 3:15 PM, DON stated when medication carts were not in use/unattended, they were to be locked to avoid drug diversions. Record review of the facility policy titled Storage of Medications, last revised April 2019, reflected: 8. Compartments (including, but not limited to, Drawers cabinets rooms refrigerators carts and boxes) containing drugs and biologicals are locked when not in use. 9 unlocked medication cards are not left unattended.

Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 1 resident (Resident #1) reviewed for consent to receive [CONDITION(S)] medications. The facility failed to obtain written consent or complete a [CONDITION(S)] Permission form and explain risks and benefits to Resident #1 and/or their responsible parties before starting the medications [MEDICATION(S)] and [MEDICATION(S)] (medications used to treat depression). This failure could place residents at risk of being unable to exercise their rights to make informed decisions regarding their treatment. Findings included: Review of facility electronic face sheet, dated 08/04/21, for Resident #1 revealed she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS, dated [DATE], reflected a Brief Interview for Mental Status score of twelve indicating moderate cognitive impairment. Resident #1 needed limited assistance with assistance of one staff for activities of daily living. Resident #2 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Care Plan, dated 03/24/20, revealed Problem: Resident is at risk for side effects from antidepressant medication use. Review of Resident #1's clinical record revealed a signed consent form for the medication [MEDICATION(S)] ,dated 06/03/21. The following sections of the consent were not completed/included: potential side effects specific to their medication and the proposed course of the medication is. A signed consent form for the medication Trazadone dated 07/19/21 reflected the following section of the consent was not completed: proposed course of the medication is. Review of August 2021 physician orders for Resident #1 reflected an order dated 06/28/21 for [MEDICATION(S)] 100 MG tablet, give two tablets to equal 200 MG, twice a day for delusional disorder and an order dated 07/19/21 for Trazadone 25 MG tablet by mouth at bedtime for [CONDITION(S)]. Review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Days initialed by staff reflected [MEDICATION(S)] was given to the resident on Tuesday, 06/29/21 thru Tuesday, 08/03/21. Resident #1 was given Trazadone 25 MG tablet by mouth at bedtime. Days initialed by staff reflected Trazadone was given to the resident on Tuesday, 07/20/21 thru Tuesday, 08/03/21, Interview on 08/04/21 at 9:50 AM with Family Member A, via telephone ,she stated a head nurse had contacted her to confirm that she wanted Resident #1 on [MEDICATION(S)], but they did not review the side effects or proposed course of the medication, and for Trazadone the proposed course of the medication was not discussed. Interview on 08/04/21 at 9:30 AM with LVN B, she stated she called Resident #1's RP on 07/19/21 regarding consent for Trazadone. She stated she only asked the RP for consent for the medication and did not include the proposed course of the medication. She stated she was responsible for the completion of the consent for the psychoactive medication. Interview on 08/04/21 at 9:35 AM with LVN C, she stated she could not remember if she called Resident #1's RP on 06/03/21 regarding consent for [MEDICATION(S)]. She stated she was responsible for the completion of the consent for the psychoactive medications. Interview on 08/04/21 at 11:00 AM with ADM revealed whomever received the order for the psychoactive medication was responsible for completing the consent. The ADM stated it was important to complete the consent with the resident/RP so they could make an informed decision regarding their care. He stated a negative outcome would be for not being completing the consent the resident/RP was not able to make an informed decision regarding the medication on how and why it could affect them. Interview on 08/04/21 at 11:10 AM with DON revealed the nurse that received the order for the psychoactive medication was responsible for the completion of the consent. The DON stated the importance of completing the consent form was to ensure side effects, alternatives and duration of medication were discussed. She stated a negative outcome for not completing the consent form would be not providing their rights to have knowledge about how the medication could affect the resident. Interview on 08/04/21 at 11:30 AM with ADON revealed the nurse assigned to resident receiving the psychoactive medication order was responsible for completing the consent. The ADON stated it was important to review the consent with the resident/RP for the appropriate side effects according to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Resident Rights, dated December 2016, reflected, .the resident's right to (p.) be informed of, and participate in, his or her care planning and treatment

Based on interview and record review, the facility failed implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 5 (CNA A, CNA B, CNA C, CNA D and LVN E) of 5 staff reviewed for implementation of abuse policies. The facility failed to conduct an annual EMR and NAR search for the CNA A, CNA B, CNA C and CNA D. The facility failed to conduct an initial EMR and NAR search for the LVN E. These failures could place all residents at risk of abuse and neglect. Findings included: Record review of the facility's Abuse Prevention Program Policy dated December 2016 stated 2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: b. have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. Record review of CNA A's employee file revealed a date of hire of 01/31/17. The last documented EMR and NAR check was dated 11/04/19. There was no documentation of a 2020 EMR and NAR check. Record review of CNA B's employee file revealed a date of hire of 04/02/15. The last documented EMR and NAR check was dated 11/14/19. There was no documentation of a 2020 EMR and NAR check. Record review of CNA C's employee file revealed a date of hire of 11/12/19. The last documented EMR and NAR check was dated 11/12/19. There was no documentation of a 2020 EMR and NAR check. Record review of CNA D's employee file revealed a date of hire of 08/18/20. There was no documentation of an initial EMR and NAR check. Record review of the LVN E's employee file revealed a date of hire as 08/17/20. There was no documentation of an initial EMR and NAR check. Interview on 12/23/20 at 12:48 PM with the Administrator, he said the HR Manager was new and was out of the facility on quarantine. He said the HR Manager is responsible for doing the EMR and NAR registry checks. He said the EMR and NAR checks should be done yearly, and we are just out of our yearly window. He stated he was not sure why the new hires had not been checked at the time of hire. Record review of the facility's Hiring Policy dated January 2008 stated . 10. Where appropriate, background investigations may be conducted on persons making application for employment with this facility and on current employees .

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services , including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for three (Residents #6, #13 and #17) of 20 residents reviewed for pharmacy services. 1) Resident #13: --Did not receive 27 of 38 scheduled doses of lactulose, which was used to help control the level of ammonia in his bloodstream, between 06/18/13 and 07/07/13. --Five of 25 scheduled doses of Lasix (diuretic for swelling caused by excess fluid and high blood pressure) were not signed as given between 06/19/13 and 06/30/13. --Ten of 25 doses of Coreg (for high blood pressure) were not signed as given between 06/19/13 and 06/30/13. --Eight of 56 doses of Clonidine (for high blood pressure) were not signed as given between 06/19/13 and 07/07/13. --Three of 13 doses of pantoprazole (for gastric reflux) were not signed as given between 06/19/13 and 06/30/13. These failures to administer Resident #13 his physician-ordered medications resulted in the resident becoming hospitalized with hepatic [DIAGNOSES REDACTED] (worsening of brain function because the liver cannot remove toxins from the blood) and altered mental status due to the high levels of ammonia in his blood. These failures also had the potential to cause Resident #13's blood pressure to become dangerously high as well as cause fluid overload leading to the potential for cardiac and circulatory problems along with respiratory distress and abdominal discomfort. 2) Resident #6 did not receive 125 of 129 physician-ordered doses of Dilantin (anti-convulsant). This failure could have affected Resident #6 by resulting in the resident experiencing seizures, which could cause loss of cognition, injury and the need for hospitalization . 3) Resident #17 had 11 of 13 doses of Fosamax (for Osteoporosis) not signed as given between 05/01/13/thru 07/31/13. This failure to administer Resident #17's Fosamax could result in the resident sustaining fractures, causing increased pain and discomfort the potential need for hospitalization . These failures to administer physician-ordered medications could affect the facility's 100 residents and placed them at risk for loss of a change in their condition, exacerbation of current health issues, development of new health issues, delayed healing time and the possibility of hospitalization . Findings included: 1) Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #13 had a BIMS score of 15, indicating he was cognitively intact. He required the extensive assistance of one person for transfers, dressing, toilet use and personal hygiene. The MDS assessment also reflected Resident #13 was receiving dialysis. Resident #13 resided on the 200 Hall. Observation on 08/01/13 at 12:52 PM revealed Resident #13 was sleeping in bed. His lunch tray was on his bed side table and appeared untouched. When LVN A was queried about Resident 13 sleeping, she explained he got up at 5:00 AM to go to his dialysis appointments and was usually very tired when he returned. On 08/01/13 at 5:02 PM, Resident #13 propelled himself to the private dining room where the survey team had assembled and asked to talk to the team. During the interview, Resident #13 reported he rarely received his medications on time. He stated he had just received his first medications of the day and should have had the medications that morning before dialysis. Resident #13 stated, "The last time they didn't give me my meds, I went to the hospital because my ammonia level went up." Resident #13 explained he did not like to take lactulose before his dialysis treatments, because it caused him to go to the bathroom a lot, which was difficult when he was hooked up to the "dialysis machine." He stated he could take it when he returned from dialysis before lunch. Review of Resident #13's admission orders [REDACTED]. Resident #13's MARs for June 2013 reflected the following: Lactulose 20 grams twice daily with doses was to be given at 9:00 AM and 9:00 PM. Resident #13's 9:00 AM dose was circled as held on 06/20/13, 06/24/13, 06/25/13, 06/26/13,06/27/13, 06/28/13, 06/29/13 and 06/30/13. His 9:00 PM dose was only signed as given on 06/18/13 and 06/29/13 with all other spaces left blank. Lasix 20 mg twice daily was to be given at 9:00 AM and 9:00 PM. It was not signed as given at 9:00 PM on 06/19/13, 06/20/13, 06/21/13, 06/27/13 and 06/28/13. Coreg 12.5 mg twice daily was to be given at 9:00 AM and 9:00 PM. It was not signed as given at 9:00 PM on 06/19/13, 06/20/13, 06/21/13, 06/24/13, 06/25/13, 06/26/13, 06/27/13, 06/28/13, 06/29/13 and 06/30/13. Clonidine 0.1 mg three times daily was to be given at 9:00 AM, 3:00 PM and 9:00 PM. It was not signed as given at 3:00 PM on 06/19/13 and 06/28/13. His 9:00 PM dose was not signed as given on 06/19/13, 06/20/13, 06/27/13 and 06/28/13. Pantoprazole 40 mg daily was to be given at 4:00 PM and was not signed as given on 06/19/13, 06/20/13 and 06/21/13. There were no entries on the June 2013 MAR to indicate why the medications were not given. Resident #13's July 2013 MARs reflected the following: Lactulose doses were scheduled at 7:00 AM and 7:00 PM. The July 2013 MAR reflected every 7:00 AM dose from 07/01/13 through 07/07/13 was circled as held. His 7:00 PM dose had been given from 07/01/13 through 07/05/13 only. His Clonidine doses were scheduled at 7:00 AM, 1:00 PM and 7:00 PM. His 1:00 PM doses were not signed as given on 07/01/13 and 07/05/13. There was one, undated entry on the back of Resident #13's July 2013 MARs, which reflected "pat. (patient) refused all his morning meds nurse (sic)." A review of the facility's MAR reflected the following instructions printed as part of the form: "Put initials in the appropriate box when medication is given. Circle initials when medication refused. State reason for refusal on reverse side...." There was a large area on the back of the MAR entitled Nurse's Medication Notes. Review of Resident #13's nursing progress notes from 06/18/13 through 07/07/13 revealed there were only two entries related to his refusal of medications: --06/25/13 at 9:30 AM reflected: Informed by CNA of resident refused scheduled lactulose. Paged PA F and left message regarding this situation (resident's refusal of medications)... Will relay to PA F or oncoming nurse to follow up...." Review of Resident #13's physician progress notes [REDACTED]. Explained to pt that purpose is to prevent hepatic [DIAGNOSES REDACTED] (with) increased ammonia levels. Pt understood and will take lactulose." Diagnosis/Impression, Management Plan ...Continue Lactulose, Ammonia levels f/u (follow up). --07/07/13 at 10:20 AM reflected: "Received report from prior nurse stating that patient returned from OOP (out on pass) with family. Exhibiting agitated and belligerent behavior. Refusing care and yelling and cursing at staff. Complaining of not eating and being really hungry walking back and forth eating snacks all night. Informed by Med Aide that resident refusing medication and treatment, entered residents room and attempted to redirect and encourage resident to comply with medicine...." Resident #13's nursing progress notes dated 07/07/13 at 2:00 PM reflected: "Reassessed resident no change in condition better or worse, retrieved labs and relayed residents (sic) status to PA F, received order to send resident to ER for evaluation r/t (related to) AMS and change in LOC...." Resident #13's nursing progress notes dated 07/07/13 at 3:00 PM reflected he was transported from the facility without incident. Resident #13's nursing progress note dated 07/09/13 at 11:15 PM reflected: "Resident returned to facility in stable condition. Report from (hospital) says that resident was treated for [REDACTED]." Resident #13's Hospital History and Physical report dated 07/08/13 reflected the following: History of Present Illness: "The patient is a [AGE] year-old male with a history of end-stage renal disease on hemodialysis, who also has cirrhosis secondary to hepatitis C and history of hepatic [DIAGNOSES REDACTED], presents with altered mental status. The patient presented from (facility). He was sent here for altered mental status since this morning. He was refusing to take his medication and food earlier today per nursing facility. Per report, he is usually alert and oriented X 3 (times three). Today, he was saying words which did not make any sense. He has been agitated and refusing to eat. At this time, the patient responds to every question with 'no.' He remains agitated and has tried to hit the nursing staff." Laboratory Studies: His Ammonia level was 182 umol/L (normal range is 11-32 umol/L). Assessment and Plan: "1. Hepatic [DIAGNOSES REDACTED]. The patient's clinical picture is consistent with hepatic [DIAGNOSES REDACTED]. He is not able to take by mouth lactulose at this time. A dose of lactulose enema was given in the emergency room . He has now had 2 bowel movements. We will continue the patient on lactulose enema until he is able to tolerate by mouth lactulose. We will recheck his ammonia level in the morning and continue to monitor his mental status closely. There is no clear precipitating factor for his hepatic [DIAGNOSES REDACTED]...." Further review of Resident #13's hospital records revealed his Ammonia level dated 07/08/13 at 2:15 PM had dropped to 88 umol/L. Resident #13's nursing progress note dated 07/09/13 at 11:15 PM reflected: "Resident returned to facility in stable condition. Report from (hospital) says that resident was treated for [REDACTED]." In an interview on 08/01/13 at 5:55 PM, LVN D was asked what the facility's procedure was if a resident did not receive a medication. LVN D explained if a resident refused to take a medication, they should notify the physician and family, circle the missed dose and document the refusal on the back of the MAR. She added if a resident continued to refuse a particular medication, she should call the physician to see if orders needed to be changed. When asked whether Resident #13 had been refusing medications, LVN D stated she had heard he had refused medications before but never on her shift. During an interview on 08/01/13 at 10:43 PM, LVN E stated she was the 10:00 PM to 6:00 AM nurse for Resident #13 and had been for the past couple of weeks. LVN E stated Resident #13 left for dialysis around 5:30 AM on Tuesdays, Thursdays and Saturdays. When asked whether Resident #13 was given any medications prior to leaving for dialysis, LVN E stated he was not. When asked if any arrangements were made to reschedule his medication dose times on dialysis days, LVN E replied, "No." LVN E stated she did not know how long he was out of the facility when he went to dialysis. During an interview on 08/02/13 at 8:16 AM, MA C was asked about Resident #13's daily medication regimen. MA C stated Resident #13's morning medications were scheduled for 7:00 AM and, "...since he's already gone, there's nothing I can do." MA C explained when Resident #13 returned from dialysis, she gave him his medications that were due at 11:00 AM. When asked if that was true of all his medications, MA C stated, "I don't get to give them, I circle that he's out, then I tell the nurse." When MA C was asked whether she documented any reasons why a medication was not given when she circled the dose, she stated she would document behind the MAR, tell the nurse, and then try again later. When MA C was shown all the circled doses of lactulose, which were not given, on Resident #13's June 2013 MAR, and asked for an explanation, she replied, "Sometimes he takes it. Sometimes he doesn't. Most of the time he'll tell me 'No.' " When asked again about her documentation on the MAR, MA C stated, "I think last month I didn't do a good job documenting." During an interview on 08/02/13 at 8:27 AM, LVN A, who confirmed she was Resident #13's 6:00 AM-2:00 PM Charge Nurse, was asked whether she knew anything about Resident #13's ammonia levels, she stated, "I know at one point they were high, and he was sent to the hospital. When he came back, they increased the dose (of the lactulose)." When asked what she did if a medication was not given to a resident, or if a resident refused, LVN A stated they would re-approach the resident and then notify the physician. When asked if she had ever notified the physician regarding Resident #13's not taking the lactulose, LVN A stated she had not because the physician was coming later in the day and would be informed then. When asked whether she had been informed of all of Resident #13's missed doses of lactulose, LVN A stated she had not. During an interview on 08/02/13 at 7:15 PM, MA B stated he had worked the 2:00 PM-10:00 PM shift in June 2013 on Resident #13's hall. When shown Resident #13's June 2013 MAR with the blank spaces and asked why the doses of medication were never given, MA B stated he could not recall. When asked what he was supposed to do if a resident missed a dose of medication, MA B stated he should circle the dose and write an explanation on the back of the MAR. MAB stated he did not think Resident #13 had missed any doses. When asked if he knew why Resident #13 was taking lactulose, MA B stated it was to keep his ammonia level down because it could cause confusion. MA B was unaware Resident #13 had been hospitalized with high ammonia levels. During an interview on 08/02/13 at 7:25 PM, LVN D, Resident #13's 2:00 PM -10:00 PM Charge Nurse, was shown Resident #13's June and July 2013 MARs and asked whether she had been told about his missing doses of lactulose. LVN D stated she had not been informed of any missed medication doses. Retrieved from <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm> on 08/05/13: Hepatic [DIAGNOSES REDACTED] Hepatic [DIAGNOSES REDACTED] is a worsening of brain function and the exact cause is unknown, however it can occur when liver function is damaged. The liver changes toxic substances in the body and makes them harmless. However, when the liver is damaged, these "poisons" may build up in the bloodstream. Ammonia, which is produced by the body when proteins are digested, is one of the harmful substances normally made harmless by the liver. Ammonia and other toxic substances can build up in the body and cause damage to the nervous system. Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Hepatic [DIAGNOSES REDACTED] may become a medical emergency, and hospitalization is required. Lactulose may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to remove blood from the intestines. 2) Resident #6 was a [AGE] year-old-female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's admission orders [REDACTED]. Review of Resident #6's Physician's Telephone Orders dated 05/30/13 revealed a "CLARIFICATION ORDER" for Dilantin suspension 125 mg per 5 ml, give 7 ml enteral two times a day. There was also a lab order for a Dilantin Level in the AM. Resident #6's hand written admission MAR for May 2013 reflected Dilantin suspension 125 mg per 5 ml and in parenthesis Give 7 ml. There were four initialed doses given, two on 05/30/13 and two on 05/31/13. Resident #6's lab report dated 05/31/13 reflected a low Dilantin level of 8.2 Ug/mL with the reference range of 10.0-20.0 Ug/mL. A hand written note on the lab report indicated, "Currently on Dilantin 7 ml BID per Peg/Tube" and "PA (PA F) notified." Resident #6's nursing progress notes dated 05/30/13 and 05/31/13 did not include documentation of a clarification order having been received for Dilantin suspension, to give 7 ml instead of the original 5 ml ordered. Resident #6's nursing progress notes dated from 05/31/13 through 06/28/13 had nothing documented about the resident's low Dilantin level and informing the PA or Resident #6's physician. Review of Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for June 2013 reflected Dilantin suspension 125 mg per 5 ml, give 5 ml enteral two times a day. There were 60 initialed entries for this dose. Resident #6's lab report dated 06/26/13 reflected an even lower Dilantin level of 5.3 Ug/mL with the reference range of 10.0 - 20.0 Ug/mL. A hand written note reflected: "PA (PA F) notified, put in box." Resident #6's nursing progress notes dated from 06/26/13 through 06/28/13 had nothing documented in regard to the resident's Dilantin levels being low and informing the PA or Resident's physician. Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for July 2013 reflected Dilantin suspension 125 mg per 5 ml, give 5 ml enteral two times a day. There were 62 initialed entries for this dose. Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for August 2013 reflected the order for Dilantin suspension 125 mg per 5 ml give 5 ml enteral two times a day. There were three initialed entries for this dose. On 08/02/13 at 7:55 PM, LVN J, who was Resident #6's 2-10 PM nurse, was interviewed. When she was asked how much Dilantin Resident #6 received, without looking at Resident #6's MAR, she answered, "We give 7.5 ml." The surveyor informed LVN J of the discrepancy in the orders for Dilantin with the orders reflecting 5 ml, not 7.5 ml. LVN J said it was probably a mistake in the new month's print out of orders. LVN J said, "It (Dilantin) might have been changed when she came back from the hospital... It was changed a few months ago cause her level was low...." The surveyor asked LVN J what dosage of Dilantin for Resident #6 was written on her August 2013 MAR. LVN J looked at the MAR and said, "Five ml. Oh, that's not right. Maybe the new month (August 2013) got it messed up." The surveyor and LVN J then reviewed Resident #6's June and July 2013 MARs, which were on the resident's chart. LVN J said, "Oh no. I clarified it. Well, let me go look at the bottle (of Dilantin suspension)." LVN J went to find Resident #6's bottle of Dilantin. On 08/02/13 at 8:10 PM, LVN J returned to the surveyor and showed the surveyor Resident #6's bottle of Dilantin. The label reflected: Dilantin 125 mg per 5 ml, "Take one teaspoon (5 ml) two times a day." The surveyor asked LVN J if she gave medication using the label or the MAR, and she replied, "The MAR." When asked again about the dosage of the Dilantin she administered to Resident #6, in response, the LVN referred to the MAR, but would not actually specify whether she administered 7.5 ml as she had said earlier in the interview (which was also incorrect) or 5 ml. LVN J said she was going to go call Resident #6's physician and find out how much Dilantin he wanted the resident to be administered. On 08/02/13 at 8:20 PM, LVN J reported to the surveyor she had called Resident #6's physician, and he ordered 7 ml of Dilantin suspension for the resident and to have a Dilantin level drawn on Monday (08/05/13). Resident #6's Physician's Telephone Order dated 08/02/13 at 8:15 PM, which LVN J documented and signed, reflected an order for [REDACTED]. The order did not include a Dilantin level to be drawn on Monday. The Care Plan dated 06/18/13 reflected the following problem: Resident #6 had a [DIAGNOSES REDACTED]. The goal was for the resident to remain free from injury related to seizure activity and for the resident's lab values to be maintained within therapeutic range. One of the Interventions was "Give medications as ordered...." Retrieved on 08/09/13 from the following web site: <http://www.medicinenet.com/phenytoin/article.htm>, which reflected the following: Phenytoin (Dilantin) is an anti-seizure medication (anticonvulsant) used for preventing or treating generalized tonic-clonic (grand mal) seizures, complex partial seizures (psychomotor seizures), and seizures occurring during or after neurosurgery. DOSING: The dosing of phenytoin (Dilantin) is patient-specific. It may be given once, twice, three, or four times daily. Doses are often adjusted to find the optimal dose based on measurement of blood levels. 3) Resident #17 was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Depression, and Unspecified Osteoporosis per her quarterly MDS assessment dated [DATE]. Resident #17's consolidated physician's orders [REDACTED]. Resident #17's MARs for June 2013 reflected the Fosamax was scheduled to be administered on 06/04/13, 06/11/13, 06/18/13, and 06/25/13. These dates were not initialed to indicate the medication had been administered. Resident #17's MARs for July 2013 reflected the Fosamax was scheduled to be administered on 07/02/13, 07/09/13, 07/16/13, 07/23/13 and 07/30/13. These dates were not initialed to indicate the medication had been administered. Resident #17's Physician's Progress Note dated and signed by the PA F on 07/05/13 reflected, "Osteoporosis...with appropriate treatment." On 08/02/13 at 8:35 PM, the surveyor asked MA B to show how many tablets of Resident #17's Fosamax was available in the medication cart. MA B retrieved one opened box of Fosamax tablets and told the surveyor the one box was all that was in the medication cart. Review of the opened box of medication revealed "4 Tablets" was printed on the outside of the box and the opened date of 07/30/13 was written on it. The label from the pharmacy reflected to reorder the medication after 06/15/13. This indicated the medication would need to be reordered at that time. The surveyor asked MA B if the Fosamax had been reordered. MA B said "No," because the re-order label was still there. The surveyor requested MA B count the number of tablets of Fosamax, which were in the box. MA A took the packaged tablets out of the box and counted six tablets. Four of the packaged tablets were connected with week 1, week 2, week 3 and week 4 marked on the back of the packaging. One of the separated packaged tablets had week 3 marked on it, and the sixth tablet had week 4 marked on it. The evidence of the extra Fosamax tablets, without having been reordered, indicated Resident #7 had not been administered the medication as ordered by the physician. 4) The facility's current policy and procedure entitled Resident Refusal of or Failure to Follow physician's orders [REDACTED]. Rationale: "Occasional refusals or failure to follow physician's orders [REDACTED]. Every attempt is made to accommodate the resident's requests and still adhere to the physician's orders [REDACTED]. Procedure: "1. Counsel the resident as to: a. Why the physician ordered the treatment, services or therapeutic diet, and b. The consequences of not following the physician's orders [REDACTED]. 2. If the resident continues to refuse treatment, services or a therapeutic diet, notify the physician. 3. Address the problem and consult with the physician for changes in the resident's treatment plan that is acceptable to the resident while meeting medical needs. 4. Document the steps taken to alleviate the problem and record resident's and physician's responses...." The facility's current policy and procedure entitled Medication Administration, dated 08/31/12, reflected: Procedure: "...5. Medications are administered within 60 minutes of the scheduled time of administration...." Documentation Guidelines: "1. Documentation on the patient's MAR by the person administering the medication: a. In the space provided under the date and on the line for that specific medication dose administered... ...3. Document withheld, refused, or medications given at other than the scheduled time by circling initialed space and providing an explanation on the reverse side of the MAR. 4. Notification of physician of withheld, refused or medications given at other than scheduled times or adverse reactions, as applicable. The facility's policy and procedure entitled Oral Medication Administration dated 08/31/12 reflected: Procedure: "1. Verify physician's orders [REDACTED]. 5) The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 07/30/13, reflected a resident census of 100 residents.

Based on observation, interview and record review, the facility failed to ensure two (Residents #6 and #13) of 19 residents, who were reviewed for medication regimen, were free of significant medication errors. 1) Resident #13 did not receive 27of 38 scheduled doses of [MEDICATION NAME] (to treat Hepatic [MEDICAL CONDITION] and/or constipation), which was used to help control the level of ammonia in his bloodstream and prevent an acute exacerbation of Hepatic [MEDICAL CONDITION] from 06/18/13 through 07/07/13. This failure to ensure Resident #13 was administered [MEDICATION NAME] resulted in the resident becoming hospitalized for [REDACTED]. 2) Resident #6 was administered 5 ml of [MEDICATION NAME] (anticonvulsant) twice a day instead of the physician-ordered dosage of 7 ml of [MEDICATION NAME] for 125 of 129 prescribed doses of [MEDICATION NAME]. This failure placed Resident #6 at risk for experiencing [MEDICAL CONDITION], which could result in discomfort, injury, loss of cognition and hospitalization . These failures to administer physician-ordered medications could affect the facility's 100 residents and placed them at risk for loss of a change in their condition, exacerbation of current health issues, development of new health issues, delayed healing time and the possibility of hospitalization . Findings included: 1) Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #13 had a BIMS score of 15, indicating he was cognitively intact. He required the extensive assistance of one person for transfers, dressing, toilet use and personal hygiene. The MDS assessment also reflected Resident #13 was receiving [MEDICAL TREATMENT]. Resident #13 resided on the 200 Hall Observation on 08/01/13 at 12:52 PM revealed Resident #13 was sleeping in bed. His lunch tray was on his bed side table and appeared untouched. When LVN A was queried about Resident 13 sleeping, she explained he got up at 5:00 AM to go to his [MEDICAL TREATMENT] appointments and was usually very tired when he returned. On 08/01/13 at 5:02 PM, Resident #13 propelled himself to the private dining room where the survey team had assembled and asked to talk to the team. During the interview, Resident #13 reported he rarely received his medications on time. He stated he had just received his first medications of the day and should have had the medications that morning before [MEDICAL TREATMENT]. Resident #13 stated, "The last time they didn't give me my meds, I went to the hospital because my ammonia level went up." Resident #13 explained he did not like to take [MEDICATION NAME] before his [MEDICAL TREATMENT] treatments, because it caused him to go to the bathroom a lot, which was difficult when he was hooked up to the "[MEDICAL TREATMENT] machine." He stated he could take it when he returned from [MEDICAL TREATMENT] before lunch. Review of Resident #13's admission orders [REDACTED]. Review of Resident #13's Physician's Telephone Orders dated 06/19/13 revealed an order for [REDACTED]. Review of Resident #13's physician progress notes [REDACTED]. Explained to pt that purpose is to prevent hepatic [MEDICAL CONDITION] (with) increased ammonia levels. Pt understood and will take [MEDICATION NAME]." Diagnosis/Impression, Management Plan: "...Continue [MEDICATION NAME], Ammonia levels f/u (follow up)." Review of Resident #13's nursing progress notes from 06/18/13 through 07/07/13 revealed there was only one entry related to his refusal of [MEDICATION NAME]. A nursing entry dated 06/25/13 at 9:30 AM reflected: "Informed by CNA of resident refused scheduled [MEDICATION NAME]. Paged PA F and left message regarding this situation. Also spoke with nurse at the [MEDICAL TREATMENT] facility regarding ammonia level labs, nurse stated that those levels were not being obtained at their facility. Will relay to PA F or oncoming nurse to follow up...." Review of Resident #13's Physician's Telephone Orders dated 07/07/13 revealed a lab order for STAT (immediate) CBC, CMP and Ammonia levels related to altered mental status and a change in level of consciousness. Review of Resident #13's MARs for June 2013 revealed the order for [MEDICATION NAME] 20 grams twice daily with doses to be given at 9:00 AM and 9:00 PM. Resident #13's 9:00 AM dose was circled as held for eight out of twelve doses. His 9:00 PM dose was only signed as given for two out of 13 possible doses. There were no entries on the MAR to indicate why the medication was not given. Review of the facility's MAR reflected the following instructions printed as part of the form: "Put initials in the appropriate box when medication is given. Circle initials when medication refused. State reason for refusal on reverse side...." There was a large area on the back of each page of the MAR entitled "Nurse's Medication Notes." Review of Resident #13's MARs from 07/01/13 through 07/07/13 revealed his [MEDICATION NAME] doses were due to be given at 7:00 AM and 7:00 PM. The MAR reflected every 7:00 AM dose from 07/01/13 through 07/07/13 was circled as held. His 7:00 PM dose had been given from 07/01/13 through 07/05/13 only. The back of Resident #13's July 2013 MAR reflected one, undated entry: "pat. (patient) refused all his morning meds nurse." Resident #13's nursing progress notes dated 07/07/13 at 10:20 AM reflected: "Received report from prior nurse stating that patient returned from OOP (out on pass) with family. Exhibiting agitated and belligerent behavior. Refusing care and yelling and cursing at staff. Complaining of not eating and being really hungry walking back and forth eating snacks all night. Informed by Med Aide that resident refusing medication and treatment, entered resident's room and attempted to redirect and encourage resident to comply with medicine. Observed resident with an altered mental status. Only using one word answers, only saying quit to every attempt to engage with resident. Continues to refuse meds and care. Informed PA F of resident's status, received order for STAT CBC, CMP, and Ammonia levels. Called (lab company) and placed order. Supervisor RN G entered the room and attempted to redirect resident, resident became belligerent again using profanity and calling her (sic) out her name... Lab Tech obtained blood specimen from resident and processed accordingly. Resident seemed withdrawn with flattened affect. Will continue to monitor patient and relay resident status to all appropriate parties." Resident #13's nursing progress notes dated 07/07/13 at 2:00 PM reflected: "Reassessed resident no change in condition better or worse, retrieved labs and relayed residents (sic) status to PA F, received order to send resident to ER for evaluation r/t (related to) AMS and change in LOC. Resident also exhibiting continued belligerence and mild combativeness. VS (vital signs) and BS (blood sugar) obtained. Family ...made aware of transfer and transportation called. Will monitor patient until transported out of facility." Review of Resident #13's nursing progress notes dated 07/07/13 at 3:00 PM revealed he was transported out of the facility without incident. Resident #13's nursing progress note dated 07/09/13 at 11:15 PM reflected: "Resident returned to facility in stable condition. Report from (hospital) says that resident was treated for [REDACTED]." Resident #13's Hospital History and Physical report dated 07/08/13 reflected the following: History of Present Illness: "The patient is a [AGE] year-old male with a history of [MEDICAL CONDITION] on [MEDICAL TREATMENT], who also has [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and history of hepatic [MEDICAL CONDITION], presents with altered mental status. The patient presented from (facility). He was sent here for altered mental status since this morning. He was refusing to take his medication and food earlier today per nursing facility. Per report, he is usually alert and oriented X3 (times three). Today, he was saying words which did not make any sense. He has been agitated and refusing to eat. At this time, the patient responds to every question with 'no.' He remains agitated and has tried to hit the nursing staff." Laboratory Studies: His Ammonia level was 182 umol/L (normal range is 11-32 umol/L ). Assessment and Plan: "1. Hepatic [MEDICAL CONDITION]. The patient's clinical picture is consistent with hepatic [MEDICAL CONDITION]. He is not able to take by mouth [MEDICATION NAME] at this time. A dose of [MEDICATION NAME] enema was given in the emergency room . He has now had 2 bowel movements. We will continue the patient on [MEDICATION NAME] enema until he is able to tolerate by mouth [MEDICATION NAME]. cWe will recheck his ammonia level in the morning and continue to monitor his mental status closely. There is no clear precipitating factor for his hepatic [MEDICAL CONDITION]." Further review of Resident #13's hospital records revealed his Ammonia level dated 07/08/13 at 2:15 PM had dropped to 88 umol/L. Review of Resident #13's laboratory records from 06/18/13 through 08/01/13 revealed he had never had an ammonia level drawn while at the facility. In an interview on 08/01/13 at 5:55 PM, LVN D was asked what the facility's procedure was if a resident did not receive a medication. LVN D explained if a resident refused to take a medication, they should notify the physician and family, circle the missed dose and document the refusal on the back of the MAR. She added if a resident continued to refuse a particular medication, she should call the physician to see if orders needed to be changed. When asked whether Resident #13 had been refusing medications, LVN D stated she had heard he had refused medications before but never on her shift. During an interview on 08/01/13 at 10:43 PM, LVN E stated she was the 10:00 PM to 6:00 AM nurse for Resident #13 and had been for the past couple of weeks. LVN E stated Resident #13 left for [MEDICAL TREATMENT] around 5:30 AM on Tuesdays, Thursdays and Saturdays. When asked whether Resident #13 was given any medications prior to leaving for [MEDICAL TREATMENT], LVN E stated he was not. When asked if any arrangements were made to reschedule his medication dose times on [MEDICAL TREATMENT] days, LVN E replied, "No." LVN E stated she did not know how long he was out of the facility when he went to [MEDICAL TREATMENT]. During an interview on 08/02/13 at 8:16 AM, MA C was asked about Resident #13's daily medication regimen. MA C stated Resident #13's morning medications were scheduled for 7:00 AM and, "...since he's already gone, there's nothing I can do." MA C explained when Resident #13 returned from [MEDICAL TREATMENT], she gave him his medications that were due at 11:00 AM. When asked if that was true of all his medications, MA C stated, "I don't get to give them, I circle that he's out, then I tell the nurse." When MA C was asked whether she documented any reasons why a medication was not given when she circled the dose, she stated she would document behind the MAR, tell the nurse, and then try again later. When MA C was shown all the circled doses of [MEDICATION NAME], which were not given, on Resident #13's June 2013 MAR, and asked for an explanation, she replied, "Sometimes he takes it. Sometimes he doesn't. Most of the time he'll tell me 'No.' " When asked again about her documentation on the MAR, MA C stated, "I think last month I didn't do a good job documenting." During an interview on 08/02/13 at 8:27 AM, LVN A, who confirmed she was Resident #13's 6:00 AM-2:00 PM Charge Nurse, was asked whether she knew anything about Resident #13's ammonia levels, she stated, "I know at one point they were high, and he was sent to the hospital. When he came back, they increased the dose (of the [MEDICATION NAME])." When asked what she did if a medication was not given to a resident, or if a resident refused, LVN A stated they would re-approach the resident and then notify the physician. When asked if she had ever notified the physician regarding Resident #13's not taking the [MEDICATION NAME], LVN A stated she had not because the physician was coming later in the day and would be informed then. When asked whether she had been informed of all of Resident #13's missed doses of [MEDICATION NAME], LVN A stated she had not. During an interview on 08/02/13 at 7:15 PM, MA B stated he had worked the 2:00 PM-10:00 PM shift in June 2013 on Resident #13's hall. When shown Resident #13's June 2013 MAR with the blank spaces and asked why the doses of medication were never given, MA B stated he could not recall. When asked what he was supposed to do if a resident missed a dose of medication, MA B stated he should circle the dose and write an explanation on the back of the MAR. MAB stated he did not think Resident #13 had missed any doses. When asked if he knew why Resident #13 was taking [MEDICATION NAME], MA B stated it was to keep his ammonia level down because it could cause confusion. MA B was unaware Resident #13 had been hospitalized with high ammonia levels. During an interview on 08/02/13 at 7:25 PM, LVN D, Resident #13's 2:00 PM -10:00 PM Charge Nurse, was shown Resident #13's june and July 2013 MARs and asked whether she had been told about his missing doses of [MEDICATION NAME]. LVN D stated she had not been informed of any missed medication doses. Retrieved from <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm> on 08/05/13: Hepatic [MEDICAL CONDITION] Hepatic [MEDICAL CONDITION] is a worsening of brain function and the exact cause is unknown, however it can occur when liver function is damaged. The liver changes toxic substances in the body and makes them harmless. However, when the liver is damaged, these "poisons" may build up in the bloodstream. Ammonia, which is produced by the body when proteins are digested, is one of the harmful substances normally made harmless by the liver. Ammonia and other toxic substances can build up in the body and cause damage to the nervous system. Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Hepatic [MEDICAL CONDITION] may become a medical emergency, and hospitalization is required. [MEDICATION NAME] may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to remove blood from the intestines. 2) The facility's current policy and procedure entitled Resident Refusal of or Failure to Follow physician's orders [REDACTED]. Rationale: "Occasional refusals or failure to follow physician's orders [REDACTED]. Every attempt is made to accommodate the resident's requests and still adhere to the physician's orders [REDACTED]. Procedure: "1. Counsel the resident as to: a. Why the physician ordered the treatment, services or therapeutic diet, and b. The consequences of not following the physician's orders [REDACTED]. 2. If the resident continues to refuse treatment, services or a therapeutic diet, notify the physician. 3. Address the problem and consult with the physician for changes in the resident's treatment plan that is acceptable to the resident while meeting medical needs. 4. Document the steps taken to alleviate the problem and record resident's and physician's responses...." The facility's current policy and procedure entitled Medication Administration, dated 08/31/12, reflected: Procedure: "...5. Medications are administered within 60 minutes of the scheduled time of administration...." Documentation Guidelines: "1. Documentation on the patient's MAR by the person administering the medication: a. In the space provided under the date and on the line for that specific medication dose administered... ...3. Document withheld, refused, or medications given at other than the scheduled time by circling initialed space and providing an explanation on the reverse side of MAR. 4. Notification of physician of withheld, refused or medications given at other than scheduled times or adverse reactions, as applicable." 3) Resident #6 was a [AGE] year-old-female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's admission orders [REDACTED]. Review of Resident #6's Physician's Telephone Orders dated 05/30/13 revealed a "CLARIFICATION ORDER" for [MEDICATION NAME] suspension 125 mg per 5 ml, give 7 ml enteral two times a day. There was also a lab order for a [MEDICATION NAME] Level in the AM. Resident #6's hand written admission MAR for May 2013 reflected [MEDICATION NAME] suspension 125 mg per 5 ml and in parenthesis Give 7 ml. There were four initialed doses given, two on 05/30/13 and two on 05/31/13. Resident #6's lab report dated 05/31/13 reflected a low [MEDICATION NAME] level of 8.2 Ug/mL with the reference range of 10.0-20.0 Ug/mL. A hand written note on the lab report indicated, "Currently on [MEDICATION NAME] 7 ml BID per Peg/Tube" and "PA (PA F) notified." Resident #6's nursing progress notes dated 05/30/13 and 05/31/13 did not include documentation of a clarification order having been received for [MEDICATION NAME] suspension, to give 7 ml instead of the original 5 ml ordered. Resident #6's nursing progress notes dated from 05/31/13 through through 06/28/13 had nothing documented about the resident's low [MEDICATION NAME] level and informing the PA or Resident #6's physician. Review of Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for June 2013 reflected [MEDICATION NAME] suspension 125 mg per 5 ml, give 5 ml enteral two times a day. There were 60 initialed entries for this dose. Resident #6's lab report dated 06/26/13 reflected an even lower [MEDICATION NAME] level of 5.3 Ug/mL with the reference range of 10.0 - 20.0 Ug/mL. A hand written note reflected: "PA (F) notified, put in box." Resident #6's nursing progress notes dated from 06/26/13 through 06/28/13 had nothing documented in regard to the resident's [MEDICATION NAME] levels being low and informing the PA or Resident's physician. Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for July 2013 reflected [MEDICATION NAME] suspension 125 mg per 5 ml, give 5 ml enteral two times a day. There were 62 initialed entries for this dose. Resident #6's consolidated physician's orders [REDACTED]. Resident #6's MARs for August 2013 reflected the order for [MEDICATION NAME] suspension 125 mg per 5 ml give 5 ml enteral two times a day. There were three initialed entries for this dose. On 08/02/13 at 7:55 PM, LVN J, who was Resident #6's 2-10 PM nurse, was interviewed. When she was asked how much [MEDICATION NAME] Resident #6 received, without looking at Resident #6's MAR, she answered, "We give 7.5 ml." The surveyor informed LVN J of the discrepancy in the orders for [MEDICATION NAME] with the orders reflecting 5 ml, not 7.5 ml. LVN J said it was probably a mistake in the new month's print out of orders. LVN J said, "It ([MEDICATION NAME]) might have been changed when she came back from the hospital... It was changed a few months ago cause her level was low...." The surveyor asked LVN J what dosage of [MEDICATION NAME] for Resident #6 was written on her August 2013 MAR. LVN J looked at the MAR and said, "Five ml. Oh, that's not right. Maybe the new month (August 2013) got it messed up." The surveyor and LVN J then reviewed Resident #6's June and July 2013 MARs, which were on the resident's chart. LVN J said, "Oh no. I clarified it. Well, let me go look at the bottle (of [MEDICATION NAME] suspension)." LVN J went to find Resident #6's bottle of [MEDICATION NAME]. On 08/02/13 at 8:10 PM, LVN J returned to the surveyor and showed the surveyor Resident #6's bottle of [MEDICATION NAME]. The label reflected: [MEDICATION NAME] 125 mg per 5 ml, "Take one teaspoon (5 ml) two times a day." The surveyor asked LVN J if she gave medication using the label or the MAR, and she replied, "The MAR." When asked again about the dosage of the [MEDICATION NAME] she administered to Resident #6, in response, the LVN referred to the MAR, but would not actually specify whether she administered 7.5 ml as she had said earlier in the interview (which was also incorrect) or 5 ml. LVN J said she was going to go call Resident #6's physician and find out how much [MEDICATION NAME] he wanted the resident to be administered. On 08/02/13 at 8:20 PM, LVN J reported to the surveyor she had called Resident #6's physician, and he ordered 7 ml of [MEDICATION NAME] suspension for the resident and to have a [MEDICATION NAME] level drawn on Monday (08/05/13). Resident #6's Physician's Telephone Order dated 08/02/13 at 8:15 PM, which LVN J documented and signed, reflected an order for [REDACTED]. The order did not include a [MEDICATION NAME] level to be drawn on Monday. The Care Plan dated 06/18/13 reflected the following problem: Resident #6 had a [DIAGNOSES REDACTED]. The goal was for the resident to remain free from injury related to [MEDICAL CONDITION] activity and for the resident's lab values to be maintained within therapeutic range. One of the Interventions was "Give medications as ordered...." Retrieved on 08/09/13 from the following web site: <http://www.medicinenet.com/[MEDICATION NAME]/article.htm>, which reflected the following: [MEDICATION NAME] ([MEDICATION NAME]) is an anti-[MEDICAL CONDITION] medication (anticonvulsant) used for preventing or treating generalized tonic-clonic (grand mal) [MEDICAL CONDITION], complex partial [MEDICAL CONDITION] (psychomotor [MEDICAL CONDITION]), and [MEDICAL CONDITION] occurring during or after neurosurgery. DOSING: The dosing of [MEDICATION NAME] ([MEDICATION NAME]) is patient-specific. It may be given once, twice, three, or four times daily. Doses are often adjusted to find the optimal dose based on measurement of blood levels. 4) The facility's current policy and procedure entitled Medication Administration, dated 08/31/12, reflected: Procedure: "Preparation to Medication Administration ...7. Prepare the medication using the five rights of medication administration: ...b. Right medicaiton name and strength... ...9. Open the MAR to the appropriate medication record sheet... 10. Prepare the medication. a. Read the medication record order... Administering the Medication ...12. Re-read the medication order(s). "...5. Medications are administered within 60 minutes of the scheduled time of administration...." Documentation Guidelines: "1. Documentation on the patient's MAR by the person administering the medication: a. In the space provided under the date and on the line for that specific medication dose administered... ...3. Document withheld, refused, or medications given at other than the scheduled time by circling initialed space and providing an explanation on the reverse side of MAR. 4. Notification of physician of withheld, refused or medications given at other than scheduled times or adverse reactions, as applicable." The facility's current policy and procedure entitled Oral Medication Administration dated 08/31/12 reflected: Procedure: "1. Verify physician's orders [REDACTED]. 5) The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 07/30/13, reflected a resident census of 100 residents.

Based on observation, interview and record review, the facility failed to consult with the physician of a potential need to alter treatment for one (Residents #13) of 19 residents, whose medication regimen was reviewed. 1) Resident #13 did not receive his scheduled doses of [MEDICATION NAME] which was to control the level of ammonia in his bloodstream. 2) Resident #13's lab tests for ammonia levels in his blood were not done. These failures resulted in Resident #13 becoming hospitalized for [REDACTED]. The failure to consult with the physician when residents do not receive their physician-ordered medications or have not had physician-ordered lab tests conducted could affect the facility's 100 residents and placed them at risk for a decline in their condition resulting in the need for further medical care and treatment and potentially hospitalization . Findings included: Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #13 had a BIMS score of 15, indicating he was cognitively intact. He required the extensive assistance of one person for transfers, dressing, toilet use and personal hygiene. The MDS assessment also reflected Resident #13 was receiving [MEDICAL TREATMENT]. Resident #13 resided on the 200 Hall Observation on 08/01/13 at 12:52 PM revealed Resident #13 was sleeping in bed. His lunch tray was on his bed side table and appeared untouched. When LVN A was queried about Resident 13 sleeping, she explained he got up at 5:00 AM to go to his [MEDICAL TREATMENT] appointments and was usually very tired when he returned. On 08/01/13 at 5:02 PM, Resident #13 propelled himself to the private dining room where the survey team had assembled and asked to talk to the team. During the interview, Resident #13 reported he rarely received his medications on time. He stated he had just received his first medications of the day and should have had the medications that morning before [MEDICAL TREATMENT]. Resident #13 stated, "The last time they didn't give me my meds, I went to the hospital because my ammonia level went up." Resident #13 explained he did not like to take [MEDICATION NAME] before his [MEDICAL TREATMENT] treatments, because it caused him to go to the bathroom a lot, which was difficult when he was hooked up to the "[MEDICAL TREATMENT] machine." He stated he could take it when he returned from [MEDICAL TREATMENT] before lunch. Review of Resident #13's admission orders [REDACTED]. Resident #13's physician progress notes [REDACTED]. Facility wants to know the stop date for Rifaximin... They also question how frequently Ammonia test would be done...." Plan: "...Ammonia level weekly...." Review of Resident #13's Physician's Telephone Orders dated 06/19/13 revealed an order for [REDACTED]. Review of Resident #13's physician progress notes [REDACTED]. Explained to pt that purpose is to prevent hepatic [MEDICAL CONDITION] (with) increased ammonia levels. Pt understood and will take [MEDICATION NAME]." Diagnosis/Impression, Management Plan: "...Continue [MEDICATION NAME], Ammonia levels f/u (follow up)." Review of Resident #13's nursing progress notes from 06/18/13 through 07/07/13 revealed there was only one entry related to his refusal of [MEDICATION NAME]. A nursing entry dated 06/25/13 at 9:30 AM reflected: "Informed by CNA of resident refused scheduled [MEDICATION NAME]. Paged PA F and left message regarding this situation. Also spoke with nurse at the [MEDICAL TREATMENT] facility regarding ammonia level labs, nurse stated that those levels were not being obtained at their facility. Will relay to PA F or oncoming nurse to follow up...." No other entries related to Resident #13 missing [MEDICATION NAME] doses and not having his ammonia levels being drawn as ordered could be found. Further review revealed no evidence of notification of his physician for the missed [MEDICATION NAME] doses or ammonia levels not being drawn could be found. Review of Resident #13's Physician's Telephone Orders dated 07/07/13 revealed a lab order for STAT (immediate) CBC, CMP and Ammonia levels related to altered mental status and a change in level of consciousness. Review of Resident #13's MARs for June 2013 revealed the order for [MEDICATION NAME] 20 grams twice daily with doses to be given at 9:00 AM and 9:00 PM. Resident #13's 9:00 AM dose was circled as held for eight out of twelve doses. His 9:00 PM dose was only signed as given for two out of 13 possible doses. There were no entries on the MAR indicated [REDACTED]. Review of the facility's MAR indicated Put initials in the appropriate box when medication is given. Circle initials when medication refused. State reason for refusal on reverse side...." There was a large area on the back of each page of the MAR indicated Review of Resident #13's MARs from 07/01/13 through 07/07/13 revealed his [MEDICATION NAME] doses were due to be given at 7:00 AM and 7:00 PM. The MAR indicated [REDACTED]. His 7:00 PM dose had been given from 07/01/13 through 07/05/13 only. The back of Resident #13's July 2013 MAR indicated pat. (patient) refused all his morning meds nurse." Resident #13's nursing progress notes dated 07/07/13 at 10:20 AM reflected: "Received report from prior nurse stating that patient returned from OOP (out on pass) with family. Exhibiting agitated and belligerent behavior. Refusing care and yelling and cursing at staff. Complaining of not eating and being really hungry walking back and forth eating snacks all night. Informed by Med Aide that resident refusing medication and treatment, entered resident's room and attempted to redirect and encourage resident to comply with medicine. Observed resident with an altered mental status. Only using one word answers, only saying quit to every attempt to engage with resident. Continues to refuse meds and care. Informed PA F of resident's status, received order for STAT CBC, CMP, and Ammonia levels. Called (lab company) and placed order. Supervisor RN G entered the room and attempted to redirect resident, resident became belligerent again using profanity and calling her (sic) out her name... Lab Tech obtained blood specimen from resident and processed accordingly. Resident seemed withdrawn with flattened affect. Will continue to monitor patient and relay resident status to all appropriate parties." NOTE: The CBC and CMP were drawn but the ammonia level was not. Resident #13's nursing progress notes dated 07/07/13 at 2:00 PM reflected: "Reassessed resident no change in condition better or worse, retrieved labs and relayed residents (sic) status to PA F, received order to send resident to ER for evaluation r/t (related to) AMS and change in LOC. Resident also exhibiting continued belligerence and mild combativeness. VS (vital signs) and BS (blood sugar) obtained. Family ...made aware of transfer and transportation called. Will monitor patient until transported out of facility." Review of Resident #13's nursing progress notes dated 07/07/13 at 3:00 PM revealed he was transported out of the facility without incident. Resident #13's nursing progress note dated 07/09/13 at 11:15 PM reflected: "Resident returned to facility in stable condition. Report from (hospital) says that resident was treated for Hepatic [MEDICAL CONDITION] and AMS. (Physician H) was notified and ordered [MEDICATION NAME] to be changed to TID (three times daily)...." Review of Resident #13's Hospital History and Physical report dated 07/08/13 reflected the following: History of Present Illness: "The patient is a [AGE] year-old male with a history of [MEDICAL CONDITION] on [MEDICAL TREATMENT], who also has [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and history of hepatic [MEDICAL CONDITION], presents with altered mental status. The patient presented from (facility). He was sent here for altered mental status since this morning. He was refusing to take his medication and food earlier today per nursing facility. Per report, he is usually alert and oriented X3 (times three). Today, he was saying words which did not make any sense. He has been agitated and refusing to eat. At this time, the patient responds to every question with 'no.' He remains agitated and has tried to hit the nursing staff." Laboratory Studies: His Ammonia level was 182 umol/L (normal range is 11-32 umol/L). Assessment and Plan: "1. Hepatic [MEDICAL CONDITION]. The patient's clinical picture is consistent with hepatic [MEDICAL CONDITION]. He is not able to take by mouth [MEDICATION NAME] at this time. A dose of [MEDICATION NAME] enema was given in the emergency room . He has now had 2 bowel movements. We will continue the patient on [MEDICATION NAME] enema until he is able to tolerate by mouth [MEDICATION NAME]. cWe will recheck his ammonia level in the morning and continue to monitor his mental status closely. There is no clear precipitating factor for his hepatic [MEDICAL CONDITION]." Further review of Resident #13's hospital records revealed his Ammonia level dated 07/08/13 at 2:15 PM had dropped to 88 umol/L. Review of Resident #13's facility laboratory records from 06/18/13 through 08/01/13 revealed he had never had an ammonia level drawn while at the facility. During an interview on 08/02/13 at 12:28 PM, PA F was asked whether he was told by nursing staff Resident #13 had not been receiving his [MEDICATION NAME] as ordered. PA F stated he remembered the resident refused the [MEDICATION NAME] at times, but when shown Resident #13's June and July 2013 MARs, he stated he was not aware the resident had missed doses of [MEDICATION NAME] to that extent. PA F stated he was also not aware the resident's ammonia levels had not been drawn. After reviewing all of Resident #13's lab reports, he saw there was no result for ammonia levels, and he reordered the labs. PA F stated he had been called about the resident's mental status change and had given orders to send Resident #13 to the hospital. In an interview on 08/01/13 at 5:55 PM, LVN D was asked what the facility's procedure was if a resident did not receive a medication. LVN D explained if a resident refused to take a medication, they should notify the physician and family, circle the missed dose and document the refusal on the back of the MAR. She added if a resident continued to refuse a particular medication, she should call the physician to see if orders needed to be changed. When asked whether Resident #13 had been refusing medications, LVN D stated she had heard he had refused medications before but never on her shift. During the same interview, LVN D was asked to print all Resident #13's lab results since his admission on 06/18/13. After they were printed, the lab results were reviewed with LVN D. She was asked why there were no results for his ammonia levels. LVN D pulled the lab orders up on her computer screen and pointed to several orders for ammonia levels, which had been entered. There was a line through every order. LVN D stated the line indicated the tests had been cancelled, but she did not know the reason the ammonia levels were cancelled. During an interview on 08/01/13 at 10:43 PM, LVN E stated she was the 10:00 PM to 6:00 AM nurse for Resident #13 and had been for the past couple of weeks. LVN E stated Resident #13 left for [MEDICAL TREATMENT] around 5:30 AM on Tuesdays, Thursdays and Saturdays. When asked whether Resident #13 was given any medications prior to leaving for [MEDICAL TREATMENT], LVN E stated he was not. When asked if any arrangements were made to reschedule his medication dose times on [MEDICAL TREATMENT] days, LVN E replied, "No." LVN E stated she did not know how long he was out of the facility when he went to [MEDICAL TREATMENT]. During an interview on 08/02/13 at 8:16 AM, MA C was asked about Resident #13's daily medication regimen. MA C stated Resident #13's morning medications were scheduled for 7:00 AM and, "...since he's already gone, there's nothing I can do." MA C explained when Resident #13 returned from [MEDICAL TREATMENT], she gave him his medications that were due at 11:00 AM. When asked if that was true of all his medications, MA C stated, "I don't get to give them, I circle that he's out, then I tell the nurse." When MA C was asked whether she documented any reasons why a medication was not given when she circled the dose, she stated she would document behind the MAR, tell the nurse, and then try again later. When MA C was shown all the circled doses of [MEDICATION NAME], which were not given, on Resident #13's June 2013 MAR, and asked for an explanation, she replied, "Sometimes he takes it. Sometimes he doesn't. Most of the time he'll tell me 'No.' " When asked again about her documentation on the MAR, MA C stated, "I think last month I didn't do a good job documenting." During an interview on 08/02/13 at 8:27 AM, LVN A, who confirmed she was Resident #13's 6:00 AM-2:00 PM Charge Nurse, was asked whether she knew anything about Resident #13's ammonia levels. She stated, "I know at one point they (ammonia levels) were high, and he was sent to the hospital. When he came back, they increased the dose (of the [MEDICATION NAME])." When asked who was responsible for monitoring a resident's labs and ensuring they were done, LVN A stated the charge nurse was responsible. The LVN stated, "They (lab results) come and we call the doctor." When asked if Resident #13's ammonia levels were being done, LVN A replied, "Yes." When asked what she did if a medication was not given to a resident, or if a resident refused, LVN A stated they would re-approach the resident and then notify the physician. When asked if she had ever notified the physician regarding Resident #13's not taking the [MEDICATION NAME] or ammonia levels, LVN A stated she had not because the physician was coming later in the day and would be informed then. When asked whether she had been informed of all of Resident #13's missed doses of [MEDICATION NAME], LVN A stated she had not. During an interview on 08/02/13 at 7:15 PM, MA B stated he had worked the 2:00 PM-10:00 PM shift in June 2013 on Resident #13's hall. When shown Resident #13's June 2013 MAR indicated [REDACTED]. When asked what he was supposed to do if a resident missed a dose of medication, MA B stated he should circle the dose and write an explanation on the back of the MAR. MAB stated he did not think Resident #13 had missed any doses. When asked if he knew why Resident #13 was taking [MEDICATION NAME], MA B stated it was to keep his ammonia level down because it could cause confusion. MA B was unaware Resident #13 had been hospitalized with high ammonia levels. During an interview on 08/02/13 at 7:25 PM, LVN D, Resident #13's 2:00 PM -10:00 PM Charge Nurse, was shown Resident #13's June and July 2013 MARs. LVN D was asked whether she had been told about his missing doses of [MEDICATION NAME]. LVN D stated she had not been informed of any of the missed medication doses. Retrieved from <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm> on 08/05/13: Hepatic [MEDICAL CONDITION] Hepatic [MEDICAL CONDITION] is a worsening of brain function and the exact cause is unknown, however it can occur when liver function is damaged. The liver changes toxic substances in the body and makes them harmless. However, when the liver is damaged, these "poisons" may build up in the bloodstream. Ammonia, which is produced by the body when proteins are digested, is one of the harmful substances normally made harmless by the liver. Ammonia and other toxic substances can build up in the body and cause damage to the nervous system. Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Hepatic [MEDICAL CONDITION] may become a medical emergency, and hospitalization is required. [MEDICATION NAME] may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to remove blood from the intestines. 2) The facility's current policy and procedure entitled Resident Refusal of or Failure to Follow physician's orders [REDACTED]. Rationale: "Occasional refusals or failure to follow physician's orders [REDACTED]. Every attempt is made to accommodate the resident's requests and still adhere to the physician's orders [REDACTED]. Procedure: "1. Counsel the resident as to: a. Why the physician ordered the treatment, services or therapeutic diet, and b. The consequences of not following the physician's orders [REDACTED]. 2. If the resident continues to refuse treatment, services or a therapeutic diet, notify the physician. 3. Address the problem and consult with the physician for changes in the resident's treatment plan that is acceptable to the resident while meeting medical needs. 4. Document the steps taken to alleviate the problem and record resident's and physician's responses...." The facility's policy and procedure entitled Medication Administration dated 08/31/12 reflected the following: Procedure: "...5. Medications are administered within 60 minutes of the scheduled time of administration...." Documentation Guidelines: "1. Documentation on the patient's MAR by the person administering the medication: a. In the space provided under the date and on the line for that specific medication dose administered...3. Document withheld, refused, or medications given at other than the scheduled time by circling initialed space and providing and explanation of the reverse side of MAR. 4. Notification of physician of withheld, refused or medications given at other than scheduled times or adverse reactions, as applicable." The facility's policy and procedure entitled: Laboratory, Radiology and Other Diagnostic Services dated 08/31/12 reflected the following: Policy: "Laboratory and radiology services are provided to: Detect risk or disease ...Monitor a condition." Rationale: "Laboratory services and radiology provide an avenue for medical staff to monitor patient outcomes and to make appropriate clinical decisions about the patient's care." Components: "...4. The Facility is responsible for: a. Providing or obtaining laboratory, radiology and other diagnostic services only when ordered by the attending physician; b. promptly notifying the attending physician of the findings...c. Assisting the patient, if needed, in making transportation arrangements to and from the source of service; and d. Maintaining laboratory reports in the clinical record...." 3) The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 07/30/13, reflected a resident census of 100 residents.

Based on observation, interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of one (Resident #13) of 14 residents reviewed for labs. Even though Resident #13 had weekly ammonia levels ordered by the physician to monitor the ammonia level in his blood and to prevent an exacerbation of his Hepatic [MEDICAL CONDITION] (confusion and altered level of consciousness due to liver disease), no ammonia levels were ever drawn at the facility. Resident #13 was hospitalized for [REDACTED]. This failure to ensure lab orders were obtained as ordered by the physician could affect the facility's other two residents identified by the facililty with liver disease and placed them at risk for the facility failing to monitor their ammonia levels, resulting in the potential for their developing Hepatic [MEDICAL CONDITION] and requiring hospitalization . . Findings included: Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #13 had a BIMS score of 15, indicating he was cognitively intact. He required the extensive assistance of one person for transfers, dressing, toilet use and personal hygiene. The MDS assessment also reflected Resident #13 was receiving [MEDICAL TREATMENT]. Resident #13 resided on the 200 Hall Observation on 08/01/13 at 12:52 PM revealed Resident #13 was sleeping in bed. His lunch tray was on his bed side table and appeared untouched. When LVN A was queried about Resident 13 sleeping, she explained he got up at 5:00 AM to go to his [MEDICAL TREATMENT] appointments and was usually very tired when he returned. On 08/01/13 at 5:02 PM, Resident #13 propelled himself to the private dining room where the survey team had assembled and asked to talk to the team. During the interview, Resident #13 reported he rarely received his medications on time. He stated he had just received his first medications of the day and should have had the medications that morning before [MEDICAL TREATMENT]. Resident #13 stated, "The last time they didn't give me my meds, I went to the hospital because my ammonia level went up." Resident #13 explained he did not like to take [MEDICATION NAME] before his [MEDICAL TREATMENT] treatments, because it caused him to go to the bathroom a lot, which was difficult when he was hooked up to the "[MEDICAL TREATMENT] machine." He stated he could take it when he returned from [MEDICAL TREATMENT] before lunch. Review of Resident #13's Physician's Telephone Orders dated 07/07/13 revealed an order for [REDACTED]. Review of all of Resident #13's laboratory records from 06/18/13 through 08/01/13 revealed there were no lab results for an ammonia level drawn while he was at the facility. Resident #13's physician progress notes [REDACTED]. Facility wants to know the stop date for Rifaximin... They also question how frequently Ammonia test would be done...." Plan: "...Ammonia level weekly...." Review of Resident #13's Physician's Telephone Orders dated 06/19/13 revealed an order for [REDACTED]. Review of Resident #13's physician progress notes [REDACTED]. Explained to pt that purpose is to prevent hepatic [MEDICAL CONDITION] (with) increased ammonia levels. Pt understood and will take [MEDICATION NAME]." Diagnosis/Impression, Management Plan: "Cont. (continue) [MEDICATION NAME], Ammonia levels f/u (follow up)...." Resident #13's nursing progress notes dated 06/25/13 at 9:30 AM reflected: The resident refused his scheduled [MEDICATION NAME]. PA F was paged and a message was left regarding Resident #13's refusal of the [MEDICATION NAME]. The resident's [MEDICAL TREATMENT] facility was contacted and lab results for an ammonia level were requested, however, the nurse at the [MEDICAL TREATMENT] facility reported ammonial levels were not conducted at [MEDICAL TREATMENT]. PA F to be notified or oncoming nurse to follow-up regarding the lab and Resident #13's refusal to take his [MEDICATION NAME]. Resident #13's nursing progress notes dated 07/07/13 at 10:20 AM reflected: "Received report from prior nurse stating that patient returned from OOP (out on pass) with family. Exhibiting agitated and belligerent behavior. Refusing care and yelling and cursing at staff. Complaining of not eating and being really hungry walking back and forth eating snacks all night. Informed by Med Aide that resident refusing medication and treatment, entered residents room and attempted to redirect and encourage resident to comply with medicine. Observed resident with an altered mental status. Only using one word answers, only saying quit to every attempt to engage with resident. Continues to refuse meds and care. Informed PA F of resident's status, received order for STAT CBC, CMP, and Ammonia levels. Called (lab company) and placed order. Supervisor (RN G) entered the room and attempted to redirect resident, resident became belligerent again using profanity and calling her (sic) out her name...Lab Tech obtained blood specimen from resident and processed accordingly. Resident seemed withdrawn with flattened affect. Will continue to monitor patient and relay resident status to all appropriate parties." NOTE: the CBC and CMP were drawn but the ammonia level was not. Resident #13's nursing progress notes dated 07/07/13 at 2:00 PM reflected: "Reassessed resident no change in condition better or worse, retrieved labs and relayed residents (sic) status to PA F, received order to send resident to ER for evaluation r/t (related to) AMS and change in LOC. Resident also exhibiting continued belligerence and mild combativeness. VS (vital signs) and BS (blood sugar level) obtained. Family...made aware of transfer and transportation called. Will monitor patient until transported out of facility." Resident #13's nursing progress notes dated 07/07/13 at 3:00 PM reflected the resident was transported from the facility without incident. Resident #13's Hospital History and Physical report dated 07/08/13 reflected the following: History of Present Illness: "The patient is a [AGE] year-old male with a history of [MEDICAL CONDITION] on [MEDICAL TREATMENT], who also has [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and history of hepatic [MEDICAL CONDITION], presents with altered mental status. The patient presented from (facility). He was sent here for altered mental status since this morning. He was refusing to take his medication and food earlier today per nursing facility. Per report, he is usually alert and oriented X3 (times three). Today, he was saying words which did not make any sense. He has been agitated and refusing to eat. At this time, the patient responds to every question with 'no.' He remains agitated and has tried to hit the nursing staff." Laboratory Studies: His Ammonia level was 182 umol/L (normal range is 11-32 umol/L). Assessment and Plan: "1. Hepatic [MEDICAL CONDITION]. The patient's clinical picture is consistent with hepatic [MEDICAL CONDITION]. He is not able to take by mouth [MEDICATION NAME] at this time. A dose of [MEDICATION NAME] enema was given in the emergency room . He has now had 2 bowel movements. We will continue the patient on [MEDICATION NAME] enema until he is able to tolerate by mouth [MEDICATION NAME]. cWe will recheck his ammonia level in the morning and continue to monitor his mental status closely. There is no clear precipitating factor for his hepatic [MEDICAL CONDITION]." Further review of Resident #13's hospital records revealed his Ammonia level dated 07/08/13 at 2:15 PM had dropped to 88 umol/L. Resident #13's nursing progress note dated 07/09/13 at 11:15 PM reflected: "Resident returned to facility in stable condition. Report from (hospital) says that resident was treated for [REDACTED]." On 08/01/13 at 5:55 PM, LVN D was asked to print all Resident #13's lab results since his admission on 06/18/13. The surveyor and LVN D reveiwed the lab results. LVN D was asked why there were no results for his ammonia levels. LVN D pulled the lab orders up on thr computer screen and pointed to several orders for ammonia levels, which had been entered. There was a line through every order. LVN D stated the line indicated the tests had been cancelled, but she did not know the reason for the cancellations. LVN A, Resident #13's 6:00 AM-2:00 PM Charge Nurse, was interviewed on 08/02/13 at 8:27 AM. LVN A was asked whether she knew anything about Resident #13's lab results for the physician-ordered ammonia levels. She responded, "I know at one point they were high, and he was sent to the hospital. When he came back, they increased the dose (of his [MEDICATION NAME])." When asked who was responsible for monitoring a resident's labs and ensuring they were done, LVN A stated the charge nurse was responsible. "They (lab results) come and we call the doctor." When asked if Resident #13's ammonia levels were being done, LVN A replied, "Yes." The DON and the facility's only ADON were interviewed on 08/02/13 at 10:29 AM. When they were asked who was responsible for ensuring laboratory tests were completed as ordered, the DON stated the charge nurses were responsible. The DON said the labs were reviewed daily in the facility stand-up meeting to ensure they were done and results were called to the physicians. When asked how they knew what lab results to look for, the DON stated they pulled the orders from the (computer) system, and the nurses were supposed to check the charts to ensure all labs were ordered. When asked if she remembered ever discussing Resident #13's ammonia levels in the stand-up meetings, the DON stated she did not remember ever discussing an ammonia level for Resident #13. The ADON stated she could recall an issue with that particular test and asked if the surveyor could speak with a representative from the facility's contracted-lab. A phone number was provided. The DON stated, in the past, residents had to be sent to the lab for ammonia levels, because the speciman had to be packed on ice. The DON stated the facility was supposed to call the lab 24 hours prior to the scheduled time the ammonia level was due. The surveyor queried the DON about Resident #13's physician order [REDACTED]. That's when we found out the lab could not draw it because it had to be packed in dry ice." The DON explained there was confusion between the facility and the new lab protocols. However, the DON agreed it was ultimately the facility's responsibility to ensure the lab tests were performed as ordered by the physician. During a telephone interview on 08/02/13 at 1:32 PM with the Lab Representative from the facility's contracted laboratory, she informed the surveyor the lab company was able to draw ammonia blood levels at the facility beginning April 2013. She stated she inserviced the DON, ADON and all the facility's nurses on the procedure for ordering ammonia levels. The Lab Representative stated the facility had to telephone the lab company the day before the ammonia level was ordered to be drawn, because the lab technician needed to bring dry ice to the facility for the lab speciman. Bringing dry ice was not a routine lab procedure. The surveyor asked the Lab Representative why all the physician-ordered ammonia lab draws were crossed out in the computer and labeled "cancelled." The Lab Representative stated the system automatically cancelled a lab order if it was not drawn within two to three weeks following the date the lab was ordered to be drawn. The Lab Representative verified Resident #13's ammonia levels dated 06/21/13, 06/26/13, 07/03/13, 07/07/13 and 07/26/13 had been entered, but a speciman was never gotten. She stated it had to do with facility staff not calling the lab the day before the ammonia level was due to be drawn. The surveyor asked the Lab Representative when the last lab audit was completed at the facility, and she stated March 25, 2013. She further stated the facility had instructions on how to conduct daily lab audits, and if they had completed a lab audit, the missed ammonia levels would have been identified as not having been done. Retrieved from <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm> on 08/05/13: Hepatic [MEDICAL CONDITION] Hepatic [MEDICAL CONDITION] is a worsening of brain function and the exact cause is unknown, however it can occur when liver function is damaged. The liver changes toxic substances in the body and makes them harmless. However, when the liver is damaged, these "poisons" may build up in the bloodstream. Ammonia, which is produced by the body when proteins are digested, is one of the harmful substances normally made harmless by the liver. Ammonia and other toxic substances can build up in the body and cause damage to the nervous system. Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start. Hepatic [MEDICAL CONDITION] may become a medical emergency, and hospitalization is required. [MEDICATION NAME] may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to remove blood from the intestines. The facility's current policy and procedure entitled: Laboratory, Radiology and Other Diagnostic Services, dated 08/31/12, reflected the following: Policy: "Laboratory and radiology services are provided to: Detect risk or disease...Monitor a condition." Rationale: "Laboratory services and radiology provide an avenue for medical staff to monitor patient outcomes and to make appropriate clinical decisions about the patient's care." Components: "...4. The Facility is responsible for: a. Providing or obtaining laboratory, radiology and other diagnostic services only when ordered by the attending physician; b. Promptly notifying the attending physician of the findings... ...d. Maintaining laboratory reports in the clinical record...." An undated list, which identified three residents, including Resident #13, as receiving [MEDICATION NAME] for [DIAGNOSES REDACTED].