Every finding on record at Green Oaks Nursing & Rehabilitation

Based on interview and record review, the facility failed to provide written notice of the facility's bed-hold policy to 3 of 3 residents (Residents #1, #2, #3) and/or the resident representative at the time the resident was transferred to the hospital. The facility failed to provide Residents #1, #2, and #3 and/ or the resident representative with written information specifying the duration of the state bed-hold period, the facility's bed hold policies, and the resident rights to return to the facility as required. This failure placed residents at risk of being unaware of the facility's bed-hold policy, including the resident's right's regarding holding the resident's bed and returning to the facility following hospitalization. Findings included: Record review of Resident #1's face sheet, dated 08/12/26, reflected Resident #1 was a [AGE] year-old female resident who was admitted to the facility on [DATE] with the diagnoses of a UTI (happens when bacteria get into any part of your urinary system), unsteadiness on feet (feeling wobbly or staggering when walking), cognitive communication deficit (a breakdown in communication caused by impaired thinking skills), adult failure to thrive (a complex syndrome marked by unexplained weight loss, reduced appetite, physical weakness, and a general decline in mental and physical functioning), osteoarthritis (when the cartilage that lines your joints is worn down and your bones rub against each other), and muscle weakness (a reduction in physical strength where muscles cannot move or contract normally). Record review of Resident #1's MDS assessment, dated 06/17/26 reflected Resident #1 had a BIMS of 5, which indicated severe cognitive impairment. Record review of Resident #1's EHR did not reflect documented evidence that a written notice of the facility's bed hold policy was given to Resident #1 or Resident #1's representative on 06/30/26 to [Hospital #1]. Record Review of Resident #2's face sheet, dated 08/14/26, reflected Resident #2 was a [AGE] year-old female resident who was initially admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of type 2 diabetes (where the body resists insulin or does not make enough of it), acute and chronic respiratory failure (severe worsening of the lung function), cognitive communication deficit (a breakdown in communication caused by impaired thinking skills), dementia (loss of memory). Record Review of Resident #2's MDS assessment, dated 07/08/26, reflected Resident #2 had a BIMS of 13, which indicated Resident #2 was cognitively intact. Record review of Resident #2's EHR did not reflect documented evidence that a written notice of the facility's bed hold policy was given to Resident #2 when she was transferred to the hospital on [DATE]. Record Review of Resident #3's face sheet, dated 08/14/26, reflected Resident #3 was an 85 -year-old male who was admitted on [DATE] with the diagnoses type 2 diabetes (where the body resists insulin or does not make enough of it), chronic kidney disease (when the kidneys are damaged and lose the ability to filter blood properly), and cardiomyopathies (a diseases where it makes it hard to pump blood to the rest of the body.) Record Review of Resident #3's MDS assessment, dated 08/05/26, did not reflect Resident #3's BIMS score. Record review of Resident #3's EHR did not reflect documented evidence that a written notice of the facility's bed hold policy was given to Resident #3 when he was transferred to the hospital on [DATE]. In an interview on 08/12/26 at 12:41 PM, Resident #1's Family Member stated she received a call from the facility when they informed her that Resident #1 would be transferred to [Hospital #1] due to Resident #1 exhibiting some aggressive behaviors. The Family Member stated she did not receive anything in writing from the facility and she was only verbally notified over the phone that Resident #1 would be transferred to the hospital. The family member stated she was verbally told that Resident #1 would be able to return to their bed when they were discharged from the hospital. In an interview via phone call on 08/12/26 at 1:14 PM, the SW stated he was unsure who was responsible for issuing a bed hold notice to residents, but he believed it would be admissions. The SW stated he is familiar with bed-hold policies from other facilities, but he had not really seen or heard this facility issue bed hold notices at all. The SW stated families should be given the option to pay privately if they would like to hold the bed. The SW stated he was unsure if the family member was notified about the resident's rights to return to the facility. The SW stated the risk of a resident or the resident representative not being provided with a written notice of the bed hold notice was that the resident or representative would not be fully aware of their rights. In an interview on 08/12/26 at 1:31 PM, the Admissions Director stated they were unsure of who was responsible for issuing bed hold notices to the residents and that would be something direct care staff would be responsible for. In an interview on 08/12/26 at 1:47 PM, the DON stated she had never heard of a bed hold notice. The DON asked if the bed hold notices were something new. The DON stated she was unfamiliar with the regulation, or their policy of the bed hold notice so she was unsure who would be responsible for issuing bed hold notices. The DON stated as a nurse mentally they noted that the resident still had a bed in the facility when transferred to the hospital and residents would be able to return to their room. The DON stated she did not know anything about the bed hold policy, but she would educate herself on the policy moving forward. The DON stated when she sent Resident #1 out to the hospital, she only filled out a transfer form and that form was only transported with the resident to the hospital and given to the EMS. The DON stated she was not sure of what the risk could be if a resident or resident representative were not issued a written bed hold notice. The DON stated it would be important to give a resident the bed hold notice form so the resident or resident representative would know if the residents bed would still be available when they returned to the facility. In an interview with on 08/12/26 at 2:22 PM, the Administrator stated the BOM would be responsible for speaking with the residents or resident representatives to give them the information about the bed hold notices due to the notices having a financial piece of information. The Administrator checked Resident #1's EHR and was unable to locate the bed hold notice or progress note that was documented. The Administrator stated she needed to verify with the DON if the facility was given the resident's bed hold notice upon transfers to the hospital and the Administrator returned and confirmed the facility had not been giving residents the written bed hold notices at all. The Administrator stated usually when a resident is transferred to the hospital the resident or the family member would ask verbally if the bed would be available when the resident returned and the facility would just verbally tell them the bed would still be available and their personal belongings would be safe. The Administrator stated that the expectation of the Business Office Manager was to inform the resident or resident representative when a resident was being sent out to the hospital to inform the family on their options to hold the bed. The Administrator stated the risk of the resident or resident representative not receiving a written notice of the bed hold form could cause a resident to have a bed when they returned to the facility. The Administrator stated the facility had a conversation with the family member about the bed was going to be held, but that conversation was never documented. The Administrator stated the expectation was to provide the bed hold notice to the resident or resident representative upon transfer to the hospital or within 24 hours of the transfer to the hospital. The Administrator stated if the bed hold notice was never documented that it was discussed the facility would not be able to verify the responsible party received the information. On 08/12/26 at 2:31 PM, via phone call the surveyor attempted to call the BOM but did not receive an answer and left a voicemail for her to return the call. Record review of the facility's Bed-Holds and Returns Policy, dated March 2017, in part reflected: Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Policy Interpretation and Implementation: 1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail:The rights and limitations of the resident regarding bed-holds;The reserve bed payment policy as indicated by the state plan (Medicaid residents);The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); andThe details of the transfer (per the Notice of Transfer) .

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for transfer/discharge rights. The facility did not allow Resident #1 to return to the facility after she was evaluated and treated at the hospital on [DATE]. This failure could place residents at risk of being discharged and not being allowed to return to the facility causing disruption in their care and services and potential decline in health. Findings included: Record review of Resident #1's face sheet, dated 08/12/26, reflected Resident #1 was a [AGE] year-old female resident who was admitted to the facility on [DATE] with the diagnoses of a UTI (happens when bacteria get into any part of your urinary system), unsteadiness on feet (feeling wobbly or staggering when walking), cognitive communication deficit (a breakdown in communication caused by impaired thinking skills), adult failure to thrive (a complex syndrome marked by unexplained weight loss, reduced appetite, physical weakness, and a general decline in mental and physical functioning), osteoarthritis (when the cartilage that lines your joints is worn down and your bones rub against each other), and muscle weakness (a reduction in physical strength where muscles cannot move or contract normally). Record review of Resident #1's MDS assessment, dated 06/17/26 reflected Resident #1 had a BIMS of 5, which indicated severe cognitive impairment. Record review of Resident #1's progress notes did not indicate any notes from the physician that reflected Resident #1 could not return to the NF on 06/30/26. Record Review of a progress note dated 06/30/26 written by SW reflected: SW was notified of residents ongoing sexual behaviors. Resident reportedly continues to make sexual comments to staff and asking for sexual acts to be done to them or to her. SW placed call to Family Member to discuss behaviors and recommendations for resident to be sent to [Hospital #1] for psychiatric evaluation, Family Member agreed for Resident #1 to be sent to [Hospital #1] due to ongoing hypersexual behaviors which are off baseline for Resident #1 per Family Member. Nursing staff placed call to non-emergency for transportation to [Hospital #1], DON/MD made aware. An telephone interview with Resident #1's Physician was attempted on 08/12/26 at 10:38 AM; however, the phone's dial tone sounded once then went to a line that continuously played music and no one answered the call with no opportunity to leave a voicemail. In an interview on 08/12/26 at 12:41 PM, Resident #1's Family Member stated Resident #1 was experiencing some aggressive behavior due to a UTI. The Family Member stated the facility informed her that they would need to send Resident #1 to [Hospital 1]. The Family Member stated the next thing she knew she received a call from Resident #1's apartment complex manager who informed her that Resident #1 was in the parking lot confused. The Family Member stated that was when she found out that [Hospital #2] discharged Resident #1 home using a ride service and had her transported to the apartment complex. The Family Member stated [Hospital #1] never informed her when Resident #1 was transported to [Hospital # 2], and [Hospital #2] never informed her that Resident #1 was discharged home. The Family Member stated due to her not having a vehicle because she was in a recent car accident she had to send Resident #1 to the facility using a ride service because Resident #1's keys and wallet were at the facility. The Family Member stated when Resident #1 was on the way to the facility she called the facility to let them know Resident #1 was on the way back. The Family Member stated that's when the facility told her they could not let Resident #1 back into the building because it would be a safety risk if she were to fall in the facility then the facility would be held liable. The Family Member stated the facility told her that staff could bring her personal belongings outside to Resident #1, but she would be unable to enter the building. The Family Member stated she asked why Resident #1 was unable to go back to the facility due to Resident #1 still needing rehab services and The Family Member stated the facility told her if she did not have a responsible party to escort Resident #1 back to the building then they would no longer accept Resident #1. The Family Member stated she was looking for other facilities to place Resident #1 in since she was unable to return to the facility. In an interview on 08/12/26 at 1:14 PM, the SW stated Resident #1 went to the hospital due to her decline, cognitive status, and sexual behaviors on 06/30/26. The SW stated Resident #1 was making sexual comments to all staff and the DON told Resident #1 that they were not going to tolerate sexual behavior. The SW stated [Hospital #1] transferred Resident #1 to [Hospital #2], and [Hospital #2] discharged Resident #1 on 07/02/26 and sent Resident #1 home using a ride service. The SW stated Resident #1's Family Member called and was asking a lot of questions as to why Resident #1 could not go back into the facility. The SW stated Resident #1 was unable to return to the facility due to her acute care setting. The SW stated Resident #1 was unable to return to the facility due to Resident #1 needing authorization on her insurance. The SW stated the authorization would need to have approval within 24 hours and due to her acute care setting she was not cleared to return to the facility which made her no longer a resident. The SW stated [Hospital #1] and [Hospital #2] never communicated with the facility and as far as they were aware Resident #1 was still at [Hospital #1] and the facility did not discover Resident #1 was sent to [Hospital #2] until she showed up at the facility on 07/02/26. The SW stated he was unsure why [Hospital #2] sent Resident #1 in a ride service vehicle, which due to her cognitive status was unsafe. The SW stated the risk of an inappropriate discharge was that it could cause missed medication, a return to the hospital, or a decline in functional abilities in reference to Resident #1's daily needs. The SW stated on 07/02/26 staff brought Resident #1's personal belongings to her and did not allow Resident #1 to go inside due to safety precautions. The SW stated staff took Resident #1 water outside while she waited for the ride service to take her home. The SW stated Resident #1 was permitted from being able to return to the facility and the Family Member paid for Resident #1 to return home. On 08/12/26 at 1:29 PM, attempted to interview the Caseworker at [Hospital #1], and the person who answered the phone stated she would be unable to assist the surveyor due to HIPAA laws and disconnected the call. In an interview on 08/12/26 at 1:47 PM, the DON stated Resident #1 had very vulgar, explicit, and inappropriate behavior. The DON stated Resident #1 had been showing a lot of sexual behaviors. The DON stated that due to Resident #1 having sexual behaviors she was sent out to [Hospital #1] for evaluation on 06/30/26 because they were unable to manage her behaviors in the facility. The DON stated she was unaware of what Resident #1's plan was as far as returning to the facility. The DON stated that she was hoping that [Hospital #1] could address Resident #1's behavior. The DON stated that when a resident was transferred to the hospital, they would typically have the admissions department reach out the hospital to find out a resident's status, if they were admitted , and what the plans were as far as any updates with the resident and what would happen next with the resident. The DON stated she was unsure why Resident #1 did not return to the facility and she did not know anything about the resident showing up to the facility and staff not letting her back into the facility. The DON stated she just could not see the staff making Resident #1 stay outside. The DON stated the risk of an inappropriate discharge could be a resident not getting their medications on time and they could possibly not be safe if they had to return home on their own. In an interview on 08/12/26 at 2:17 PM, the Admissions Director stated usually a hospital would send a referral to the facility to update the facility on where the resident may be medically and they would assess; however, since the resident never returned from the hospital, they never received a referral. In an interview on 08/12/26 at 2:22 PM, the Administrator stated she remembered having to deal with Resident #1 making a lot of overly sexual comments to the staff. The Administrator stated the comments were so provocative that she did not want to repeat them. The Administrator stated one of the comments Resident #1 made to staff was that she wanted them to perform oral sex on her. The Administrator stated Resident #1 also told staff if she could perform oral sex on the staff then she would. The Administrator stated they would have to remove Resident #1 from the dining room because she would make sexual comments to other residents. The Administrator stated the facility had to remove all male staff from Resident #1's room because she was reaching for the male staff's private areas. The Administrator stated Resident #1's last straw was when she grabbed a female staff by her private area. The Administrator stated the intervention they attempted was getting psych to evaluate Resident #1. The Administrator stated Resident #1 also refused to take her medications. The Administrator stated that they spoke with the Family Member and they informed them that the facility would send Resident #1 out to the hospital. The Administrator stated she told the Family Member that it would be more appropriate to place Resident #1 in an all-female unit, but she was also being inappropriate with female staff as well and she was unsure that would work also. The Administrator stated she was out of town when she had received a call from the SW that Resident #1 was discharged from [Hospital #1] and transferred to [Hospital #2] where she was then discharged home. The Administrator stated Resident #1 was sent to the hospital on [DATE] and then Resident #1 showed up at the facility on 07/02/26. The Administrator stated they were expecting a call from [Hospital #1] because they thought Resident #1 was still at [Hospital #1]. The Administrator stated they did not find out Resident #1 was sent to [Hospital #2] until the Family Member had Resident #1 sent to the facility to pick up their personal belongings. The Administrator stated that was not the first time [Hospital #1] had not communicated with them regarding a resident and they have had numerous problems with [Hospital #1] not communicating. The Administrator stated the Family Member called the facility to ask why Resident #1 was unable to return to the facility and she was told it was due to [Hospital #1] nor [Hospital #2] sending any updated clinicals to show whether or not Resident #1 was cleared to be able return to the facility. The Administrator stated she told the Family Member that she would need to call the hospital to find out if Resident #1 was cleared. When asked did the facility attempt to get the discharge paperwork for Resident #1 the Administrator stated since [Hospital #2] discharged Resident #1 home the facility would be unable to call and request the discharged paperwork. The Administrator stated it would be different if Resident #1 were still in the hospital, then they would have been able to call to find out the findings. The Administrator stated the risk of discharging a resident inappropriately would be that the resident may not have safety measures to go home. The Administrator stated there was never an immediate discharge ordered by the facility's physician and they were expecting Resident #1's return until [Hospital #2] discharged the Resident #1 home. The Administrator stated they were unable to let Resident #1 back into the facility because it would have been like accepting someone off the street at that point. The Administrator stated that was with any residents being discharged home from the hospital then the facility would be unable to accept them because they would need their updated medications, and clinicals. The Administrator stated without the hospitals not communicating the clinicals to know what was completed and to know if Resident #1 were still exhibiting behaviors she would have been a danger to the other residents in the building. The Administrator stated they would have taken Resident #1 back only if the clinicals were cleared. When asked if the facility had a policy regarding residents not being able to return to the facility the administrator stated the only policy the facility had was the Notice of a Transfer and/or Discharge. Record review of the facility's current, undated Notice of a Transfer and/or Discharge, reflected: Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy and Interpretation and Implementation: l . Except as specified below, a resident, and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility:The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility;The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;The safety of individuals in the facility is endangered;The health of individuals in the facility would otherwise be endangered;The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility;An immediate transfer or discharge is required by the resident's urgent medical needs;The resident is transferred for other than medical reasons;The resident has not resided in the facility for thirty (30) days; and/orThe facility ceases to operate.

Based on observation, interview, and record review, the facility failed to secure,label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for five residents( Resident#10, Resident #33, Resident#13's , Resident#122, and Resident#19's) on two medication carts (100 and ,200 hall nurses medication carts ) of four medication carts reviewed for medication storage. 1. The facility failed to ensure Resident #33's Naphcon A Eye drop was secured in the medcart.2. The facility failed to ensure Resident#10's: Fiasp FlexTouch 100 UNIT/ML Solution pen-injector (a rapid-acting mealtime insulin) was dated after opening and before it was stored in the medication cart.3. The facility failed to ensure Resident#13's Insulin Lispro Protamine &Lispro (is a rapid-acting insulin given at mealtimes) was dated after opening and before it was stored in the medication cart.4. The facility failed to ensure Resident#122's Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (a long-acting human insulin) was dated after opening and before it was stored in the medication cart.5. The facility failed to ensure Resident#19's Insulin Degludec Subcutaneous Solution 100UNIT/ML (Long-acting insulin) was dated after opening and before it was stored in the medication cart.6. The facility failed to ensure an open Lyumjev (a fast-acting mealtime insulin). had the patient's label and was dated after opening and before it was stored in the medication cart.These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Based on observation, interview, and record review, the facility failed to secure, label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for five residents (Resident#10, Resident #33, Resident#13's , Resident#122, and Resident#19's) on two medication carts (100 and ,200 hall nurses medication carts ) of four medication carts reviewed for medication storage. 1. The facility failed to ensure Resident #33's Naphcon A Eye drop was secured in the medcart.2. The facility failed to ensure Resident#10's: Fiasp FlexTouch 100 UNIT/ML Solution pen-injector (a rapid-acting mealtime insulin) was dated after opening and before it was stored in the medication cart.3. The facility failed to ensure Resident#13's Insulin Lispro Protamine &Lispro (is a rapid-acting insulin given at mealtimes) was dated after opening and before it was stored in the medication cart.4. The facility failed to ensure Resident#122's Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (a long-acting human insulin) was dated after opening and before it was stored in the medication cart.5. The facility failed to ensure Resident#19's Insulin Degludec Subcutaneous Solution 100UNIT/ML (Long-acting insulin) was dated after opening and before it was stored in the medication cart.6. The facility failed to ensure an open Lyumjev (a fast-acting mealtime insulin). had the patient's label and was dated after opening and before it was stored in the medication cart.These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents. Findings included: 1. Record review of Resident #33's Quarterly MDS Assessment, dated [DATE], reflected he had a BIMS score of 10, which indicated moderate cognitive impairment, suggesting potential issues with memory and thinking skills. Resident #33 was identified as having adequate vision and no corrective lenses. Record review of Resident #33's Care plan active as of [DATE] did not indicate any goals or interventions related to the medication that was at bedside or self administration.Record review of Resident #33's active Physician's Orders, dated [DATE], reflected there were no orders for Naphcon A Eye drop.Record review of Resident #33's Physician's Orders, dated [DATE], reflected there were no orders for Resident #33 to self-administer medications.An observation on [DATE] at 10:10 am revealed Resident #33 was in his bed a bottle of Naphcon A Eye drop on his bedside table.During an interview on [DATE] at 10:10 am with Resident #33, revealed he self-administered his eye drops.During an interview on [DATE] at 10:20am with MA C, revealed she was not aware Resident #33 had eye drops in his room. She stated Resident#33 was not supposed to have any medication at bedside. She stated the risk of leaving medication at beside was that the resident would self-administer inappropriately, another resident could have access to medication that is not properly secured. She stated she had been serviced on medication administration and storage in the room During an interview on [DATE] at 10:22am with LVN D, she stated she was not aware Resident #33 had eye drops in his room. She stated Resident #33 may be at risk of infection, drug overdose, and use of expired medication by unauthorized self-medication. During an interview on [DATE] at 11:00am with the DON, revealed Resident #33 was unable to safely self-administer medications. The DON stated the bottle of eye drops on Resident #33's bedside table should have been appropriately secured and stored in the facility's medication cart. The DON stated the risk of unsecured medications included the potential for drug interactions and overdose.2. Record review of Resident #10's MDS assessment, dated [DATE], reflected he was a [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMS score was 12, indicating her cognitive status was moderately impaired. Her diagnoses included Diabetes Mellitus.Record review of Resident #10's active care plan, Initiated [DATE], revealed Resident #10's has Diabetes Mellitus. Facility interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Dietary consult for nutritional regimen and ongoing monitoring. Fasting Serum Blood Sugar as ordered by doctor. Observe/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing,Record review of Resident #10's active Physician Order, dated [DATE], reflected: Fiasp FlexTouch 100 UNIT/ML Solution pen-injector. Inject as per sliding scale: if 151 - 200 = 2 Units; 201 -250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8Units; 351 - 400 = 10 Units; 401 - 450 = 12 Units, subcutaneously before meals for Diabetes HOLD if BS LESS than 70. USE Humalog until Fiasp arrives. order start date [DATE].3. Record review of Resident #13's MDS assessment, dated [DATE], reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMS score was 11, indicating her cognitive status was moderately impaired. Her diagnoses included Diabetes Mellitus. Record review of Resident #13's active care plan, Initiated [DATE], revealed: [NAME] as the potential for hypo/hyperglycemia related to Diabetes Mellitus. Facility Interventions included: Accu-Chek (is a brand of blood glucose monitoring devices for diabetes management) with sliding scale coverage as ordered. Administer diabetes medication as per MD ordersRecord review of Resident #13's active Physician Order, dated [DATE], reflected: Humalog Mix 75/25 Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine &Lispro) Inject 22 unit subcutaneously every morning and at bedtime for DM start date [DATE].4. Record review of Resident #122's annual MDS assessment, dated [DATE], reflected he was an [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMs score was 07, indicating her cognitive status was severely impaired. Her diagnoses included Diabetes Mellitus.Record review of Resident #122's active care plan, Initiated [DATE], revealed: [NAME] as the potential for hypo/hyperglycemia related to Diabetes Mellitus. Facility Interventions included: Accu-Chek (is a brand of blood glucose monitoring devices for diabetes management) with sliding scale coverage as ordered. Administer diabetes medication as per MD ordersRecord review of Resident #122's active Physician Order, dated [DATE], reflected: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for Diabetes start date [DATE].5. Record review of Resident #19's annual MDS assessment, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Her BIMs score was 07, indicating her cognitive status was severely impaired. Her diagnoses included Diabetes Mellitus.Record review of Resident #19's active care plan, Initiated [DATE], revealed: [NAME] has the potential for hypo/hyperglycemia related to Diabetes Mellitus. Facility Interventions included: Accu-Chek (is a brand of blood glucose monitoring devices for diabetes management) with sliding scale coverage as ordered Administer diabetes medication as per MD orders.Record review of Resident #19's active Physician Order, dated [DATE], reflected: Insulin Degludec Subcutaneous Solution 100UNIT/ML (Insulin Degludec) Inject 15 unit subcutaneously at bedtime related to start date [DATE].An observation on [DATE] at 9:21 am with LVN D on the 100 nurses' medication cart revealed Resident#10's Fiasp FlexTouch 100 UNIT/ML Solution pen-injector, Resident#13's insulin pro, Resident#122's Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML, Resident#19's insulin aspart were all opened with no with no opening dates. The Lyumjev had no patient's label and no opening date. During an interview on [DATE] at 9:32 am with LVN D revealed the nurses were responsible for checking that all insulin pens and vials had patient labels and open dates. LVN D stated that she did not realize the opened insulin pens did not have labels and opened dates. She stated that it was important to date opened insulins, because once opened, insulin expired after 28 days. LVN D stated that the risk to the resident receiving expired insulin could cause negative drug effects that due to reduced effectiveness of the medication. She stated having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in hospitalization. She stated she knew that he was supposed to check and ensure all medications were not expired before administering to the residents. LVN D stated she had been in-serviced on medication storage and dating all opened insulin and medication. She stated that she would remove the unlabeled and undated insulin from the cart immediately. An interview on [DATE] at 2:32 pm with RN E revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that were discontinued, were removed from the cart for proper disposal. She stated the risk to the resident was medication error and medication not being effective if it was expired. She stated that she had been in-serviced on medication storage. An interview on [DATE] at 11:00am with the DON, revealed all insulin pens and vials should be labeled, and they should have an open date. She stated that it was the responsibility of every nurse to check the label and open date before the administering insulin to a resident. The DON stated insulin was supposed to be dated because opened insulin expired 28 days after opening. She stated that failure to have open dates on insulin could result in administrating medication that was expired and could not be effective or that could have negative side effects to the residents. The DON stated all expired medication, discontinued medication, and medication of discharged residents should immediately be removed from the medication cart. She stated the risk to the residents was medication error administering expired medication could lead to adverse side effects and or not be effective. She stated that the DON and the ADON audited the medication carts biweekly and as needed, but there was no set schedule. She stated that the pharmacist audited the medication carts monthly. Review of the facility's policy Storage of Medication Revised [DATE] reflected the following 1.Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers. Drug containers that have missing, incomplete, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Compartments containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Drugs shall be stored in an orderly manner in cabinets, drawers' carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 3 residents medication (Resident#4, Resident #200's and Resident#99) medications on 2 of 4 medication carts,(200 hall nurses cart and 200 hall medication aides cart ) reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident#4's Tylenol 300/30mg (controlled medication) by taping the blister pack of a narcotic medication. 2. The facility failed to ensure proper disposal of Resident#4's Tylenol 300/30mg (controlled medication) medication that was discontinued. 3. The facility failed to ensure proper disposal of Resident #99's Lyrica capsule 300mg (controlled medication) when the blister pack was damaged.4.The facility failed to ensure Resident #200's (deceased and discharged ) expired Bactroban Cream 2 % (Mupirocin Calcium) (a topical antibiotic ointment or cream used to treat bacterial skin infections) was removed from the medication cart and properly disposed.5. The facility failed to ensure an expired opened Hemorrhoid cream expired 01/2026 was removed from the 400 hall nurses' medication cart and disposed of.6. The facility failed to ensure an expired 2026 Argiment (supplement specialized, non-digestible plant fibers that act as fertilizer to nourish and stimulate the growth of beneficial bacteria in the gut) expired [DATE] was removed from the 400 hall nurses' medication cart and disposed of.This failure could place residents at risk of drug diversion, medication errors, and risk of pills contamination due to broken seals.Finding included:1. Record review of Resident #4's MDS Assessment, dated [DATE], reflected Resident #4 was a [AGE] year-old female, admitted [DATE] and readmitted [DATE].She had a BIMS score of 15, indicating intact cognition. The resident had diagnoses including Peripheral Vascular Disease (a slow, progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart, commonly affecting the legs and feet). Record review of Resident #4's Comprehensive Care Plan, Date Initiated [DATE] reflected [Resident #4] has an UNAVOIDABLE pressure injury to LEFT HEEL STAGE 3 with potential for further pressure injury development r/t fragile skin, Hx of skin breakdown, Hx of ulcers. Interventions included pain meds as ordered, report unrelieved pain to MD.Record review of Resident #4's active physician orders, dated [DATE], reflected the resident had no orders for Tylenol with codeine #3 tablet 300-30mg (Acetaminophen-Codeine). The order was discontinued [DATE].2. Record review of Resident 99's Comprehensive MDS Assessment, dated [DATE], reflected the Resident #99 was a [AGE] year-old female, admitted [DATE]. She had a BIMS score of 11, indicating moderate cognitive impairment. The resident had diagnoses including Respiratory failure (a life-threatening condition where the lungs cannot adequately supply oxygen to the blood), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life), and Post Traumatic Stress Disorder (PTSD).Record review of Resident #99's Comprehensive Care Plan, dated [DATE], reflected Resident #99 has (acute/chronic) pain. Interventions included pain meds as ordered, report unrelieved pain to MD .Record review of Resident 99's active physician orders, dated [DATE], reflected Lyrica capsule 300mg. Give 1 capsule by mouth twice daily for pain order date [DATE].3. Record review of Resident #200's Discharge MDS assessment, dated [DATE], reflected he was a [AGE] year-old female admitted to the facility on [DATE] readmitted on [DATE] and was discharged [DATE]. No BIMs was recorded (indicating no interview was conducted). Resident #200's discharge status indicated she was deceased .Record review of Resident #200's care plan, Initiated [DATE], revealed: RESOLVED [NAME] has rash to face requiring topical Bactroban x 7days. Facility Interventions included RESOLVED: Administer antibiotic ointment as per MD orders.Record review of Resident #200's Discontinued Physician Order, dated [DATE], reflected: Bactroban Cream 2 % (Mupirocin Calcium) Apply to Face topically two times a day for Rash until [DATE]. Discontinued [DATE].An observation on [DATE] at 1:30 PM with MA C of the 200 Hall Medication Aide Cart station, revealed Resident #99's Lyrica capsule 300mg had a damaged blister bubble and the capsule still inside, at the time the surveyor inspected the medication cart.During an interview with MA C on [DATE] at 1:40 PM, she stated she did not notice the blister was damaged before the surveyor brought it to her attention. She stated the nurses and medication aides were responsible for inspecting the blister packs at every shift change when they did the narcotic count.An observation on [DATE] at 2:22 PM of the 200 Hall Nurses Cart station, revealed Resident #4's Tylenol with codeine #3 tablet 300-30mg (Acetaminophen-Codeine) had 2 blister seals broken and taped , and Resident #200's expired Bactroban Cream 2 % (Mupirocin Calcium) expired 08/2025.The damaged blister had the pills still inside secured with tape at the time the surveyor inspected the medication cart. During an interview on [DATE] at 2:32 pm with RN E revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that were discontinued, were removed from the cart for proper disposal. RN E stated she did not notice the blister was damaged before the surveyor brought it to her attention. She stated the nurses and medication aides are responsible for inspecting the blister packs at every shift change when they do the narcotic count. She stated Resident #4's Tylenol with codeine #3 tablet 300-30mg was discontinued [DATE]. She stated discontinued narcotics should be removed from the cart immediately and given to the DON. RN E stated if a narcotic blister seal was broken, the medication should be discarded wasted and witnessed by two nurses. She stated that the risk of a damaged blister would be the potential for drug diversion and contamination of medication. She stated the risk to the resident was medication error and medication not being effective if it was expired. She stated that she had been in-serviced on medication storage. In an interview on [DATE] at 2:50 pm, LVN D stated she was unaware Resident#99's Lyrica capsule 300mg blister pack seal was broken. She stated that the risk of a damaged blister would be the potential for drug diversion and contamination of the medication. She stated the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated she had been in-serviced on medication storage.An Interview on [DATE] at 9:12 am with MA F revealed that when a narcotic bubble seal was broken, he would notify the charge nurse so that the medication could be discarded. He stated all discontinued narcotics should be removed from the medication cart and given to the DON. He stated the risk of a damaged blister and discontinued medication would be the potential for drug diversion and contamination of the medication. He stated he was in-serviced on medication storage, and damaged narcotic blisters should never be taped.In an interview on [DATE] at 11:00am, the DON stated if a narcotics was discontinued, the nurses and medication aides were supposed to remove the medication from the cart and take it to her office to be secured properly until the pharmacist consultant disposed it. She stated if the blister pack seal was broken on any controlled medications, the pill should be discarded and witnessed by two nurses. The DON stated it was not acceptable to keep a pill in a blister pack that was opened. She stated that if a blister pack seal was broken it should not be taped. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses and Medication Aides were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON audit the medication carts bi-weekly, then the pharmacy consultant audits the medication room and the medication carts every month. She stated the nurses and the MAs had been in-serviced on medication storage, and narcotics were not to be taped if the blister seal was broken.Review of the facility's policy Storage of Medication Revised [DATE] reflected the following: Drugs and biologicals are stored in the packaging containers or other dispensing systems they are received in . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to conduct a Comprehensive Assessment within 14 calendar days after admission, as well as at least once every 12 months, for one (Resident #124) of seven residents reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #124 was completed within 14 days after his admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included: Review of Resident #124's Face Sheet, dated 03/12/26, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including seizures (a sudden surge of abnormal electrical activity in the brain, leading to changes in behavior, movements, feelings, and levels of consciousness), morbid (severe) obesity due to excess calories (having a body mass index of 40 or over), pain (physical suffering or discomfort caused by illness or injury), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation.). Review of Resident #124's MDS Assessment, dated 02/20/26, reflected the assessment was completed on 03/02/26 (17 days after admission). During an interview with the MDS/PPS Nurse on 03/11/26 at 10:25 AM, she stated Resident #124's MDS Assessment was not completed within the required timeframe due to her being on vacation when the assessment was due. She stated she did not believe MDS Assessments, not being completed within the required timeframe, posed a risk to residents, as necessary care was still provided for residents. Review of the facility's Electronic Transmission of the MDS policy, dated December 2009, reflected, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's computer MDS informational system and transmitted to the State database in accordance with current OBRA regulations governing the transmission of MDS data. The policy did not reflect the specific timeframe for MDS completion.

Based on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for one of six residents (Resident #16) reviewed for assessments. Resident #16's PASRR Level I was negative for mental illness despite having a diagnosis of anxiety, depression, and schizoaffective disorder. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.Record review of Resident #16's MDS assessment dated [DATE], reflected an [AGE] year-old female, originally admitted to the facility on [DATE], with a BIMS score of 12 which indicated moderate cognitive impairment and diagnoses that included: Anxiety Disorder (ongoing uncontrollable, and excessive worry, fear, or dread that significantly interferes with daily life), Depression (feelings of severe sadness and inability to initiate activity), and Schizoaffective Disorder (a serious mental illness blending symptoms of schizophrenia - psychosis like hallucinations/delusions, with mood disorders like depression or bipolar mania involving extreme mood swings, disorganized thinking, and disrupted reality perception.) Record review of Resident #16's Care Plan dated 11/28/2026, reflected she received antipsychotic medication to treat symptoms of schizoaffective disorder, antianxiety to treat anxiety, and antidepressant medications to treat depression. Record review of Resident#16's PASRR Level 1 Screening dated 10/21/2025 after re-admission, reflected the resident did not have evidence of a mental illness. During an interview on 03/11/2026 at 12:45 PM, the MDS Coordinator reported she oversaw PASRR screenings for the facility. She reported that she reviewed Resident 16's PASRR Level 1 Screening dated 10/21/2025 and acknowledged it was incorrect. She stated the screening was completed by a hospital. She stated if an incoming screening was incorrectly filled out by a hospital, she was supposed to complete form 1012 (a form used by Texas nursing facilities to determine whether a resident with a negative PASRR Level I Screening requires further evaluation for mental illness or has a primary dementia diagnosis) and submit the form through the Long-Term Care Portal. The MDS Coordinator stated the 1012 form was not completed for Resident #16. The MDS Coordinator reported the resident was not at risk because the resident did not qualify for PASRR because the resident did not have an intellectual disability. She further stated the resident was not at risk because the resident received psychiatric and mental health services through a contracted mental health provider. During an interview on 03/11/2026 at 1:00 PM with the MDS/PPS Nurse, she stated Resident #16 had a diagnosis of Dementia that would override her, making her ineligible for PASRR services. She reported Resident #16's primary diagnosis upon admission was not dementia but was a urinary tract infection. She reported if a resident had an inaccurate PASRR Level I Screening, they could miss out on receiving specialized services. Record Review of the facility's PASRR Policy dated May 2014, reflected in part the following: The PASRR Level I (PL1) Screening is designed to identify persons who are suspected of having a Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions (RC). The PASRR evaluation is designed to confirm the suspicion of MI, ID, or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning.If Alzheimer/Dementia is the primary diagnosis and there is MI diagnosis, no PASRR Evaluation (PE) is needed.If Alzheimer/Dementia is not the primary diagnosis and there is MI diagnosis, PASRR Evaluation (PE) is needed.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #124) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #124 within 48 hours of his admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #124's Face Sheet, dated 03/12/26, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including seizures (a sudden surge of abnormal electrical activity in the brain, leading to changes in behavior, movements, feelings, and levels of consciousness), morbid (severe) obesity due to excess calories (having a body mass index of 40 or over), pain (physical suffering or discomfort caused by illness or injury), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation.). Review of Resident #124's Interim Plan of Care [baseline care plan], dated 02/13/26, reflected LVN A signed the document as completed on 02/13/26. The document was not completed as it did not address required areas such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or PASARR recommendations. During an interview with LVN A on 03/11/26 at 1:30 PM, she stated she was the individual who completed the Interim Plan of Care (identified as being the same as the baseline care plan) for Resident #124. She said baseline care plans were to be completed on the day of a resident's admission. She stated she did not complete all sections of the baseline care plan for Resident #124 because she had been told it was not necessary to complete all sections, unless the resident required increased care for that specific area of the care plan. During an interview with the DON on 03/11/26 at 2:00 PM, she confirmed the Interim Plan of Care completed for Resident #124 was the same as a baseline care plan. The DON stated she was not sure of the timeframe in which the baseline care plan was supposed to be completed or the areas which were required to be included. She stated she did not believe an incomplete baseline care plan posed any risks to residents, as necessary care was still provided for residents. Review of the facility's Care Plans - Baseline policy, dated 12/2016, reflected, .1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #16) reviewed for comprehensive care plans. The facility failed to ensure Resident #16's comprehensive care plan was accurate and reflected the resident's PASRR status. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.Record review of Resident #16's MDS assessment dated [DATE], reflected an [AGE] year-old female, originally admitted to the facility on [DATE], with a BIMS score of 12 which indicated moderate cognitive impairment and diagnoses that included: Anxiety Disorder (ongoing uncontrollable, and excessive worry, fear, or dread that significantly interferes with daily life), Depression (feelings of severe sadness and inability to initiate activity), and Schizoaffective Disorder (a serious mental illness blending symptoms of schizophrenia - psychosis like hallucinations/delusions, with mood disorders like depression or bipolar mania involving extreme mood swings, disorganized thinking, and disrupted reality perception.) Record Review of Resident #16's comprehensive care plan dated 11/28/2026, reflected Resident #16 PASRR assessment identified needs for specialized services. The plan stated specialized services would be provided to maintain the highest level of function for Resident #16.Record review of Resident #16's PASRR Level 1 Screening dated 10/21/2025 reflected the resident did not have evidence of a mental illness.In an interview on 03/11/2026 at 1:00 PM with the MDS/PPS Nurse, she stated she completed Resident #16's Comprehensive Care Plan. She acknowledged Resident #16 never received PASRR services. She stated the resident's Comprehensive Care Plan was inaccurate. Record Review of the facility Comprehensive Care Plan policy dated December 2016, reflected in part: The comprehensive care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 4 residents (Resident#99) reviewed for respiratory care. The facility failed to ensure that Resident #99's oxygen tubing's were bagged in a plastic bag, and which was consistent with professional standards when the nasal cannula was observed dragging on the floor.The facility failed to ensure that Resident #99 was receiving continuous oxygen per physician orders when she was observed without oxygen. These failures could place residents at increased risk of receiving inadequate oxygen support, infections that could result in a decline in health. Based on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 4 residents (Resident #99) reviewed for respiratory care.1. The facility failed to ensure that Resident #99's oxygen tubing were bagged in a plastic bag when not use, and the nasal cannula was not dragging on the floor.2. The facility failed to ensure that Resident #99 was receiving continuous oxygen per physician orders when she was observed without oxygen.These failures could place residents at increased risk of receiving inadequate oxygen support, infections that could result in a decline in health.Findings included:Record review of Resident #99's Comprehensive MDS Assessment, dated 02/07/2026, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. She had a BIMS score of 11, which indicated she had moderate cognitive impairment. Resident #99 was identified as requiring oxygen therapy. Her diagnosis included diagnoses including acute and chronic respiratory failure with hypercapnia (a specific type of respiratory failure characterized by elevated levels of carbon dioxide in the blood), and dependence on supplemental oxygen (a condition where an individual requires supplemental oxygen due to respiratory disorders or other medical conditions).Record review of Resident #99's Care Plan, dated 03/10/2026, reflected Resident #99's has altered respiratory status/Difficulty Breathing. Identified goals included: Resident #99 to have no signs or symptoms of poor oxygen absorption. Interventions included for Resident #99 will have no s/s of poor oxygen absorption.Record review of Resident #99's Physician's Orders, dated 02/03/2026, reflected oxygen (2 liters per minute)via nasal cannula continuously for Order start date 02/03/2026. During an observation on 03/11/2026 at 9:00AM, Resident #99 was in the wheelchair pushed by the personal care attendant. Resident #99 had a portable oxygen tank on the back of the wheelchair. The oxygen level indicator reflected the oxygen tank was empty, and the oxygen nasal canula (a flexible, lightweight tube used to deliver supplemental oxygen) was dragging on the floor while the resident was pushed on the hallway by the personal care attendant in sight of 2 other CNAs and a nurse.An interview on 03/11/2026 at 9:03AM, Resident #99 revealed she was not experiencing shortness of breath at that moment but stated she needed the oxygen tank replaced because she was supposed to be on continuous oxygen.An interview on 03/11/2026 at 09:05 AM with Resident #99's personal care attendant revealed she was taking the resident to the nurse to replace the oxygen tank that was empty, and did know that the nasal canula was dragging on the floor until the surveyor brought it to her attention. She stated the oxygen tubing should not be dragging on the floor because of possible infection.An interview on 03/11/2026 at 9:55AM with LVN D, revealed Resident #99 had a physician's order for continuous oxygen therapy. She confirmed the portable oxygen tank was empty. LVN D stated the last time she saw Resident# 99, she was receiving oxygen from the concentrator in her room. LVN D stated the risks to the residents was shortness of breath, respiratory distress (difficulty breathing, where a person struggles to get enough air, often showing rapid, shallow, or labored breathing and other signs of low oxygen), and confusion. LVN D stated the risk of a resident's nasal canula dragging on the floor was infection. She stated she had been in-serviced on infection control respiratory care.During an interview with the DON on 03/11/2026 at 12:10PM, she stated her expectation, for residents with physician's orders for continuous oxygen, was for those residents to always have access to oxygen. The DON stated the risk of a resident not receiving continuous oxygen, as ordered, included not getting enough oxygen and the potential for shortness of breath. The DON also stated the risk of the oxygen nasal canula dragging on the floor was infection. She stated the staff had been in-serviced on infection control respiratory care. Record review of the facility's Oxygen Administration policy, revised October 2010, reflected, .Oxygen therapy is administered by way an oxygen mask, nasal cannula, and /or nasal catheter. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head.

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 one of one hydration carts observed for infection control. The facility failed to ensure proper infection control procedures were followed when Resident #49's family member utilized a metal ice scoop to obtain ice from the hydration cart, located in the residential hallway. Resident #49's family member then poured the ice into two personal cups, touching the metal scoop on the insides of each cup. This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included: Review of Resident #49's Face Sheet, dated 03/12/26, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including closed fracture with routine healing (a broken bone that has not pierced the skin (closed) and is recovering normally without complications (routine healing)) and pneumonia (an infection that inflames the air sacs (alveoli) in one or both lungs, causing them to fill with fluid or pus). Observation on 03/10/26 at 12:40 PM revealed Resident #49's family member utilized a metal ice scoop to obtain ice from the hydration cart, located in the residential hallway (Hall 200). Resident #49's family member then poured the ice into two personal cups, touching the metal scoop on the insides of each cup. During an interview with Resident #49's family member on 03/10/26 at 12:57 PM, she stated she frequently utilized the hydration cart to obtain ice for herself and Resident #49 and had done so since his admission to the facility. She stated she had not been advised of the need for staff to obtain the ice in order to maintain proper infection control protocols. During an interview with the Administrator on 03/10/26 at 2:30 PM, she stated residents and visitors were not supposed to use the hydration cart located on the residential hallway. She stated the hydration cart was meant for staff use; residents and visitors were encouraged to only allow staff to use the cart. When asked about the potential risk to residents, the Administrator stated it was unfortunate that the hydration cart was utilized by a visitor. The Administrator stated the facility did not have a specific policy and procedure related to hydration carts. Review of the facility's Policies and Practices - Infection Control policy, dated 07/2014, reflected, .The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required it for 1 of 8 residents (Resident #1) reviewed for pain. The facility failed to make sure that each resident's clinical record contains the physician's signed and dated orders that also were handled appropriately if any changes were made for 1 (Resident #1) of 8 Residents reviewed for physician orders in that: - Facility failed to obtain physician orders for [[NAME]] Cold Therapy Unit which was used to provide cold therapy to reduce pain and swelling for Resident #1. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records Findings included: Record review of Resident #1's admission record dated 09/04/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of unspecified hyperlipidemia (this is elevated lipid levels in the body without a clearly identifiable cause). admission record did not have other diagnoses. Record review of Resident #1's hospital discharge date d 08/29/25, revealed Resident #1 was a [AGE] year-old female who had Type II Diabetes mellitus [uncontrolled blood sugars], Atrial fibrillation [heart irregularity and arrhythmia], Hyperlipidemia, GERD [heart burn/irritation], and Chronic low back pain. [Resident #1] presents with a chief complaint of left knee pain. She has had the symptoms for 2 years. She was previously diagnosed with osteoarthritis in 2006 [(a degenerative joint diseases that primary affects the left knee joint causing pain. Stiffness, and reduced mobility)] and underwent an arthroscopic debridement [(this a surgical procedure that involves removing damaged tissue from a joint)]. She had relief for 1-2 years. She has had progressive pain in the knee over time. She has had multiple steroid injections with temporary relief. Her last steroid injection was in February 2025. She did not have any relief with [name] supplementation. She has been receiving home physical therapy, which has been helping her mobility and strength, but pain persists. She still has popping in the knee, as well as deep pain. She has been receiving Oxycodone [(pain medication)] and Lyrica [(nerve pain medication)] for chronic pain from [Physician name], a pain management specialist. Record review Resident #1's admission MDS on 09/04/25, revealed document was in progress status. Record review of Resident #1's active physician orders on 09/04/25 did not reflect physician order for ICTU therapy. Record review of Resident #1's care plan initiated on 09/03/25 did not reflect focus, goals, or interventions for use of ICTU therapy. Observation and interview with Resident #1 and Medication Aide on 09/04/25 at 07:50 AM, revealed Resident #1 was in bed with both legs uncovered. The left leg had a black knee immobilizer brace on and on top of her knee opening was a blue ice pad of the [[NAME]] Cold Therapy Unit in place connected. The ICTU cooler box was placed on the floor at the end of the bed. She said that she had the ICTU since she admitted [9/2/25], and the ice was only refilled yesterday [09/03/25] at 7 pm. Resident #1 stated that the nurse had already administered pain medication, however she was still having some knee pain. At this time of observation, MA administered Aspirin 81 mg, 1 tablet, Diazepam 10 mg tablet [antianxiety], take 1 tab by mouth 2 a day, Pregabalin 75 mg capsule [nerve pain medicine], take 1 cap oral route 3 times a day- 1 cap given, Divalproex DR 250 MG [depression medication], give 1 tablet by mouth 2 times a day-1 tab given, Metformin ER 500 MG TAB [controls blood sugar], give 1 tablet by mouth one time a day-1 tab given, Trintellix 20 mg Tab [antidepressant], give 1 tab by mouth 1 time a day-1 tab given, and Vraylar 1.5 MG[antipsychotic], Capsule, take 1 cap by mouth every day, 1 tab given. The MA stated that it was the nurse and the CNAs who were responsible for the resident's equipment's such as the ICTU and she would let them know that the machine needed ice and that the resident was still in pain. In an interview with RN A on 09/04/25 at 08:00 AM, revealed she had administered pain medication at 6 AM to Resident #1. She stated she did not check the [[NAME]] to see if there was ice water in it. She said herself and the CNA were responsible for monitoring that the machine had ice water in it. She said she was not sure who had ordered the [[NAME]], but it had been on Resident #1's knee for pain management. She said the orders might have come from the hospital, but she was not sure because the resident was new to the facility. She stated the admitting nurse was responsible for entering the physician orders at admission. RN said that she was monitoring Resident #1's circulation every 4 hours. She said the risk to resident not having ice water in her [[NAME]] was increased pain. In an interview with CNA on 09/04/25 at 09:42 AM, revealed she was not responsible for monitoring for Ice water in the ICTU machine. She said that was the nurse's responsibility. She said prior to today [09/4/25], the nurse nor the resident had not asked her to check the machine for ice water but she passed ice in the hydration cups this morning. She said the nurse (RN A) asked for her help a little while ago to get something to discard the old water from the machine. She said she did not know how to operate the ICTU but it looked easy. In an interview on 09/04/25 at 01:33 PM, the DON stated her expectation was all orders were transcribed correctly, and every nurse was trained to make sure that all physician orders were clarified. She said THE [[NAME]] was used to help with pain control. She stated the nurses were responsible for obtaining physician orders and the nurse managers should make sure all orders were in and accurate. The DON said she was unaware of who had ordered the [[NAME]] or how long Resident #1 had it for. The DON said the risk of not having orders was not knowing how long to keep the [[NAME]] on and off. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment . Record review of facility policy titled, Pain Assessment and management, revision date April 2009, revealed4. The physician and staff will establish a treatment regimen based on consideration of the following:a. The resident's medical condition;b. Current medication regimen;c. Nature, severity and cause of the pain;d. Course of the illness; ande. Treatment goals. Reference www.midline.com/ [[NAME]]-classic, DJO Global [[NAME]]-CLASSIC-.PDF Product Description The [[NAME]] CLASSIC cold therapy unit helps reduce pain and swelling, speeding up rehabilitation. The [[NAME]] provides extended cold therapy for a variety of indications and protocols as directed by a medical professional. Using DonJoy's patented semi-closed loop recirculation system, [[NAME]] delivers more consistent and accurate temperatures than other cold therapy units. The DonJoy [[NAME]] features a semi-closed loop recirculation system that allows water warmed after flowing through the pad to be preserved and remixed with cooler ice water at a constant flow rate, providing consistent cool water distribution throughout the cold pad.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for one (Resident #1) of two residents reviewed for perenteral fluids. 1. The facility failed to ensure the dressing on Resident #1's PICC line (used to deliver medications and other treatments directly to the large central veins near the heart) was changed timely. Resident #1 went without a dressing change for 19 days. 2. The facility failed to have orders for PICC line dressing changes and flushes. The failures could affect residents by placing them at risk for infections. Findings included: Review of Resident #1 MDS assessment, dated 02/11/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses in part included amputation of the right foot, chronic osteomyelitis of the right ankle and foot (infection in the bone), deep vein thrombosis (a blood clot in a leg vein), hypertension (high blood pressure), and diabetes (a group of diseases affecting how the body uses sugar). The resident received IV (intravenous) medications while a resident in the facility and he was cognitively intact. Review of Resident #1's current care plan dated 02/07/25 reflected Resident #1 was receiving antibiotic therapy related to chronic osteomyelitis of the right ankle and foot. Review of Resident #1's admission progress note written by LVN A and dated 02/07/25, reflected Resident #1 was admitted to the facility on [DATE] with a PICC line to his left upper arm with the dressing intact. Review of Resident #1's February 2025 TARs and progress notes reflected Resident #1's PICC line dressing was not changed and there was no documentation of the PICC line being flushed from 02/07/25 through 02/26/25. Review of Resident #1's physician orders reflected there were no orders for PICC line care, including no orders to flush the PICC line and no orders to change the PICC line dressing. In an interview on 02/26/25 at 03:00 pm RN B reported she was a visiting nurse who had visited Resident #1 on 02/26/25. She stated that she had noted his PICC line dressing was very dirty, and there was no date and no initials on the dressing. She stated Resident #1 had reported to her that the dressing had not been changed since before he was admitted to the facility. She reported she went and told the ADON (name unknown) and told her what she had found. She stated the ADON stated, thank you. RN B reported that Resident 1's IV antibiotics had completed yesterday. Review of physician order by Physician E dated 02/26/25 at 01:56 pm ordered the PICC line catheter to the left upper arm to be discontinued. In an interview and observation on 02/26/25 at 02:40 pm, Resident #1 reported his Veteran's Affair nurse was here today (02/26/25) and had noted that his PICC line dressing was dirty. He stated the dressing had never been changed since he was admitted to the facility and the dressing did not have a date on it. He reported that a facility nurse had discontinued the PICC line within the past two hours. A small round scab was noted to his left upper arm. He reported the Band-Aid had fallen off. In an interview on 02/26/25 at 04:27 pm, LVN C reported she had worked with Resident #1 for two weeks in the evenings on Monday through Fridays and had given him his IV antibiotic once each day. She reported she had never changed his PICC line dressing. She reported that PICC line dressings are supposed to be changed every seven days. She stated she does not remember what the date on his PICC line dressing was. She reported there was no order that prompted her to change the dressing. She reported she flushed the PICC line with normal saline before and after each medication administration. She reported that a risk of not changing the dressing would be a risk to the resident for infection and that the dressing could become loose and the PICC line possibly fall out. She reported that signs of infection including abnormal drainage, redness, tenderness/pain, swelling are some signs of infection at the sight. She reported that Resident #1 has not had any of those signs of infection at his PICC line sight since she has been providing his care. She reported she had not received any PICC line training at the facility since her hire two weeks ago In an interview on 02/26/26 at 005:00 pm, LVN D reported that she had provided Resident #1 with IV antibiotics on the weekends over the past two weeks through his left upper arm PICC line. She reported she did not remember what the date on the dressing was. She reported she had flushed the port with normal saline before and after the medication. She reported she had never done the dressing change because she did not see an order to do one and there was usually an order. She reported the policy was to change the dressing every seven days and that failing to do so could place the resident at risk of infection or embolism. She reported there was no redness, warmth, infiltration, or other sign of infection at the PICC line site of Resident #1. She reported she had previously received PICC line training at the facility including the need to change the dressing weekly. In an interview on 02/26/25 at 05:30 pm, the DON reported she was aware that a Veteran's Affair nurse had visited Resident #1 today (02/26/25) and had reported an issue with his PICC line dressing not being changed. She reported the physician ordered the PICC line discontinued because the resident had completed his IV antibiotics. She reported she had begun educating the nurses to make sure there are orders present for PICC line care. reported that not having the orders could increase the risk of nurses failing to provide the care. She stated her expectation is that nurses will add the orders for PICC line care in the the electronic medical record upon the admission of a resident, including flush orders, monitoring site orders, and dressing change orders. She did not state who was responsible for monitoring this. She reported the facility policy was that PICC line dressing were changed every seven days. She reported she expected that PICC line dressing changes were documented in the resident's electronic medical record. She did not discuss what training nurses had previously received for PICC line care. She She reported a resident would be at risk for infection if their dressing was not changed. Review of Resident #1's records did not reflect PICC line related infection or complications. In an interview on 02/26/25 at 06:10 pm, Physician E reported that he was unaware that Resident #1's dressing was not being changed or that his orders for PICC line care had not been entered. He reported these orders are part of standing orders when a resident is admitted to the facility with a PICC line. He reported PICC line dressings are typically changed weekly. He reported that Resident #1 had not experienced any infection or adverse reaction related to the dressing not being changed, and that Resident 1's recent blood work showed his inflammatory markers had improved. He reported that today he gave an order to discontinue the PICC line as Resident #1 had completed his antibiotics. Review of the facility's policy (undated) titled, Central Venous and Midline Catheter Flushing reflected to, Flush catheters at regular intervals to maintain patency AND before and after the following: b. administration of medications . Review of the facility's policy (undated) titled, Central Venous Catheter Dressing Changes reflected to, Change transparent semi-permeaable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .

Based on interview and record review the facility failed to maintain privacy of medical records for 1 (Resident #2) of 5 residents reviewed for privacy of medical records. The facility (RN B) failed to ensure the privacy of Resident #2's personal information on 1/31/25. During Resident #1's discharge home, RN B included Resident #2's Methocarbamol Blister Pack (pain medication) which contained Resident #2's personal identifying information labeled (name and date of birth) to Resident #1 and Resident#1's FM. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals. Findings included: Record review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and was discharged home on 1/31/25. Resident #1 diagnoses included acute kidney failure (inability to remove waste products and maintain fluid and electrolyte balance), Paroxysmal Atrial Fibrillation (heart rhythm disorder), Chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing difficulties), Dysphagia (difficulty swallowing), Transient Ischemic Attack (temporary interruption of blood flow to the brain) and Cerebral Infarction (blood flow to the brain is interrupted). Record review of Resident #1's MD discharge order dated 1/31/25 reflected: May discharge home with home health services of choice. Skilled nursing, meds and disease education, wound care per wound care orders, PT/OT to home evaluate and medical social worker if needed. Record review of Resident #2's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 2/5/25. Resident #2 diagnoses included type 2 diabetes (body doesn't use insulin properly), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (sodium level in the blood is lower than normal), major depressive disorder (persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life). Record review of Resident #2's Care Plan reflected the following entry: Date initiated 1/7/25: [Resident #2] has acute/chronic pain. Interventions included Monitor/record pain characteristics . Observe and report changes in usual routine . [Resident #2] prefers to have pain controlled by medication, treatment). Record review of Resident #2's Administration Record dated January 2025 revealed an order for: Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 0.5 tablet by mouth three times a day for spasms give half tab = 250mg dose Record review of Resident #2's Discharge Summary reflected Resident #2 discharged home on 2/5/25 with all her medications documented accordingly. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility on 1/31/25. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM read the Blister Pack and provided Resident #2's name, date of birth and her room number at the facility. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he printed a Medication Summary and obtained the keys to both medication carts from RN A. RN B stated he collected all of Resident #1's medications, compared the Blister Packs to the printed Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her on following up with Resident #1's primary care physician within 7-10 days, reminded her that she needed to pick up Resident #1's medication from the pharmacy, any treatments, and recommended diet for Resident #1. RN B stated he was unsure how Resident #2's medication was included. As it was confirmed that the FM was able to provide Resident #2's name, her date of birth and the name of the medication, RN B stated it was important to confirm all information to respect the privacy and confidentiality of all Residents. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated she believed RN B mistakenly pulled the other resident's medication due to Resident #2's medication being directly behind Resident #1's medication. The DON stated RN B informed her that he gathered the medications and went through each individual Blister Pack with the FM but he did not recall the other resident's medication being in there. The DON stated it was important to protect all residents' personal information and medication history. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated the FM informed him when Resident #1 discharged home, there was one medication belonging to another resident (Resident #2). The ADM stated starting today (2/21/25), the nursing staff was re-educated on discharging medications including the importance of protecting residents' personal information and medication history by the DON. The ADM stated all staff were responsible to ensure residents' confidentiality. Record review of the facility's policy titled, Resident Rights, dated Revised December 2016 reflected the following: . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality; Record review of an undated Confidentiality and Non-Disclosure Agreement signed on 2/21/23 by RN B reflected the following: . Our facility information systems contain confidential records pertaining to our business operations, our residents, business associates, health care professionals, and employees. This information is vital to the operation of our facility in providing quality care and services to our residents, therefore it must be protected. As such, in accordance with current HIPAA regulations and facility policies governing the access, use, and disclosure of protected health or facility information, you have the responsibility to protect such data. As an employee of this facility, .Your signature on this document indicates that the information contained herein has been explained to you, you received a copy of this document and that you understand the rules set forth. YOU AGREE: . 3. To disclose confidential resident, business, financial or employee information ONLY to those authorized to receive it.

Based on interviews and record review, the facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility (RN B) failed to complete the Discharge Summary Nursing Section regarding a reconciliation of Resident #1's medications when she discharged home on 1/31/25. This failure placed residents at risk for a lack of continuity of care and adequate medication administration after they are discharged home. Findings included: Record review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 1/31/25. Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 13 indicating she was cognitively intact. Resident #1's diagnoses included acute kidney failure (inability to remove waste products and maintain fluid and electrolyte balance), Paroxysmal Atrial Fibrillation (heart rhythm disorder), Chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing difficulties), Dysphagia (difficulty swallowing), Transient Ischemic Attack (temporary interruption of blood flow to the brain) and Cerebral Infarction (blood flow to the brain is interrupted). Record review of Resident #1's undated Care Plan reflected the following entries: Date initiated 1/21/25: [Resident #1] has potential for impairment to skin integrity related to fragile skin. Interventions included administer treatment as ordered. Assist resident with turning and repositioning during rounds. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. Do not apply on the site of injury. Date initiated 1/10/25: [Resident #1] exhibits ADL self-care performance deficits, requires assistance: limited mobility, uses a wheelchair. Interventions included provide assistance with eating, bathing, toileting and grooming as needed; provide appropriate diet; bath per schedule and praise resident for all efforts made. Record review of Resident #1's progress notes reflected the following entries: 1/8/25: [Resident] is a [AGE] year-old female, new admit to the facility from [hospital name], arrived via wheelchair accompanied by the driver and [family] . AAOx4, able to communicate all needs . Signed by LVN A 1/31/25: Medications called into pharmacy of choice: [pharmacy] [phone number], per MD 30-day supply with no refills. Signed by DON Record review of Resident #1's Physician's Discharge Order dated 1/31/25 reflected: May discharge home with home health services of choice. Skilled nursing, meds and disease education, wound care per wound care orders, PT/OT to home evaluate and medical social worker if needed. Record review of Resident #1's Discharge Summary reflected Resident #1 discharged home on 1/31/25 with her FM. Resident #1's Discharge Summary revealed all sections were completed and signed, except Section 4 Nursing - A. Medications. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM stated she had not contacted the facility immediately afterward. The FM stated Resident #1 was supposed to discharge on Monday, 2/3/25, but she decided to pick her up instead on Friday, 1/31/25. The FM stated she did not speak with the ADM until 2/17/25 whereas she voiced her concerns and that she received one medication that belonged to a different resident. The FM stated the ADM informed her that they would look into it and that himself, or someone else would call her back. The FM stated after not hearing from anyone in three days, she called in the report to HHS. The FM confirmed she received a printout of Resident #1's discharge summary and a separate list with her medications. During an interview on 2/21/25 at 1:25 PM with RN A, she stated she was the assigned nurse for Resident #1's hall. RN A stated she was completing rounds with the MD, so RN B handled Resident #1's discharge. RN A stated she gave RN B the keys to the medication carts and she assumed RN B went over the medications because he was in the room with Resident #1 and the FM. RN A stated the nurse completing the discharge was responsible for completing Section 4 (Medications) of the Discharge Summary and reconciling the medications with the resident/family. RN A stated during a discharge, the nurse went over the entire Discharge Summary with the resident/family. RN A stated due to the incident, she was in-serviced by ADON A on Friday, 2/21/25. RN A stated they went over that they no longer provided Blister Packs at discharge and all medications needed to be called into the pharmacy. RN A stated you made sure all sections of the Discharge Summary was completed, signed, and had the family sign it. RN A stated moving forward, if existing medications were being sent home with the family, you must obtain approval from an ADON or the DON. RN A stated she should had followed up with RN B since Resident #1 was one of her residents. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he assisted RN A with Resident #1's discharge. RN B stated he printed a Medication Summary and RN A gave him the keys to the medication carts. RN B stated he collected all of Resident #1's medications, compared them to the Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her. RN B stated while he went over the medications, he had the printed paper and the Blister Packs to ensure everything matched. RN B stated he was unsure how Resident #2's medication was included. RN B stated he checked the list and medications several times. RN B stated the FM was engaged and had a firm understanding of the medications as well as Resident #1's upcoming appointments. RN B stated he did not recall the FM handling the Blister Packs. RN B stated the discharge process was to confirm the resident being discharged and make sure the family was aware. RN B stated you made sure there was a Physician's Discharge Order and that all medications were listed on the Discharge Summary. RN B stated normally you do not send medications home with the residents, you called the orders into the pharmacy. RN B stated once the resident discharged , you document who they left with and their status. RN B stated he was in-serviced by the DON today (2/21/25) and he learned to be more mindful and if he is not clear about something, to ask questions to prevent errors. RN B stated they were no longer sending medications home and to ensure the family is aware that all medications were called into the pharmacy of their choice. RN B stated he was also in-serviced on making sure all sections of the Discharge Summary was completed fully. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated when time permitted, they requested all medications from their pharmacy to be delivered to the facility. The DON stated medications arrived from the pharmacy in a bundle inside of a large envelope. The DON stated if there was not enough time, the facility would call the orders into the pharmacy of the family's choice. The DON stated when pharmacies sent over medications, they sent more than one Blister Pack. The DON stated RN B must had pulled the other resident's medication out by mistake due to it being directly behind Resident #1's medication. The DON stated she was informed by RN B that RN A was discharging Resident #1 and RN A asked him to assist. The DON stated RN B informed her that he gathered Resident #1's medications and went through each one with the FM but he did not recall the other resident's Blister Pack. The DON stated she was unsure how the medication was overlooked. The DON stated the only time they discharged residents with medications was if it was a specialty medication. The DON stated it was not against their policy to discharge with medications, they just preferred the orders were called in to ensure residents had enough medication once they arrived home. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated he had not received a call from the FM until 2/17/25, almost three weeks after Resident #1 discharged home. The ADM stated the FM informed him that Resident #1 received all her medications, but there was one medication included that did not belong to Resident #1. The ADM stated starting today (2/21/25), the DON re-educated the nursing staff on discharges and sending medications home. The ADM stated the normal process was the nurse assigned to the hall would pull the medications and send the medications home with the resident. The ADM stated in this situation, RN A asked for assistance and RN B stepped in to assist. During an interview on 2/24/25 at 10:05 AM with ADON A, she stated a Discharge Order was obtained from the MD. ADON A stated the assigned nurse went over all medications with the family and followed up with the MD if needed. ADON A stated Resident #1's allotted discharge time was scheduled for Monday (2/3/25), but the FM arrived on Friday (1/31/25). ADON A stated due to this they allowed the FM to take the Blister Packs home and the DON called the Orders into the family's preferred pharmacy. ADON A stated all medications should had been listed on the Discharge Summary along with the details of the discharge. ADON A stated if the FM had waited until the scheduled day of discharge, the pharmacy would have sent the medications to the facility. ADON A stated normally Blister Packs were not sent home because the facility paid for the medications for Skilled Residents. ADON A stated what went wrong was two different nurses working on the discharge and normally, only the floor nurse completed the discharge. ADON A stated RN A should had handled the discharge and not RN B even though he was an RN. ADON A stated RN A should had double-checked the Blister Packs and ensured there were no extra Blister Packs. ADON A stated the DON in-serviced her on the discharge policy moving forward. ADON A stated the only thing new is if Blister Packs were being released with the Resident, an ADON or the DON must sign off. ADON A stated she assisted with in-servicing the nurses. ADON A stated the worst that could had happened was Resident #1 could had taken medication not prescribed to her. During an interview on 2/24/25 at 10:30 AM with LVN A, she stated the nurses completed the Nursing Section of the Discharge Summary. LVN A stated you printed the Discharge Summary, confirmed the information with the family and had the family or resident sign it. LVN A stated the pharmacy normally delivered a discharge package of medications to the facility prior to discharge. LVN A stated if the discharge packet were not ready at discharge, the facility would call in the orders to the family's preferred pharmacy. LVN A stated they normally do not discharge residents with the Blister Packs. LVN A stated RN B may have gone through the printed list of medications, but not the actual Blister Packs. LVN A stated she was in-serviced this morning (2/24/25) by ADON A on Discharges. LVN A stated now before you could discharge a Resident with Blister Packs you must obtain approval from an ADON or the DON. LVN A stated they must double-check everything regardless of how busy it may be. LVN A stated the worse that could had happened was if the family had not noticed the name on the Blister Pack, Resident #1 could have had a bad reaction. During an interview on 2/24/25 at 11:10 AM with ADON B, she stated once they were aware a resident would be discharged , they completed assessments, went over scheduled medications, and the DON called in orders to the pharmacy. ADON B stated time-permitting, the pharmacy delivered a Medication Package for the resident to the facility. ADON B stated the package from the pharmacy would contain a list of all medications and all the Medication Packs inside of the envelope. ADON B stated all pertinent departments completed their portion of the Discharge Summary and signed off on it. ADON B stated the nurse would go over all the medications with the resident and family and have one of them sign it. ADON B stated when RN B grabbed the Medication Packs out of the cart, one of the other resident's Medication Packs was grabbed mistakenly due to human error. ADON B stated she was in-serviced on Discharges by the DON on Friday (2/21/25). ADON B stated she then assisted with in-servicing the remaining nurses. ADON B stated the worse that could had happened was Resident #1 could had been harmed if she had taken the incorrect medication. During a follow-up interview on 2/24/25 at 11:55 AM with the DON, she stated she completed in-services on Discharges and completing the Discharge Summary in its entirety. The DON stated her expectations moving forward was for the nursing staff to follow procedures. The DON stated if a resident was discharging, the social worker would setup the discharge. The DON stated the facility would request the pharmacy to send over a 30-day supply of medications to the facility. The DON stated if there were not enough time, they would call the Orders into the family's pharmacy of choice. The DON stated they would only discharge with in-house medications if the pharmacy was unable to get the medication delivered to the facility in a timely manner. The DON stated the worse that could had happened was the resident having access to someone else's medication and personal information. The DON stated the resident could had been administered the incorrect medication by her family. During a follow-up interview on 2/24/25 at 1:45 PM with the ADM, he stated the nursing staff had been educated on the discharge process by the DON and the ADONs. The ADM stated they would discuss the incident this week at their QAPI meeting on Wednesday (2/26/25). The ADM stated they would start auditing the Discharge Summaries at a minimum, monthly or whatever is decided during the meeting. The ADM stated his expectations moving forward was that the facility would call all medications into the pharmacy. The ADM stated if the facility must send medications home with the residents, all requests must be approved by an ADON or the DON. The ADM stated the worse that could had happened was Resident #1 could had taken a medication not prescribed to her and had a potential reaction. Review of in-service documentation, titled, Discharging, dated 2/21/25, reflected the following: . -Skilled Discharge Resident must have discharge package or medications called into pharmacy prior to leaving. -Do not send pharmacy blister pack home with residents without ADON or DON's knowledge. -Discharge Summary must be completed, printed, and signed. Record review of the facility's policy titled, Discharge Summary and Plan, dated Revised December 2016 reflected the following: . 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. Record review of the facility's policy titled, Discharge Medications, dated Revised December 2016 reflected the following: . 2. The Charge Nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use. 6. The nurse shall complete the medication disposition record .

Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility (LVN B) failed to follow the facility's policy for reconciling unused medications when Resident #1 discharged home on 1/31/25, which resulted in an inaccurate reconciliation of Resident #1's medications. LVN B sent Resident #2's Methocarbamol Blister Pack (pain medication) home with Resident #1 and Resident#1's FM. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversions. Findings included: Record review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and was discharged home on 1/31/25. Resident #1 diagnoses included acute kidney failure (inability to remove waste products and maintain fluid and electrolyte balance), Paroxysmal Atrial Fibrillation (heart rhythm disorder), Chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing difficulties), Dysphagia (difficulty swallowing), Transient Ischemic Attack (temporary interruption of blood flow to the brain) and Cerebral Infarction (blood flow to the brain is interrupted). Record review of Resident #1's Physician's Discharge Order dated 1/31/25 reflected: May discharge home with home health services of choice. Skilled nursing, meds and disease education, wound care per wound care orders, PT/OT to home evaluate and medical social worker if needed. Record review of Resident #1's Discharge Summary reflected Resident #1 discharged home on 1/31/25 with her FM. Resident #1's Discharge Summary revealed all sections were completed and signed, except Section 4 Nursing - A. Medications. Record review of Resident #2's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 2/5/25. Resident #2 diagnoses included type 2 diabetes (body doesn't use insulin properly), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (sodium level in the blood is lower than normal), major depressive disorder (persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life). Record review of Resident #2's Care Plan reflected the following entry: Date initiated 1/7/25: [Resident #2] has acute/chronic pain. Interventions included Monitor/record pain characteristics . Observe and report changes in usual routine . [Resident #2] prefers to have pain controlled by medication, treatment). Record review of Resident #2's Administration Record dated January 2025 revealed an order for: Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 0.5 tablet by mouth three times a day for spasms give half tab = 250mg dose Record review of Resident #2's Discharge Summary reflected Resident #2 discharged home on 2/5/25 with all her medications documented accordingly. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility on 1/31/25. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM read the Blister Pack and provided Resident #2's name, date of birth and her room number at the facility. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he printed a Medication Summary and obtained the keys to both medication carts from RN A. RN B stated he collected all of Resident #1's medications, compared the Blister Packs to the printed Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her on following up with Resident #1's primary care physician within 7-10 days, reminded her that she needed to pick up Resident #1's medication from the pharmacy, any treatments, and recommended diet for Resident #1. RN B stated he was unsure how Resident #2's medication was included. As it was confirmed that the FM was able to provide Resident #2's name, her date of birth and the name of the medication, RN B stated it was important to confirm all information to respect the privacy and confidentiality of all Residents. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated when time permitted, they requested all medications from their pharmacy to be delivered to the facility. The DON stated RN B must had pulled Resident #2's medication out by mistake due to it being directly behind Resident #1's medication. The DON stated RN B informed her that he gathered Resident #1's medications and went through each one with the FM but he did not recall the other resident's Blister Pack. The DON stated she was unsure how the medication was overlooked. The DON stated it was not against their policy to discharge with medications, they just preferred the orders were called in to ensure residents had enough medication once they arrived home. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated he had not received a call from the FM until 2/17/25, almost three weeks after Resident #1 discharged home. The ADM stated the FM informed him that Resident #1 received all her medications, but there was one medication included that did not belong to Resident #1. The ADM stated starting today (2/21/25), the DON re-educated the nursing staff on discharges and sending medications home. The ADM stated the normal process was the nurse assigned to the hall would pull the medications and send the medications home with the resident. The ADM stated in this situation, RN A asked for assistance and RN B stepped in to assist. During a follow-up interview on 2/24/25 at 11:55 AM with the DON, she stated she completed in-services on Discharges and completing the Discharge Summary in its entirety. The DON stated her expectations moving forward was for the nursing staff to follow procedures. The DON stated if a resident was discharging, the social worker would setup the discharge. The DON stated the facility would request the pharmacy to send over a 30-day supply of medications to the facility. The DON stated if there were not enough time, they would call the Orders into the family's pharmacy of choice. The DON stated they would only discharge with in-house medications if the pharmacy was unable to get the medication delivered to the facility in a timely manner. The DON stated the worse that could had happened was the resident having access to someone else's medication and personal information. The DON stated the resident could had been administered the incorrect medication by her family. During a follow-up interview on 2/24/25 at 1:45 PM with the ADM, he stated his expectations moving forward was that the facility would call all medications into the pharmacy. The ADM stated if the facility must send medications home with the residents, all requests must be approved by an ADON or the DON. The ADM stated the worse that could had happened was Resident #1 could had taken a medication not prescribed to her and had a potential reaction. Record review of the facility's policy titled, Discharge Medications, dated Revised December 2016 reflected the following: . 2. The Charge Nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use. 4. The nurse will reconcile pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented. 6. The nurse shall complete the medication disposition record .

Based on observations, interviews, 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 the standby refrigerator temperature measured at 41F or less. 2. The facility failed to ensure walk-in refrigerator food items were dated and labeled. 3. The facility failed to ensure dry storage food items were dated, labeled, and stored securely. 4. The facility failed to ensure canned goods were free of dents. 5. The facility failed to ensure prepared foods items were covered and utilized separate utensils to ensure the food was free of cross-contamination. Findings included: Observation on 01/07/2025 at 9:09 AM upon entry to the kitchen revealed the following: Bread rolls sitting in uncovered muffin pans on counter tops. Interview on 01/07/2025 at 9:09 AM with the Dietary Manager revealed that the bread rolls had not been baked and that they had to rise before baking. Observation on 01/07/2025 at 9:12 AM of the stand-by refrigerator revealed the following: The digital thermometer on the outside door displayed it was in defrost cycle mode and prepared fruit cups were stored on the shelves. No thermometer on the inside to read the temperature. Observation on 01/07/2025 at 9:13 AM revealed the Dietary Manager placing a thermometer gauge in the refrigerator. Observation on 01/07/2025 of the walk-in refrigerator at 9:17 AM revealed the following: A plastic bag with sliced cheese dated 12/15/24 with no use by date. A box of cream cheese dated 12/31 with no use by date. A container of yellow mustard dated 5/15 with no use by date. Interview on 01/07/2025 at 9:17 AM with the Dietary Manager, he stated that the date written on the food item references the delivery date. Observation on 01/07/2025 of dry storage at 9:19 AM revealed the following: An open package of pancake mix in an unsealed zip closure bag and dated 5/15, with no use by date. An open package of spaghetti noodles in an unsealed zip closure bag and dated 12/26/24, with no use by date. Toasted oats in a large bin with an unsealed lid and dated 9/6/24, with no use by date. Multiple dented canned goods. Observation on 01/07/2025 at 9:27 AM of the stand-by refrigerator thermometer gauge revealed a temperature reading of 49F. Observation on 01/08/2025 at 11:33 AM upon entry of the kitchen revealed the following: Uncovered metal pans with lunch food items on the steam tray table. Food items included pork, mashed potatoes, brussels sprouts, Salisbury steak, brown gravy, pasta noodles, and mechanically altered forms of these foods. Uncovered small metal pans of mashed potatoes and gravy sat in a large metal pan with simmering water heated by cooking stove top. Observation on 01/08/2025 at 11:44 AM of steam tray service line revealed the following: [NAME] A used one serving tong to pick up slices of bread and pick up slices of pork. Interview on 01/08/2025 at 12:26 PM with [NAME] F, she stated that she knew each food item should have its own utensil when serving and that she did not have a separate utensil for the bread. [NAME] F stated that using the same serving utensil for different food items was a cross-contamination risk . Interview on 1/13/2025 at 9:04 AM with the Dietary Manager revealed that he did not know how often the stand-by refrigerator went into defrost cycle mode. If he noticed the stand-by refrigerator was not holding the maximum safe temperature, he would throw away the food and report it to maintenance. He stated that the prepared fruit that was stored in the standby refrigerator could cause the residents to get sick and the food could grow bacteria. He stated that sticker labels were only used on food items that were put into containers without labels to be able to tell (identify) the food items. The refrigerators had signs on the doors for staff to use to know how to label foods, what days the foods were prepared on and when to use the food by. He stated that food items should have a received on and opened on date on them and should be labeled as they come off the (delivery) truck. He stated that dents can compromise the seal of the can and cause botulism. He stated that the serving tongs [NAME] A used for both the bread and meat was only for the bread and there were usually separate tongs for the meat. He stated that two separate tongs were used to prevent cross contamination . Review of the facility's policy, Food Preparation and Service policy dated 2019 revealed, . Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices . Appropriate measures are used to prevent cross contamination. These include . cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines . Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date) . All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . Refrigerated foods must be stored below 41 F unless otherwise specified by law . Other opened containers must be dated and sealed or covered during storage . Record review of the U.S. FDA Food Code 2022 reflected: 3-501.16 Time/Temperature Control for Safety Food, Hot, and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained . (2) At 5 C (41 F) or less. 4-204.112 Temperature Measuring Devices . temperature measuring device must be placed in a location that is representative of the actual storage temperature of the unit to ensure that all time/temperature control for safety foods are stored at least at the minimum temperature required in Chapter 3 . A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms should the temperature of the unit exceed Code requirements . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of . (B) Single-service and single-use articles . 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.

48520 Based on observations, interviews, and record reviews 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 1 of 6 Residents (Resident #82) observed for infection control and 4 of 4 quarters reviewed for water management. 1. The facility staff failed to use proper technique when flushing Resident #82's IV while the resident was on enhanced barrier precautions. 2. The facility failed to implement a water management program per facility policy. These failures could place residents at risk of cross-contamination and infections. Findings included: 1. Review of Resident # 82's admission record revealed [AGE] year-old male was admitted to the facility on [DATE] with an initial admitted [DATE]. Primary diagnosis included metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism). Review of Resident #82's Care Plan, undated, reflected resident was on Enhanced Barrier Precautions- resident was at risk for infection related to indwelling medical devices. Interventions wear gloves and gown during high-contact care activities for with indwelling medical devices, wounds, and colonized or infection with a CDC targeted MDRO (Multi drug-resistant Organism). Review of Resident #82's Minimum Data Set (MDS) Comprehensive Set dated 12/28/2024 reflected a BIMS score of 15 which indicated an intact cognitive response and suggested that the resident was capable of normal cognition. Review of Resident # 82's Treatment Administration Record dated 01/10/2025 reflected Cefazolin Sodium Intravenous Solution Reconstituted 2 GM . Use 2 grams intravenously every 8 hours for bacteria in the blood. Observation on 01/07/2025 at 3:45 PM reflected signage posted outside resident #82's room stated Permissions Based Precautions. LVN G wore latex gloves and used an alcohol wipe to clean resident #82's IV port, then LVN allowed the port to lay on Resident #82's skin while she prepared the saline flush. LVN F then attached Saline flush with 5cc to the port. After she administered the saline, she then placed the syringe directly on the bedside table. Interview with LVN G on 01/07/2024 at 3:53 PM reflected she was in-serviced on EBP before Christmas. She stated that she was in-serviced to wear a gown when in direct contact with the resident. She stated that she did not look at the sign at the door and she did not see the PPE outside the resident's room. She stated that the risk of not wearing PPE while performing high-contact resident care was the spread of infection. She stated that she should have thrown the sterile saline in the resident's trash cans since he was on isolation. The risk of leaving it on the bedside table was cross contamination. Interview on 01/13/2025 at 11:02 AM with ADON A reflected the LVN G should have gowned and gloved up prior to entering the room to administer IV medication. The reason for the procedure was to prevent any additional bacteria from coming in to the resident. She stated that once the porst was sterilized it should not have come into contact with the resident's skin again because it was dirty. The risk was it could become more septic and the risk of additional bacteria. 2. Interview on 01/13/25 at 01:33 PM with the Administrator revealed the current Maintenance Director was new. The Administrator stated he requested information from corporate, who said another company was managing water. No documentation was provided by the facility that a water management program was developed or implemented. Review of facility policy titled Peripheral IV Catheter Insertion revision date April 2016, reflected: Definition 1. A peripheral short catheter is defined as a catheter that is less than 3 inches (7.5cm) in length. The tip of a peripheral short catheter ends in the peripheral vein. Dressings 1. Use sterile dressings (transparent or gauze, as appropriate) to cover the insertion site. 2. Label on dressing should include date and time of dressing placement, initials, gauge size, and length of catheter . Record review of the facility policy titled, Legionella Water Management program revised July 2017, reflected in part: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team .6. The water management program will be review at least once per year .

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids administered were consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #68) of six residents reviewed for periperal intravenous care. The facility failed to ensure Resident #68's peripheral intravenous (this is a catheter placed into the vein for short term fluids and or antibiotics use) dressing was dated with the insertion date. These failures could place residents at risk of cross-contamination and infections. Findings included: Review of Resident #68's admission record dated 01/08/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with an initial admission of 01/11/22. His diagnoses included unspecified dementia with agitation (this is a brain disease that alters brain function causes cognitive decline), protein calorie malnutrition, pneumonia (fluid in the lungs), diabetes (uncontrolled blood sugars), and acquired absence of left and right below the knee (amputation of both legs below the knee). Review of Resident #68's quarterly MDS dated [DATE] reflected a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Review of Resident #68's physician order for January 2025 revealed, 1.Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift for dehydration for 1 day. Administer flush after medication administration. Order dated 01/03/25. 2. Sodium Chloride intravenous Solution 0.9% (Sodium Chloride) use 75 ml/hr intravenously one time only for hydration for 1 day. Order dated 01/03/25. Review of Resident #68's care plan on 01/07/25 revealed Resident # 68 was a potential risk for pressure ulcer development related to infection, impaired mobility, incontinence, nutritional deficit, diabetes, and malnutrition. The goal was to minimize the risk for further pressure ulcers and or deterioration of current wounds. Interventions were to keep skin clean and dry, to notify nurses immediately of any signs of skin breakdown, redness, blisters bruises and discoloration noted during bath or daily care. The care plan did not address the peripheral IV. Observation and interview with Resident #68 on 01/07/25 at 10:06 AM, revealed Resident #68 lying in bed with his right arm exposed which revealed a peripheral IV with dressing intact and undated. Resident # 68 stated he had gotten some fluid electrolytes last week. Resident #68 could not remember the exact date of the IV insertion. He stated he only had the fluids for 1 day. He stated he did not know why he still had the IV as no one had used it since last week. In an interview with LVN D on 01/07/25 at 12:52 PM she stated she was Resident #68's nurse. She stated she was aware Resident #68 had a peripheral IV and she was waiting for the physician to give her orders to discontinue the IV or to give more fluids. LVN D did not state why it was not dated and what the risk was to the resident . In an interview with RN C on 01/13/25 at 08:50 AM, he stated LVN D asked him to remove Resident #68's IV after obtaining orders from the physician to remove it on 01/07/25. He stated that all IV's should have a date on it so that you can see how long it had been in. He stated it was infection control to make sure that IV dressing was dated with an insertion date. RN C stated it was good nursing practice to get clarifications on IV orders to avoid medication errors . In an interview with ADON A on 01/13/25 at 10:56 AM, she stated she was the infection control preventionist. She stated all IVs were expected to have a date on them when they were inserted. She stated IVs were to be checked daily for infection and to note when the dressing needed to be changed, which for peripheral intravenous, was 72 hours. She stated the nurse that inserted the IV should have written the date on the IV so that another nurse can just look at the date and know when to change it. She stated the risk was infection and infiltration. In an interview with the DON on 01/13/25 at 12:55 PM, she stated the expectation was that all IV's were dated with the insertion date, were clean, intact, dry and no signs and symptoms of infection. She stated the nurses were responsible for making sure that the IV's were dated. She stated the nurse that inserted the IV should have put the date on the dressing. She stated dating IV helped to reduce infection. Review of facility policy titled Peripheral IV Catheter Insertion revision date April 2016, reflected: Definition 1. A peripheral short catheter is defined as a catheter that is less than 3 inches (7.5cm) in length. The tip of a peripheral short catheter ends in the peripheral vein. Dressings 1. Use sterile dressings (transparent or gauze, as appropriate) to cover the insertion site. 2. Label on dressing should include date and time of dressing placement, initials, gauge size, and length of catheter .

Based on observations, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for one of eight residents (Resident #67) reviewed for storage of medication and 1 of 6 medication storage carts (Nurses' Treatment Cart) observed for drug security. 1. Nurses' Treatment Cart was left unattended and unlocked outside the women's bathroom on 01/08/25. 2. The facility failed to ensure medications were not left at bedside for Resident #67. This deficient practice could affect residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. The findings included: In an observation on 01/08/25 at 06:25 AM and at 07:51 AM, the Nurses' Treatment Cart was observed unlocked and unattended with the lock mechanism out (indicating it was unlocked) outside the women's bathroom. The cart did not contain narcotic medications. The Nurses' Treatment Cart included over the counter and prescription topical medications, multiple over the counter medications for wound care, and one bottle of betadine antiseptic cleaner. Staff and residents were observed in the immediate vicinity. In an interview on 01/08/25 at 07:51 AM, RN C stated the Nurses' Treatment Cart was his responsibility. RN C stated the Nurses' Treatment Cart was an extra one of 2 that he used. He stated he did not know who had left it unattended and unlocked. RN C stated the Nurse's Treatment Cart should not be left unlocked when unattended. He stated the risk was that a resident could get into it and have adverse effects to medications in the cart. In an interview on 01/08/25 at 07:51 AM, the DON stated all medication carts and treatment carts were to be secured when not in use. The DON stated one of the floor nurses might have left the cart unlocked after getting some wound care supplies out of the Nurses Treatment Cart. The DON stated she would initiate staff In-Servicing. The DON stated residents could have been negatively impacted if one had obtained medication from the unattended Nurses Treatment Cart and used it inappropriately. Record review of Resident #67's face-sheet dated 01/10/2025, revealed a [AGE] year-old male, initially admitted to facility on 10/26/2023, and readmitted on [DATE]. Resident's diagnosis included: Unspecified dementia severe without behavioral disturbance, and psychotic disturbance, mood disturbance, and anxiety (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances); essential (primary) hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause); and unspecified atrial fibrillation (a chronic heart condition where the upper chambers of the heart beat irregularly). Record review of Resident #67's quarterly MDS (Minimum Data Set) dated 11/09/2024 revealed Resident's cognitive status intact. Further review of MDS revealed Resident's BIMS (Brief Interview of Mental Status) score was 15/15. Record review of Resident #67's Medication administration record dated 01/14/2025 revealed: Biofreeze Professional External Gel 5 % (Menthol (Topical Analgesic)) Apply to Neck, Shoulders, and BUE topically every 12 hours as needed for pain. -Start Date- 08/19/2024 In an observation and interview on 01/07/2025 at 11:03 AM, Resident #67 was observed in her room and in bed. Observed resident's overbed table placed over her in bed and next to her water picture was a bottle of AZO Dual Protection Urinary & Vaginal Support (over-the-counter pills designed to help restore bacterial balance to support urinary and vaginal health) and Biofreeze Roll-On gel (fast acting and long lasting, cooling menthol formulation delivers penetrating pain relief for sore muscles and joints). Resident #67 revealed that her family member brought in the urinary pills for her because she has problems with UTIs and the Biofreeze was for her stiff neck and shoulders. She revealed the staff did not know her brought in the medication. Interview with LVN E on 01/14/2024 at 11:15 AM, revealed that LVN E was not aware of the bottle of AZO Dual Protection Urinary & Vaginal Support medication and Biofreeze Roll-On gel on Resident #67's over-bed table. LVN E immediately went to to room and removed the medication. LVN E revealed that Resident #67 did not have orders to self-medicate. There were orders for the Biofreeze every 12 hours. No orders for the AZO Dual Protection Urinary & Vaginal Support medication. LVN E revealed a negative outcome would be Resident #67 could over-dose on the AZO Dual Protection Urinary & Vaginal Support medication. LVN E was not aware of a negative out-come to resident with having the Biofreeze at bedside. A dementia resident could wander into resident's room and take the pills and Biofreeze off the over-bed table. Interview with the DON on 01/14/2025 at 11:30 AM revealed that the DON was unaware that Resident #67 had AZO Dual Protection Urinary & Vaginal Support medication and Biofreeze Roll-On gel on the over-bed table. The DON reviewed Resident #67's physician orders and revealed there were orders for the Biofreeze, but not at the bedside. The DON revealed a negative outcome would be that a dementia resident could have wondered into resident's room and taken the medication by mistake. The DON revealed that she informed Resident #67's family member that he was not allowed to bring in any medications to the resident. Interview with the ADM on 01/13/2025 at 4:00 PM revealed he was aware of medication on Resident #67's over-bed table. The DON informed the ADM of the medication mistake. The ADM revealed that several negative outcomes could have occurred with this mistake. A confused resident could have wondered into room and taken the medication by mistake and taken the Biofreeze off the over-bed table. Record review of the facility's policy, Security of Medication Cart, revised April 2007, revealed 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2.The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. Record review of facility's policy General guidelines - Storage of Medications, Procedures revealed in part .Administration: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 48520

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 5 residents (Resident #1) reviewed for Care Plans. The facility failed to complete a comprehensive care plan for Resident #1. This failure could place residents at risk of not receiving necessary care and services. Findings included: Review of Resident #1's Admission Record, dated 07/30/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with hypercapnia, chronic viral Hepatitis C, morbid obesity, depression, obstructive sleep apnea, chronic obstructive pulmonary disease, other cirrhosis of liver, cellulitis of right and lower limb, and patient's other noncompliance with medication regimen for other reason. Review of Resident #1's Admission MDS, dated [DATE], reflected a BIMS score of 14, indicating intact cognition. The MDS further reflected Resident #1 was dependent on staff for toileting and showering, required partial/moderate assistance of staff for personal hygiene, and supervision for eating. The MDS revealed Resident #1 was frequently incontinent of bladder and bowel, had an external catheter and was at risk of developing pressure ulcers/injuries. The MDS reflected Resident #1 was taking an anticoagulant and diuretic and was on oxygen therapy. Review of Resident #1's care plan, dated 06/07/24, revealed [Resident Name] has little or no activity involvement r/t Resident wishes not to participate. The care plan did not reflect any other care areas. Observation and interview on 07/30/24 at 11:13 am revealed Resident #1 lying in bed and had O2 on. Resident declined to answer questions. In an interview on 07/30/24 at 1:44 pm, the MDS Coordinator stated she had worked there for 6 months. She stated she was responsible to complete the comprehensive care plan, and she said she had gotten behind and was trying to get caught up. She said there was another MDS Coordinator that would be starting in Mid-August. She said the baseline care plan was supposed to be done in the first 24 hours which the nurses filled out, and she had 21 days to complete the comprehensive care plan. She said Resident #1's care plan was due on 6/26/24 and should have included his diagnoses, medication, fall risk, difficulty walking, cellulitis to lower extremities, cirrhosis to liver, congestive heart failure, chronic obstructive pulmonary disease, and Resident #1's refusal of care. The MDS Coordinator stated the care plan was supposed to be done to see how to care for the resident. In an interview on 07/30/24 at 2:09 pm, the DON stated a comprehensive care plan should have been done for Resident #1. She said the care plan was important because it identified care or if anything needed to be put in place. She said her expectation was for care plans to be done timely. Interview on 07/30/24 at 2:35 pm, the Administrator stated care plans were important to know what care to give the patient. He stated his expectation was for care plans to be done timely. Record review of facility's policy titled, Care Plans - Comprehensive revised December 2009, reflected in part: 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 3. Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables, and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

Based on, interview and record review, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 11 residents reviewed for significant medication error. The facility staff failed to verify Resident #1's allergy to penicillin before administering antibiotic containing penicillin from [DATE] to [DATE]. The facility staff failed to recognize or check to ensure the antibiotic Resident #1 was receiving did not have penicillin in it when some staff knew the resident was allergic to penicillin. Resident #1 expired on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:15 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of more than minimal harm that is not immediate jeopardy because all staff had not been trained on identifying resident allergies and medications including those allergies. This failure could affect residents with known allergies who received medication that contained the allergy, putting resident at risk for the potential for severe side effects, injury, or death. Findings included: Review of Resident #1's admission record, dated [DATE], revealed the resident was a male [AGE] year-old resident who was admitted on [DATE] with the following diagnoses of heart disease, high cholesterol, high blood pressure, muscle wasting, difficulty walking, type 2 diabetes, depression, obesity, neuropathy, unspecified ileus (food intolerance), chronic kidney disease. Resident #1 was allergic to penicillin and tramadol. Review of Resident #1's quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the facility's self-reported incident dated [DATE], revealed Resident #1 was found on the floor, unresponsive, with a faint pulse. The facility responded immediately by attempting to revive the resident. 911 Emergency Medical Serves was called. Resident #1 expired. No autopsy was done. Review of Resident #1's physician orders , dated [DATE], revealed Augmentin Oral Tablet ,d+[DATE] MG {Amoxicillin (class: Penicillin) & Potassium Clavulanate} Give 1 tablet by mouth two times a day for abnormal Chest X-ray for 7 Days. Active date [DATE] and End date [DATE]. Review of Resident #1's physician orders, dated [DATE], revealed Augmentin Oral Tablet ,d+[DATE] MG {Amoxicillin (class: Penicillin) & Potassium Clavulanate} Give 1 tablet by mouth two times a day for UTI for 7 Days. Active date [DATE] and End date [DATE]. Review of Resident #1's progress notes dated [DATE] and [DATE], revealed Resident #1 did not provide a consent stating he knew the risks, and outweighed benefits of taking medication he was allergic to, to treat his infection. Progress notes did not reveal Resident #1 got education about the antibiotic he was given, noting his allergy to penicillin. Review of Resident #1's care plan, dated [DATE], revealed Resident #1 was at risk for allergic reaction to the following: penicillin and tramadol. The goal was for Resident #1 to not have allergic reactions. Interventions included were: monitor for [signs] and symptoms of possible allergic reactions such as hives, rash, swelling, watery eyes, wheezing and report finding to MD as indicated. Notify MD if patient has an allergic reaction to new medications or food. Interview on [DATE] at with CNA A, revealed that Resident #1 was acting funny on [DATE] by dropping his remote on the floor multiple times and he spilled his ice water on his bed. CNA A said that he had to get him cleaned and got him fresh ice. He said that Resident #1 called multiple times asking for his remote control. CNA A said the remote was laying on Residents #1's bedside table next to him. CNA A said that he did not report this because Resident #1 sometimes had intermittent confusion. CNA A said he left facility at 10pm on [DATE] without giving report to the oncoming CNA (CNA B). Interview on [DATE] at 03:22pm with CNA B, revealed he worked a double shift on [DATE], from 02:00 pm-10:00 pm then again from10:00pm to 06:00am. CNA B said that he did not get report from outgoing CNA A. He said Resident #1 was already in bed when he checked on him at 11:20 pm. He said at around 11:45pm or 12 midnight LVN C was yelled for him to go and help her in Resident #1's room. CNA B said Resident #1 was on the floor in a seated position with chin tucked on his chest. Interview on [DATE] at 5:24 pm with LVN C, revealed she worked 10 pm to 6 AM shift, and did not normally administer any medications to Resident #1 unless it was as needed medication (PRN). She said when she went to do her rounds in Resident #1's room between 11:30 PM or 11:45 PM on [DATE], Resident #1 was on the floor close to window besides his bedside slumped over and pale. She said she called for help and called a Code Blue. EMS was called and they arrived within 5 minutes. She said EMS worked on Resident #1 to try and revive him for 20 minutes before pronouncing him dead. Interview on [DATE] at 3:15 pm with LVN H , revealed that she administered first doses of antibiotic Augmentin to Resident #1 on [DATE]. LVN H said she was not aware that Augmentin contained Amoxicillin which was a penicillin antibiotic. She said if she knew, she would not have administered Augmentin to Resident #1. LVN H stated she was aware Resident #1 had a penicillin allergy. She said she monitored Resident #1 the entire shift of [DATE]. She said Resident #1 had some wheezing before medication administration, and she gave him a breathing treatment and his shortness of breath and wheezing stopped. LVN H said the antibiotic was continued because Resident #1 was doing better and did not show any adverse reactions. She said she normally would send a text to the physician to tell them about a resident's allergies, but she did not do it for Resident #1. She said the risk of administering a medication a resident was allergic to could cause signs and symptoms of allergic reaction such as shortness of breath, rash, low or high blood pressure, dizziness, sweating, and throat swelling. Interview on [DATE] at 4:20 pm with LVN D, revealed she did not know that Resident #1 had a penicillin allergy. LVN D said she was the charge nurse on the unit on [DATE] and LVN E asked her to transcribe Resident #1 antibiotic order to pharmacy. She said she did not verify Resident #1 allergies prior to transcribing order to pharmacy. She said she did not know that antibiotic Augmentin contained Amoxicillin, a penicillin antibiotic. She said that she always double checked the physician orders when someone asked her to transcribe for them. She said she asked for the original physician order and then transcribed to pharmacy to fill the medication. She said she did not verify that Augmentin contained penicillin that Resident #1 was allergic to. She said some risks of allergic reaction are hive, shortness of breath, hospitalization , anaphylactic shock, and death. Interview on [DATE] at 6:39 pm with DON, revealed she was not aware that Augmentin contained Amoxicillin a penicillin antibiotic, nor was she aware Resident #1 had a penicillin allergy. She said the pharmacy would not fill a prescription if a resident had an allergy to it. She said the process was to review a resident allergy before medication administration especially antibiotics. Risks were adverse reactions and anaphylactic reactions. Interview on [DATE] at 4:48 pm with Physician I, revealed he was not Resident #1 physician. He said Augmentin Oral Tablet ,d+[DATE] MG was a combination of Amoxicillin & Potassium Clavulanate. Physician I said Amoxicillin was in the penicillin class of drug. He said that people can have different reactions if they have a penicillin allergy. Some signs and symptoms are shortness of breath, rash, abdominal pain, and worst-case reaction is anaphylactic reaction. Interview on [DATE] at 7:04 pm with Physician H, revealed he was Resident #1's attending physician. He said Augmentin had a mixture of penicillin and other components. He said that it was unlikely for a person to show an allergic reaction after 2 weeks. The Doctor said that he prescribed the antibiotic for Resident #1. He said he was aware that Resident #1 received an antibiotic that had penicillin. He said the risk for taking medication a resident was allergic to was skin rash, hives, reaction with lots of redness, skin issues, diarrhea, nausea and vomiting, stomach upset. He said skin allergy showed within 12- 24 hours after exposure and it was unlikely the resident expired due to the medication prescribed since the resident did not have a reaction. Interview with the Pharmacist on [DATE] at 10:46 AM, revealed she cannot answer specific questions and would have to send inquires to QA department. She said that if a person was allergic to a medication noted on the patients' chart, then she would not fill the prescription. She would call facility to clarity and ask facility to contact physician to verify order or to change the order. The Pharmacist said that if she knew that a resident had a penicillin allergy, she would not give Augmentin to them. Interview on [DATE] at 10:53 am with Physician H, revealed he was aware that Resident #1 had penicillin allergy. He said that he would prescribe Augmentin to a Resident with Penicillin allergy because it was not a pure penicillin medication as it only had 50 % of penicillin and other additives. He said that he uses it in the hospitals, and it was a good antibiotic. Review of the facility's Administering Medications policy, revised [DATE], revealed . information must be checked /verified for each resident prior to administering medications: a. Allergies to medications . Review of the facility's Medication Regimen Review policy, revised [DATE], revealed . the primary purpose is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible . The Administrator was informed on [DATE] at 12:00 PM that an Immediate Jeopardy (IJ) existed on [DATE], and a copy of the IJ Template was provided on [DATE] at 12:01 pm. The following Plan of Removal was accepted on [DATE] at 04:48 PM: [Impact Statement: On [DATE] an abbreviated survey re-entrance was initiated at [Facility Name] [Facility Address]. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to administering antibiotics that contained penicillin, in which resident was allergic to. How were other residents at risk affected by this deficient practice identified? The facility completed an audit of all Antibiotic medications ordered in the last 30 days to ensure the residents did not have a known allergy and received the treatment and care they required to ensure residents did not experience allergic interactions. Residents with new medication for Antibiotics orders have the potential to be affected by this deficient practice, 7 of the residents who were identified as being on antibiotics were not affected. What corrective actions have been implemented for the identified resident? The resident with deficient practice no longer resides in the building as [DATE]. a. All Nurses to receive in-service on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. b. All Med Aides received in-service on medication administration to include identification of known allergies prior to antibiotic medication administration and notifying charge nurse if identified. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE]. c. On [DATE] an audit was completed by DON (Director of Nursing) and/or designee on all residents with new medication orders for Antibiotics in the last 30 days to ensure the residents did not have a known allergy. 7 residents currently on Antibiotics were identified and noted not to be affected by deficient practice. d. Director of Nursing was educated on [DATE] by Clinical Services Director on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. e. Initiated in-services on [DATE] with licensed nurses by Director of Nursing /Designee on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. f. Initiated in-service on [DATE] with Licensed Medication Aides on medication administration to include identification of known allergies prior to antibiotic medication administration and notifying charge nurse if identified. g. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process on identification of known allergies when obtaining antibiotic medication orders and verifying allergies prior to administering antibiotic medications, monitoring for allergic reactions. 2. How will the system be monitored to ensure compliance? A. DON/Designee Will review the ordering listing report for newly received orders and compare to resident allergies daily for 4 wks. If discrepancies identified will notify physician immediately. Staff will receive further training and disciplinary action up to termination. When discrepancies with medications are identified, The CMA will notify the charge nurse, the charge nurse will notify the physician. When obtaining an [ATB] order and a resident has a listed allergy the nurse will notify the physician. The pharmacy is integrated with [Electronic Record] and has the resident allergies. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal.] Monitoring of the POR included the following: Interviews were conducted with facility staff across multiple shifts on [DATE] from 12:15 p.m. to 6:50 p.m. Staff interviewed were RN C, RN G, LVN D, LVN E, LVN F, LVN H, LVN I, LVN J, and MA K. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering, antibiotic medications and monitoring for allergic reactions. They were all aware of the QA work sheet to fill and turn to the DON for any new medications. They stated that each time a nurse received a new order for antibiotics, the nurse must always check for allergies of medication type. They said that a resident will be monitored for 3 days after receiving an antibiotic. Record review of in-service training logs and competency tests, dated [DATE] and [DATE], revealed education included new orders for antibiotics, allergy orders on admission, incidents & accidents, fall precautions, how to prevent falls, abuse, neglect, exploration, allergic reactions signs & symptoms, notification to the DON after QA form is filled. The Administrator was informed the Immediate Jeopardy was removed [DATE] at 5:00 p.m. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of corrective systems that were put into place.

Based on interviews, observations, and record reviews the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for falls. On 02/24/23 CNA A failed to ensure she had assistance while providing care to Resident #1, who was care planned to have the assistance of two-persons for ADL care. This resulted in Resident #1 falling from bed on 02/24/23 and sustaining a right arm fracture and fracture of the right great toe. This failure placed the residents at risk for injury. Findings included: Review of Resident #1's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke resulting in left sided paralysis, dementia, high blood pressure, and difficulty speaking after stroke. Review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 6 indicating severe cognitive impairment. Her Functional Status indicated she required extensive assistance of two persons with all of her ADLs, including bed mobility and toileting. Review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS score improved to 12, indicating moderate cognitive impairment. Her Functional Status indicated she required extensive assistance of two persons with all of her ADLs, including bed mobility and toileting. Review of Resident #1's care plan, dated 01/23/23, revealed she was at risk for falls, as well as a self-care deficit, related to left sided paralysis. Resident #1 required the assistance of two staff for all ADLs except dressing. Review of Resident #1's Fall Risk Assessment from 01/25/23 revealed she was considered a moderate fall risk. Review of Resident #1's Nursing Progress notes reflected the following entries: 02/24/23 at 9:25 AM by LVN H - pt was receiving perineal care and she turned to far over and rolled out of bed resulting in an injury pt has a c/o of right shoulder pain and she states that she hit the left side of her head on her night stand. pt has a bruise to her right knee, left forearm, and she has a bruise on the left side of her face, nurse spoke with her daughter and dr was called and nurse is awaiting a return phone call. nurse order a stat xray for pt neuro checks stared 02/24/23 at 2:01 PM by LVN H - Pt x-ray results have arrived pt has a right fractured arm pt daughter is aware of pt change in condition and wants pt to go to hospital and Dr has the results as well pt sent to ER via emt 02/24/23 at 2:05 PM by LVN I - Resident received X-RAY in house, results reported to PA. New orders given to transfer resident to ER. Resident daughter was notified and request resident to be transferred to [the hospital]. EMS called and resident transferred. Interview on 03/07/23 at 12:22 PM the DON stated all new hire CNAs attended a one-day facility and corporate orientation, followed by three days of orientation with another CNA. The DON stated CNAs had a checklist of skills that needed to be accomplished in two weeks, and any skills not completed were covered with a 1:1 demonstration with the ADON. The DON stated the CNAs did not have to have their checklist completed before they worked the floor. The DON stated CNA A had started her three days of orientation on 02/15/23 and should have been aware that Resident #1 was a two-person assist from reading the Kardex and from verbal report from other CNAs. The DON stated CNA A should not have attempted to turn Resident #1 without another staff member being present the morning of 02/24/23 when Resident #1 fell out of bed. The DON stated staff were expected to review each resident's Kardex, which indicated how much assistance each resident required, as well as receive a verbal report from the off-going CNA on each resident. The DON stated CNA A had no reason not to know Resident #1 was a two -person assist. The DON stated Resident #1 went to the hospital and was diagnosed with a right shoulder fracture and a right great toe fracture. The DON stated the resident did not return to the facility. Interview on 03/07/23 at 1:53 PM, CNA A stated she had not received a full orientation, she had spent the first day with another CNA; on the second day the CNA was pulled from her and the Staffing Coordinator would spot check her during the shift. CNA A stated on her third day of orientation she was on her own. CNA A stated on 02/24/23 she was providing incontinence care for Resident #1 and turned her to her left side. CNA A stated Resident #1 said, Let me help you and pulled herself further over, causing her to slide out of bed an onto the floor. CNA A stated she called for help, the resident was placed back in bed with the assist of two other staff members. CNA A stated Resident #1 complained of right shoulder pain and was sent to the hospital. CNA A stated she did not have computer access to the residents charts, therefore she had not ever reviewed the Kardex for any of the residents; she learned from the other CNAs. CNA A stated she did not know Resident #1 was a two person assist. CNA A also stated a verbal report was never given from one shift to the other. CNA A stated she had been given her computer access during orientation, but it had never worked, she never reported the issue to anyone. Interview and observation on 03/07/23 at 12:00 PM with CNA B she stated residents that were considered a fall risk had a small gold star beside their name outside their room to alert staff. CNA B was able to demonstrate how to access the Kardex and where to find the type of assistance a resident required. She stated not using the proper number of staff to turn a resident could result in the resident being hurt. Interview on 03/07/23 at 2:45 PM CNA C stated the gold star outside a resident's room indicated they were a fall risk. CNA C stated he had been in-serviced on how to find the Kardex last week by the DON, he did not know about it until then. Interview and observation on 03/07/23 at 2:50 PM, MA D and MA E stated the gold star indicated the resident was a fall risk. They were unable to access a resident's chart to view the Kardex. Both admitted they had been in-serviced last week on it. Interview on 03/07/23 at 2:55 PM CNA F and CNA G stated the gold star indicated the resident was a fall risk. They stated when they accessed their list of residents the number in front of their room number (i.e. 3-301) indicated how many staff were required to lift that resident. CNA G affirmed that all the residents on 300 Hall were three person assists. Interview on 03/07/23 at 3:00 PM the DON stated the number before a resident's room indicated what hall they resided on, it had nothing to do with how many people were required to lift the resident. The DON stated she had in-serviced all staff on the Kardex last week. The DON stated she was unaware CNAs still did not know how to access the Kardex. Review of CNA A's education file revealed her competency for Moving a Patient in bed had been completed on 02/25/23, and her competency for Perineal care (Female) had been completed on 02/27/23. Both were completed after the fall on 02/24/23. Review of hospital records unsuccessful, hospital unable to locate resident's records. Resident did not return to the facility, hospital records not part of her EHR. Review of X-ray report not available, per Nursing Progress note on 02/24/23 at 2:01 PM by LVN H Pt x-ray results have arrived pt has a right fractured arm pt daughter is aware of pt change in condition and wants pt to go to .Hospital and Dr .has the results as well pt sent to ER via emt.

Based on observation, interview and record review, the facility failed to ensure the services provided by one (LVN C) of one LVN reviewed for IV therapy met professional standards of quality for one (REsident #1) of two residents reviewed for IV therapy. Resident #1, with a history of [MEDICAL CONDITION] and [MEDICAL CONDITION], was administered a liter (1000 ml) of 0.9% Sodium Chloride (NS) instead of 500 ml NS via IV over a period of two hours instead of ten hours resulting in his receiving 500 ml/hr instead of 100 ml/hr. Facility staff were unaware Resident #1 received twice as much IV fluid as ordered at five times the rate ordered until surveyor intervention. These failures could have caused fluid overload for Resident #1, resulting in respiratory distress, [MEDICAL CONDITIONS], elevated blood pressure, elevated heart rate and even death. An Immediate Jeopardy (IJ) was identified on 06/12/14. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. These failures could affect the two residents with IV access, Resident #1 and Resident #2, who had a PICC line, and placed them at risk for not receiving IV medications and fluids at the rate ordered by the physician resulting in the resident being at risk for fluid over-load and not receiving the therapeutic benefit intended by his physician. Findings included: The Texas Administrative Code (TAC), Title 222, Part 11, Chapter 217, Rule 217.11(1) for Standards Applicable to all Nurses reflected "all vocational nurses...shall..."(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; ...(D) Accurately and completely report and document: ...(ii) nursing care rendered; (iii) physician ...orders; (iv) administration of medications and treatments; ...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices;...." The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.12 reflected: "The unprofessional conduct rules are intended to protect clients and the public from incompetent ...conduct of licensees. The purpose of these rules is to identify unprofessional ...behaviors of a nurse which the board believes are likely to ...injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice--actions or conduct including, but not limited to: (A) Carelessly failing ...to perform vocational ...nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11. (B) Carelessly . . . failing to conform to generally accepted nursing standards in applicable practice settings; ...(4) Careless ...conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established. ...(6) Misconduct--actions or conduct that include, but are not limited to: ...(C) Causing or permitting ...neglect to the client...." Resident #1's hospital History and Physical dated 04/07/14 reflected [DIAGNOSES REDACTED]. Resident #1's Face Sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE] following a cholecystectomy (gall bladder removal). His [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/30/14, reflected a BIMS score of three, which indicated he was severely impaired cognitively; required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Active [DIAGNOSES REDACTED]. Resident #1's Insertion Record dated 06/06/14 reflected a Midline IV was inserted in the resident's right arm just above the inner elbow. The midline inner catheter was 11 cm (approximately 4 1/12 inches) and the exposed part was 2 cm (approximately ? inch) long. Review of Resident #1's Comprehensive Plan of Care with most recent being dated 06/11/4 revealed the care and treatment of [REDACTED]. Resident #1's laboratory results dated [DATE] and printed at 10:40 AM reflected an elevated BUN (Blood Urea Nitrogen) of 68 mg/dL (normal 7 - 18 mg/dL), and an elevated creatinine level of 2.9 mg/dL (normal 0.6 - 1.3 mg/dL). A handwritten note on the lab results reflected check BMP/CBC in AM (06/12/14) give 500 ml of NS now x 1 dose. There was nothing to identify who wrote the note. Retrieved on 06/30/14 from www.mayoclinic.org/tests-procedures reflected the following: --A BUN reveals how well your kidney and liver are working to remove the urea from your blood. The liver forms urea, a waste product, and sends it through the blood to the kidneys, which filters the urea from the body as urine. When the BUN is higher than normal, it can indicate your kidneys or liver are not working properly. --An above normal Creatinine level means that the kidneys are not working well. Resident #1's physician telephone order dated 06/11/14 and written by LVN C reflected lab orders for a CBC & BMP in AM and 0.9% NS via midline one time now. There was no amount of the infusion or rate of the infusion included on the physician's orders [REDACTED]. Resident #1's June 2014 MAR indicated [REDACTED]." Resident #1's Daily Skilled Nurse's Note dated 06/11/14 , no time, reflected MD S was called and an order was received to re-check the resident's BMP and CBC in the AM. And to give 500 ml NS one time "now." The note was signed by LVN C. Resident #1 was observed on 06/11/14 at 2:20 PM. The resident was in his room lying on his bed watching TV. Observation revealed a 1,000 ml bag of 0.9% NS was infusing via the resident's midline catheter. Approximately 200 ml of fluid was left in the bag of fluid. The IV was not infusing via an IV infusion pump, but instead the bag hung from an IV pole and dripped by gravity. No label was applied to the IV bag to provide information as to who hung the bag, when the bag was hung and/or reference to the physician's orders [REDACTED]. Note: An infusion pump ensures accurate amounts of IV fluid are infused to the patient. Interview on 06/12/14 at 9:45 AM with CNA O revealed she was in Resident #1's room on 06/11/14 when LVN C came in and started the IV. She stated she was feeding lunch to Resident #1's roommate, and it was about 12:30 PM. An interview on 06/12/14 at 10:13 AM with LVN C revealed she hung Resident #1's IV of NS before lunch at 10:00 AM on 06/11/14. She stated the IV was infusing at 100 ml per hour. Note: The lab results were printed at on 06/11/14 at 10:40 AM. RN M was interviewed on 06/11/14 at 2:55 PM in regard to Resident #1's IV. She stated she disconnected the IV at 2:30 PM, because the bag of IV fluid was empty. At 3:00 PM on 06/11/14, ADON A was informed by the surveyor Resident #1 had 1,000 ml of 0.9% NS infused too quickly and only 500 ml of 0.9% NS had been ordered by the physician. ADON A was then asked whether she was supposed to review the physician's orders [REDACTED].#1's order. She then stated she would call the physician and notify him of what had happened with Resident #1. Potter and Perry's Fundamentals of Nursing, 7th Edition, pages 1004, 1021 reflected the following: IV fluid volume excess, which occurs when the client has received a too-rapid administration of IV solution can result in [MEDICAL CONDITION](elevated pulse rate), crackles in the lungs, shortness of breath and [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th Edition, page 711, reflected with [MEDICAL CONDITION], adjust fluid intake to avoid fluid overload and dehydration. Fluids should be distributed throughout the day. Resident #1's Daily Skilled Nurse's Noted dated 06/11/14 at 3:10 PM reflected: "...was brought to this writer's attention that order for IV fluid needed clarification and that IV fluids may have been infused too quickly. (MD R) notified. Order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter. NS infused & completed. Physician made aware. New orders received: continue to monitor resident & physician will see tomorrow on nursing home rounds. Res. Alert & aware. Skin warm & dry. LS CTA. (no) resp. distress. Denies SOB, dyspnea, or cough. Voiding clear yellow urine. Denies pain or discomfort. (Family member) notified via phone. - (ADON A)" Resident #1's physician telephone orders dated 06/11/14 at 3:10 PM reflected: "order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter (1,000 ml)." Interview on 06/12/14 at 7:45 am with ADON A for Hall 200 revealed after it was brought to her attention by the surveyor the IV had infused too quickly, she called the doctor at 3:10 PM on 06/11/14 and clarified the order and explained to the doctor what had happened with the Resident #1's IV. The doctor gave new orders to monitor the resident and told her he would be in tomorrow and check on Resident #1 during his rounds. She stated she gave LVN C verbal and written instructions on IV administration. During an interview on 06/12/14 at 10:30 AM the Administrator was asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently. The Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." She stated the 24 hour report was used as a tool to achieve this. The facility's current policy/procedure, Abuse Prevention Policy, reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. The facility's current policy/procedure for Intravenous Fluid and Drug Administration, General Policies dated April 2008, reflected the following: "...4. The nurse shall assess the following: ... -- The dose. -- The route. -- The rate of the solution/medication ordered. ...7. The nurse is accountable for achieving effective deliver of the prescribed therapy... ...13. Recommended rate for continuous infusion in the geriatric resident should not exceed 150 ml/hr due to potential adverse reactions...." On 06/12/14 an IJ was identified. On 06/12/14 at 11:48 AM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview on 06/16/14 at 11:30 AM with DON revealed that she was not aware that LVN C was not using an operable pump until after the fact. She stated she had educated all nurses to use an operable pump and if one was not available, to use a Dial- A-Flow or wait for an operable pump and call the physician. She stated they were working on getting a facility pump. She stated it was the responsibility of the two ADONs to check all physician orders [REDACTED]. The Plan of Removal was accepted on 06/13/14 and reflected the following: The facility had two residents with IVs, Residents #1 and #2. Resident #2 was assessed by the DON and ADON B on 06/11/14 at 7:00 PM and reviewed his physician orders [REDACTED]. The Medical Director was notified on 06/11/14 of the incident involving Resident #1. All nurses assigned to IV care are certified and have received additional training, which began on 06/11/14 following the findings of the surveyor. Date of completion was 06/13/14. Licensed staff were re-educated with return demonstration by the DON, RN N or RN Q regarding completion of IV orders. Physician orders [REDACTED]. 100% audit of all licensed staff assigned to IV care was conducted by the DON to verify IV certifications were on file. IV certification will be verified upon hire for licensed nurses and competency will be completed by the DON, RN N and RN Q prior to assignment to residents requiring IV therapy. Ten of ten IV certified licensed nurses have completed competency exams conducted by the DON on 06/13/14. Observation of IV certified nurses providing IV care will be done by the DON, RN N or RN Q daily times one week, weekly times four, monthly times one and then as directed by QAPI. Results of competencies will be taken to QAPI monthly and results will be reviewed for ongoing compliance. was competed for currently employed IV certified nurses. MONITORING Interview on 06/12/14 at 11:25 AM with LVN E revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/12/14 at 11:20 AM with LVN F revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 6/16/14 at 11:05 AM with LVN G revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 1:15 PM with LVN H revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 2:40 PM with LVN D revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/16/14 at 11:10 AM with LVN I revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:20 AM with LVN J revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician 's order and Abuse/Neglect. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/13/14 at 3:30 PM with LVN K revealed he received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:00 AM with LVN L revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 06/11/14 and signed by LVN P reflected there were two residents receiving intravenous therapy.

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of two residents reviewed for neglect. Resident #1, with a history of [MEDICAL CONDITION] and [MEDICAL CONDITION], was administered a liter (1000 ml) of 0.9% Sodium Chloride (NS) instead of 500 ml NS via IV over a period of two hours instead of ten hours resulting in his receiving 500 ml/hr instead of 100 ml/hr. Facility staff were unaware Resident #1 received twice as much IV fluid as ordered at five times the rate ordered until surveyor intervention. These failures could have caused fluid overload for Resident #1, resulting in respiratory distress, [MEDICAL CONDITIONS], elevated blood pressure, elevated heart rate and even death. An Immediate Jeopardy (IJ) was identified on 06/12/14. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. These failures could affect the two residents with IV access, Resident #1 and Resident #2, who had a PICC line, and placed them at risk for not receiving IV medications and fluids at the rate ordered by the physician resulting in the resident being at risk for fluid over-load and not receiving the therapeutic benefit intended by his physician. Findings included: Resident #1's hospital History and Physical dated 04/07/14 reflected [DIAGNOSES REDACTED]. Resident #1's Face Sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE] following a cholecystectomy (gall bladder removal). His [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/30/14, reflected a BIMS score of three, which indicated he was severely impaired cognitively; required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Active [DIAGNOSES REDACTED]. Resident #1's Insertion Record dated 06/06/14 reflected a Midline IV was inserted in the resident's right arm just above the inner elbow. The midline inner catheter was 11 cm (approximately 4 1/12 inches) and the exposed part was 2 cm (approximately ? inch) long. Review of Resident #1's Comprehensive Plan of Care with most recent being dated 06/11/4 revealed the care and treatment of [REDACTED]. Resident #1's laboratory results dated [DATE] and printed at 10:40 AM reflected an elevated BUN (Blood Urea Nitrogen) of 68 mg/dL (normal 7 - 18 mg/dL), and an elevated creatinine level of 2.9 mg/dL (normal 0.6 - 1.3 mg/dL). A handwritten note on the lab results reflected check BMP/CBC in AM (06/12/14) give 500 ml of NS now x 1 dose. There was nothing to identify who wrote the note. Retrieved on 06/30/14 from www.mayoclinic.org/tests-procedures reflected the following: --A BUN reveals how well your kidney and liver are working to remove the urea from your blood. The liver forms urea, a waste product, and sends it through the blood to the kidneys, which filters the urea from the body as urine. When the BUN is higher than normal, it can indicate your kidneys or liver are not working properly. --An above normal Creatinine level means that the kidneys are not working well. Resident #1's physician telephone order dated 06/11/14 and written by LVN C reflected lab orders for a CBC & BMP in AM and 0.9% NS via midline one time now. There was no amount of the infusion or rate of the infusion included on the physician's orders [REDACTED]. Resident #1's June 2014 MAR indicated [REDACTED]." Resident #1's Daily Skilled Nurse's Note dated 06/11/14 , no time, reflected MD S was called and an order was received to re-check the resident's BMP and CBC in the AM. And to give 500 ml NS one time "now." The note was signed by LVN C. Resident #1 was observed on 06/11/14 at 2:20 PM. The resident was in his room lying on his bed watching TV. Observation revealed a 1,000 ml bag of 0.9% NS was infusing via the resident's midline catheter. Approximately 200 ml of fluid was left in the bag of fluid. The IV was not infusing via an IV infusion pump, but instead the bag hung from an IV pole and dripped by gravity. No label was applied to the IV bag to provide information as to who hung the bag, when the bag was hung and/or reference to the physician's orders [REDACTED]. Note: An infusion pump ensures accurate amounts of IV fluid are infused to the patient. Interview on 06/12/14 at 9:45 AM with CNA O revealed she was in Resident #1's room on 06/11/14 when LVN C came in and started the IV. She stated she was feeding lunch to Resident #1's roommate, and it was about 12:30 PM. An interview on 06/12/14 at 10:13 AM with LVN C revealed she hung Resident #1's IV of NS before lunch at 10:00 AM on 06/11/14. She stated the IV was infusing at 100 ml per hour. Note: The lab results were printed at on 06/11/14 at 10:40 AM. RN M was interviewed on 06/11/14 at 2:55 PM in regard to Resident #1's IV. She stated she disconnected the IV at 2:30 PM, because the bag of IV fluid was empty. At 3:00 PM on 06/11/14, ADON A was informed by the surveyor Resident #1 had 1,000 ml of 0.9% NS infused too quickly and only 500 ml of 0.9% NS had been ordered by the physician. ADON A was then asked whether she was supposed to review the physician's orders [REDACTED].#1's order. She then stated she would call the physician and notify him of what had happened with Resident #1. Potter and Perry's Fundamentals of Nursing, 7th Edition, pages 1004, 1021 reflected the following: IV fluid volume excess, which occurs when the client has received a too-rapid administration of IV solution can result in [MEDICAL CONDITION](elevated pulse rate), crackles in the lungs, shortness of breath and [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th Edition, page 711, reflected with [MEDICAL CONDITION], adjust fluid intake to avoid fluid overload and dehydration. Fluids should be distributed throughout the day. Resident #1's Daily Skilled Nurse's Noted dated 06/11/14 at 3:10 PM reflected: "...was brought to this writer's attention that order for IV fluid needed clarification and that IV fluids may have been infused too quickly. (MD R) notified. Order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter. NS infused & completed. Physician made aware. New orders received: continue to monitor resident & physician will see tomorrow on nursing home rounds. Res. Alert & aware. Skin warm & dry. LS CTA. (no) resp. distress. Denies SOB, dyspnea, or cough. Voiding clear yellow urine. Denies pain or discomfort. (Family member) notified via phone. - (ADON A)" Resident #1's physician telephone orders dated 06/11/14 at 3:10 PM reflected: "order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter (1,000 ml)." Interview on 06/12/14 at 7:45 am with ADON A for Hall 200 revealed after it was brought to her attention by the surveyor the IV had infused too quickly, she called the doctor at 3:10 PM on 06/11/14 and clarified the order and explained to the doctor what had happened with the Resident #1's IV. The doctor gave new orders to monitor the resident and told her he would be in tomorrow and check on Resident #1 during his rounds. She stated she gave LVN C verbal and written instructions on IV administration. During an interview on 06/12/14 at 10:30 AM the Administrator was asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently. The Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." She stated the 24 hour report was used as a tool to achieve this. The facility's current policy/procedure, Abuse Prevention Policy, reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. The facility's current policy/procedure for Intravenous Fluid and Drug Administration, General Policies dated April 2008, reflected the following: "...4. The nurse shall assess the following: ... -- The dose. -- The route. -- The rate of the solution/medication ordered. ...7. The nurse is accountable for achieving effective deliver of the prescribed therapy... ...13. Recommended rate for continuous infusion in the geriatric resident should not exceed 150 ml/hr due to potential adverse reactions...." On 06/12/14 an IJ was identified. On 06/12/14 at 11:48 AM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview on 06/16/14 at 11:30 AM with DON revealed that she was not aware that LVN C was not using an operable pump until after the fact. She stated she had educated all nurses to use an operable pump and if one was not available, to use a Dial- A-Flow or wait for an operable pump and call the physician. She stated they were working on getting a facility pump. She stated it was the responsibility of the two ADONs to check all physician orders [REDACTED]. The Plan of Removal was accepted on 06/13/14 and reflected the following: The facility had two residents with IVs, Residents #1 and #2. Resident #2 was assessed by the DON and ADON B on 06/11/14 at 7:00 PM and reviewed his physician orders [REDACTED]. The Medical Director was notified on 06/11/14 of the incident involving Resident #1. All nurses assigned to IV care are certified and have received additional training, which began on 06/11/14 following the findings of the surveyor. Date of completion was 06/13/14. Licensed staff were re-educated with return demonstration by the DON, RN N or RN Q regarding completion of IV orders. Physician orders [REDACTED]. 100% audit of all licensed staff assigned to IV care was conducted by the DON to verify IV certifications were on file. IV certification will be verified upon hire for licensed nurses and competency will be completed by the DON, RN N and RN Q prior to assignment to residents requiring IV therapy. Ten of ten IV certified licensed nurses have completed competency exams conducted by the DON on 06/13/14. Observation of IV certified nurses providing IV care will be done by the DON, RN N or RN Q daily times one week, weekly times four, monthly times one and then as directed by QAPI. Results of competencies will be taken to QAPI monthly and results will be reviewed for ongoing compliance. was competed for currently employed IV certified nurses. MONITORING Interview on 06/12/14 at 11:25 AM with LVN E revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/12/14 at 11:20 AM with LVN F revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 6/16/14 at 11:05 AM with LVN G revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 1:15 PM with LVN H revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 2:40 PM with LVN D revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/16/14 at 11:10 AM with LVN I revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:20 AM with LVN J revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician 's order and Abuse/Neglect. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/13/14 at 3:30 PM with LVN K revealed he received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:00 AM with LVN L revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 06/11/14 and signed by LVN P reflected there were two residents receiving intravenous therapy.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures, which prohibit neglect for one (Resident #1) of two residents reviewed for neglect. Resident #1, with a history of [MEDICAL CONDITION] and [MEDICAL CONDITION], was administered a liter (1000 ml) of 0.9% Sodium Chloride (NS) instead of 500 ml NS via IV over a period of two hours instead of ten hours resulting in his receiving 500 ml/hr instead of 100 ml/hr. Facility staff were unaware Resident #1 received twice as much IV fluid as ordered at five times the rate ordered until surveyor intervention. These failures could have caused fluid overload for Resident #1, resulting in respiratory distress, [MEDICAL CONDITIONS], elevated blood pressure, elevated heart rate and even death. An Immediate Jeopardy (IJ) was identified on 06/12/14. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. These failures could affect the two residents with IV access, Resident #1 and Resident #2, who had a PICC line, and placed them at risk for not receiving IV medications and fluids at the rate ordered by the physician resulting in the resident being at risk for fluid over-load and not receiving the therapeutic benefit intended by his physician. Findings included: The facility's current policy/procedure, Abuse Prevention Policy, reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. The facility's current policy/procedure for Intravenous Fluid and Drug Administration, General Policies dated April 2008, reflected the following: " ...4. The nurse shall assess the following: ... -- The dose. -- The route. -- The rate of the solution/medication ordered. 7. The nuse is accountable for achieving effective deliver of the prescribed therapy ... 13. Recommended rate for continuous infusion in the geriatric resident should not exceed 150 ml/hr due to potential adverse reactions." Resident #1's hospital History and Physical dated 04/07/14 reflected [DIAGNOSES REDACTED]. Resident #1's Face Sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE] following a cholecystectomy (gall bladder removal). His [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/30/14, reflected a BIMS score of three, which indicated he was severely impaired cognitively; required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Active [DIAGNOSES REDACTED]. Resident #1's Insertion Record dated 06/06/14 reflected a Midline IV was inserted in the resident's right arm just above the inner elbow. The midline inner catheter was 11 cm (approximately 4 1/12 inches) and the exposed part was 2 cm (approximately ? inch) long. Review of Resident #1's Comprehensive Plan of Care with most recent being dated 06/11/4 revealed the care and treatment of [REDACTED]. Resident #1's laboratory results dated [DATE] and printed at 10:40 AM reflected an elevated BUN (Blood Urea Nitrogen) of 68 mg/dL (normal 7 - 18 mg/dL), and an elevated creatinine level of 2.9 mg/dL (normal 0.6 - 1.3 mg/dL). A handwritten note on the lab results reflected check BMP/CBC in AM (06/12/14) give 500 ml of NS now x 1 dose. There was nothing to identify who wrote the note. Retrieved on 06/30/14 from www.mayoclinic.org/tests-procedures reflected the following: --A BUN reveals how well your kidney and liver are working to remove the urea from your blood. The liver forms urea, a waste product, and sends it through the blood to the kidneys, which filters the urea from the body as urine. When the BUN is higher than normal, it can indicate your kidneys or liver are not working properly. --An above normal Creatinine level means that the kidneys are not working well. Resident #1's physician telephone order dated 06/11/14 and written by LVN C reflected lab orders for a CBC & BMP in AM and 0.9% NS via midline one time now. There was no amount of the infusion or rate of the infusion included on the physician's orders [REDACTED]. Resident #1's June 2014 MAR indicated [REDACTED]." Resident #1's Daily Skilled Nurse's Note dated 06/11/14 , no time, reflected MD S was called and an order was received to re-check the resident's BMP and CBC in the AM. And to give 500 ml NS one time "now." The note was signed by LVN C. Resident #1 was observed on 06/11/14 at 2:20 PM. The resident was in his room lying on his bed watching TV. Observation revealed a 1,000 ml bag of 0.9% NS was infusing via the resident's midline catheter. Approximately 200 ml of fluid was left in the bag of fluid. The IV was not infusing via an IV infusion pump, but instead the bag hung from an IV pole and dripped by gravity. No label was applied to the IV bag to provide information as to who hung the bag, when the bag was hung and/or reference to the physician's orders [REDACTED]. Note: An infusion pump ensures accurate amounts of IV fluid are infused to the patient. Interview on 06/12/14 at 9:45 AM with CNA O revealed she was in Resident #1's room on 06/11/14 when LVN C came in and started the IV. She stated she was feeding lunch to Resident #1's roommate, and it was about 12:30 PM. An interview on 06/12/14 at 10:13 AM with LVN C revealed she hung Resident #1's IV of NS before lunch at 10:00 AM on 06/11/14. She stated the IV was infusing at 100 ml per hour. Note: The lab results were printed at on 06/11/14 at 10:40 AM. RN M was interviewed on 06/11/14 at 2:55 PM in regard to Resident #1's IV. She stated she disconnected the IV at 2:30 PM, because the bag of IV fluid was empty. At 3:00 PM on 06/11/14, ADON A was informed by the surveyor Resident #1 had 1,000 ml of 0.9% NS infused too quickly and only 500 ml of 0.9% NS had been ordered by the physician. ADON A was then asked whether she was supposed to review the physician's orders [REDACTED].#1's order. She then stated she would call the physician and notify him of what had happened with Resident #1. Potter and Perry's Fundamentals of Nursing, 7th Edition, pages 1004, 1021 reflected the following: IV fluid volume excess, which occurs when the client has received a too-rapid administration of IV solution can result in [MEDICAL CONDITION](elevated pulse rate), crackles in the lungs, shortness of breath and [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th Edition, page 711, reflected with [MEDICAL CONDITION], adjust fluid intake to avoid fluid overload and dehydration. Fluids should be distributed throughout the day. Resident #1's Daily Skilled Nurse's Noted dated 06/11/14 at 3:10 PM reflected: "...was brought to this writer's attention that order for IV fluid needed clarification and that IV fluids may have been infused too quickly. (MD R) notified. Order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter. NS infused & completed. Physician made aware. New orders received: continue to monitor resident & physician will see tomorrow on nursing home rounds. Res. Alert & aware. Skin warm & dry. LS CTA. (no) resp. distress. Denies SOB, dyspnea, or cough. Voiding clear yellow urine. Denies pain or discomfort. (Family member) notified via phone. - (ADON A)" Resident #1's physician telephone orders dated 06/11/14 at 3:10 PM reflected: "order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter (1,000 ml)." Interview on 06/12/14 at 7:45 am with ADON A for Hall 200 revealed after it was brought to her attention by the surveyor the IV had infused too quickly, she called the doctor at 3:10 PM on 06/11/14 and clarified the order and explained to the doctor what had happened with the Resident #1's IV. The doctor gave new orders to monitor the resident and told her he would be in tomorrow and check on Resident #1 during his rounds. She stated she gave LVN C verbal and written instructions on IV administration. During an interview on 06/12/14 at 10:30 AM the Administrator was asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently. The Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." She stated the 24 hour report was used as a tool to achieve this. On 06/12/14 an IJ was identified. On 06/12/14 at 11:48 AM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview on 06/16/14 at 11:30 AM with DON revealed that she was not aware that LVN C was not using an operable pump until after the fact. She stated she had educated all nurses to use an operable pump and if one was not available, to use a Dial- A-Flow or wait for an operable pump and call the physician. She stated they were working on getting a facility pump. She stated it was the responsibility of the two ADONs to check all physician orders [REDACTED]. The Plan of Removal was accepted on 06/13/14 and reflected the following: The facility had two residents with IVs, Residents #1 and #2. Resident #2 was assessed by the DON and ADON B on 06/11/14 at 7:00 PM and reviewed his physician orders [REDACTED]. The Medical Director was notified on 06/11/14 of the incident involving Resident #1. All nurses assigned to IV care are certified and have received additional training, which began on 06/11/14 following the findings of the surveyor. Date of completion was 06/13/14. Licensed staff were re-educated with return demonstration by the DON, RN N or RN Q regarding completion of IV orders. Physician orders [REDACTED]. 100% audit of all licensed staff assigned to IV care was conducted by the DON to verify IV certifications were on file. IV certification will be verified upon hire for licensed nurses and competency will be completed by the DON, RN N and RN Q prior to assignment to residents requiring IV therapy. Ten of ten IV certified licensed nurses have completed competency exams conducted by the DON on 06/13/14. Observation of IV certified nurses providing IV care will be done by the DON, RN N or RN Q daily times one week, weekly times four, monthly times one and then as directed by QAPI. Results of competencies will be taken to QAPI monthly and results will be reviewed for ongoing compliance. was competed for currently employed IV certified nurses. MONITORING Interview on 06/12/14 at 11:25 AM with LVN E revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/12/14 at 11:20 AM with LVN F revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 6/16/14 at 11:05 AM with LVN G revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 1:15 PM with LVN H revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 2:40 PM with LVN D revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/16/14 at 11:10 AM with LVN I revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:20 AM with LVN J revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician 's order and Abuse/Neglect. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/13/14 at 3:30 PM with LVN K revealed he received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:00 AM with LVN L revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 06/11/14 and signed by LVN P reflected there were two residents receiving intravenous therapy.

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of two residents reviewed for IV therapy received the proper treatment and care for IV therapy. Resident #1, with a history of [MEDICAL CONDITION] and [MEDICAL CONDITION], was administered a liter (1000 ml) of 0.9% Sodium Chloride (NS) instead of 500 ml NS via IV over a period of two hours instead of ten hours resulting in his receiving 500 ml/hr instead of 100 ml/hr. Facility staff were unaware Resident #1 received twice as much IV fluid as ordered at five times the rate ordered until surveyor intervention. These failures could have caused fluid overload for Resident #1, resulting in worsening of Kidney Failure, respiratory distress, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], elevated blood pressure, elevated heart rate and even death. An Immediate Jeopardy (IJ) was identified on 06/12/14. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. These failures could affect the two residents with IV access, Resident #1 and Resident #2, who had a PICC line, and placed them at risk for not receiving IV medications and fluids at the rate ordered by the physician resulting in the resident being at risk for fluid over-load and not receiving the therapeutic benefit intended by his physician. Findings included: Resident #1's hospital History and Physical dated 04/07/14 reflected [DIAGNOSES REDACTED]. Resident #1's Face Sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE] following a cholecystectomy (gall bladder removal). His [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/30/14, reflected a BIMS score of three, which indicated he was severely impaired cognitively; required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Active [DIAGNOSES REDACTED]. Resident #1's Insertion Record dated 06/06/14 reflected a Midline IV was inserted in the resident's right arm just above the inner elbow. The midline inner catheter was 11 cm (approximately 4 1/12 inches) and the exposed part was 2 cm (approximately ? inch) long. Review of Resident #1's Comprehensive Plan of Care with most recent being dated 06/11/4 revealed the care and treatment of [REDACTED]. Resident #1's laboratory results dated [DATE] and printed at 10:40 AM reflected an elevated BUN (Blood Urea Nitrogen) of 68 mg/dL (normal 7 - 18 mg/dL), and an elevated creatinine level of 2.9 mg/dL (normal 0.6 - 1.3 mg/dL). A handwritten note on the lab results reflected check BMP/CBC in AM (06/12/14) give 500 ml of NS now x 1 dose. There was nothing to identify who wrote the note. Retrieved on 06/30/14 from www.mayoclinic.org/tests-procedures reflected the following: --A BUN reveals how well your kidney and liver are working to remove the urea from your blood. The liver forms urea, a waste product, and sends it through the blood to the kidneys, which filters the urea from the body as urine. When the BUN is higher than normal, it can indicate your kidneys or liver are not working properly. --An above normal Creatinine level means that the kidneys are not working well. Resident #1's physician telephone order dated 06/11/14 and written by LVN C reflected lab orders for a CBC & BMP in AM and 0.9% NS via midline one time now. There was no amount of the infusion or rate of the infusion included on the physician's orders [REDACTED]. Resident #1's June 2014 MAR indicated [REDACTED]." Resident #1's Daily Skilled Nurse's Note dated 06/11/14 , no time, reflected MD S was called and an order was received to re-check the resident's BMP and CBC in the AM. And to give 500 ml NS one time "now." The note was signed by LVN C. Resident #1 was observed on 06/11/14 at 2:20 PM. The resident was in his room lying on his bed watching TV. Observation revealed a 1,000 ml bag of 0.9% NS was infusing via the resident's midline catheter. Approximately 200 ml of fluid was left in the bag of fluid. The IV was not infusing via an IV infusion pump, but instead the bag hung from an IV pole and dripped by gravity. No label was applied to the IV bag to provide information as to who hung the bag, when the bag was hung and/or reference to the physician's orders [REDACTED]. Note: An infusion pump ensures accurate amounts of IV fluid are infused to the patient. Interview on 06/12/14 at 9:45 AM with CNA O revealed she was in Resident #1's room on 06/11/14 when LVN C came in and started the IV. She stated she was feeding lunch to Resident #1's roommate, and it was about 12:30 PM. An interview on 06/12/14 at 10:13 AM with LVN C revealed she hung Resident #1's IV of NS before lunch at 10:00 AM on 06/11/14. She stated the IV was infusing at 100 ml per hour. Note: The lab results were printed at on 06/11/14 at 10:40 AM. RN M was interviewed on 06/11/14 at 2:55 PM in regard to Resident #1's IV. She stated she disconnected the IV at 2:30 PM, because the bag of IV fluid was empty. At 3:00 PM on 06/11/14, ADON A was informed by the surveyor Resident #1 had 1,000 ml of 0.9% NS infused too quickly and only 500 ml of 0.9% NS had been ordered by the physician. ADON A was then asked whether she was supposed to review the physician's orders [REDACTED].#1's order. She then stated she would call the physician and notify him of what had happened with Resident #1. Potter and Perry's Fundamentals of Nursing, 7th Edition, pages 1004, 1021 reflected the following: IV fluid volume excess, which occurs when the client has received a too-rapid administration of IV solution can result in [MEDICAL CONDITION](elevated pulse rate), crackles in the lungs, shortness of breath and [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th Edition, page 711, reflected with [MEDICAL CONDITION], adjust fluid intake to avoid fluid overload and dehydration. Fluids should be distributed throughout the day. Resident #1's Daily Skilled Nurse's Noted dated 06/11/14 at 3:10 PM reflected: "...was brought to this writer's attention that order for IV fluid needed clarification and that IV fluids may have been infused too quickly. (MD R) notified. Order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter. NS infused & completed. Physician made aware. New orders received: continue to monitor resident & physician will see tomorrow on nursing home rounds. Res. Alert & aware. Skin warm & dry. LS CTA. (no) resp. distress. Denies SOB, dyspnea, or cough. Voiding clear yellow urine. Denies pain or discomfort. (Family member) notified via phone. - (ADON A)" Resident #1's physician telephone orders dated 06/11/14 at 3:10 PM reflected: "order clarification: 0.9% NS per IV @ 100 ml/hr x 1 liter (1,000 ml)." Interview on 06/12/14 at 7:45 am with ADON A for Hall 200 revealed after it was brought to her attention by the surveyor the IV had infused too quickly, she called the doctor at 3:10 PM on 06/11/14 and clarified the order and explained to the doctor what had happened with the Resident #1's IV. The doctor gave new orders to monitor the resident and told her he would be in tomorrow and check on Resident #1 during his rounds. She stated she gave LVN C verbal and written instructions on IV administration. During an interview on 06/12/14 at 10:30 AM the Administrator was asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently. The Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." She stated the 24 hour report was used as a tool to achieve this. The facility's current policy/procedure for Intravenous Fluid and Drug Administration, General Policies dated April 2008, reflected the following: "...4. The nurse shall assess the following: ... -- The dose. -- The route. -- The rate of the solution/medication ordered. ...7. The nurse is accountable for achieving effective deliver of the prescribed therapy... ...13. Recommended rate for continuous infusion in the geriatric resident should not exceed 150 ml/hr due to potential adverse reactions...." On 06/12/14 an IJ was identified. On 06/12/14 at 11:48 AM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview on 06/16/14 at 11:30 AM with DON revealed that she was not aware that LVN C was not using an operable pump until after the fact. She stated she had educated all nurses to use an operable pump and if one was not available, to use a Dial- A-Flow or wait for an operable pump and call the physician. She stated they were working on getting a facility pump. She stated it was the responsibility of the two ADONs to check all physician orders [REDACTED]. The Plan of Removal was accepted on 06/13/14 and reflected the following: The facility had two residents with IVs, Residents #1 and #2. Resident #2 was assessed by the DON and ADON B on 06/11/14 at 7:00 PM and reviewed his physician orders [REDACTED]. The Medical Director was notified on 06/11/14 of the incident involving Resident #1. All nurses assigned to IV care are certified and have received additional training, which began on 06/11/14 following the findings of the surveyor. Date of completion was 06/13/14. Licensed staff were re-educated with return demonstration by the DON, RN N or RN Q regarding completion of IV orders. Physician orders [REDACTED]. 100% audit of all licensed staff assigned to IV care was conducted by the DON to verify IV certifications were on file. IV certification will be verified upon hire for licensed nurses and competency will be completed by the DON, RN N and RN Q prior to assignment to residents requiring IV therapy. Ten of ten IV certified licensed nurses have completed competency exams conducted by the DON on 06/13/14. Observation of IV certified nurses providing IV care will be done by the DON, RN N or RN Q daily times one week, weekly times four, monthly times one and then as directed by QAPI. Results of competencies will be taken to QAPI monthly and results will be reviewed for ongoing compliance. was competed for currently employed IV certified nurses. MONITORING Interview on 06/12/14 at 11:25 AM with LVN E revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/12/14 at 11:20 AM with LVN F revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 6/16/14 at 11:05 AM with LVN G revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 1:15 PM with LVN H revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/14/14 at 2:40 PM with LVN D revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/16/14 at 11:10 AM with LVN I revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:20 AM with LVN J revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician 's order and Abuse/Neglect. She stated the DON and RNs will monitor the licensed nurses during the administration and use of IV therapy. Interview on 06/13/14 at 3:30 PM with LVN K revealed he received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. Interview on 06/16/14 at 11:00 AM with LVN L revealed she received in-service training on IV infusions, PICC lines, flushes, medications, how to correctly write a physician's orders [REDACTED]. While the the IJ was removed on 06/16/14, the facility remained out of compliance at a scope of pattern and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," due to the facility continuing to train staff and monitoring the implementation of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 06/11/14 and signed by LVN P reflected there were two residents receiving intravenous therapy.

Based on observation, interview, and record review it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #1) of seven residents reviewed for pain/comfort by failing to assess for pain. Resident #1 experienced pain (yelling "Ouch" and exhibiting facial grimacing) on two different occasions during care. Five staff (CNA N, CNA O, OTR Q, PTA P and LVN V) were aware of the pain, and no interventions were implemented to decrease the pain and/or manage the pain for Resident #1 until after surveyor inquiry. These failures caused Resident #1 to suffer from untreated, unnecessary pain, a total of six days, and could affect the facility's 68 residents who were identified as being on a pain management program, including Resident #1, by placing them at risk for unrelieved pain when staff failed to assess and treat them for pain, resulting in continued unrelieved pain, having a negative impact on their health and quality of life. Findings included: Resident #1's initial admission orders [REDACTED]. Resident #1's "Admission Nursing Evaluation" dated 09/19/11 reflected, "Can't answer" was written in on pain frequency and "unable to answer" was written in on pain intensity. Resident #1's "Pain Evaluation" dated 09/19/11 reflected: "I. Pain Management... A. Is on a scheduled pain medication regimen? No. B. Receiving PRN pain medication? Yes. Tylenol. C. Receiving non-medication intervention for pain? Repositioning. D. Numeric Rating Scale (0-10). Unable to rate. II. Pain Interview A. Pain Presence ...Have you had pain or hurting at any time in the last 5 days? Unable to say. B. Pain Frequency How much of the time have you experienced pain or hurting over the last 5 days? Unable to say. C. Pain Effect on Function Over the last 5 days, has pain made it hard for you to sleep at night? Unable to say. Over the last 5 days, have you limited your day-to-day activities because of pain? Unable to answer D. Indications of pain or Possible Pain 1. Non-verbal sounds (crying, whining, gasping, moaning, or groaning)." Note: The number "1" was circled, indicating Resident #1 exhibited "Non-verbal sounds" as indicators of pain or possible pain. Resident #1's "Interim Plan of Care" dated 09/19/11 reflected, "Goal: Manage Pain, Scale (0-10)" was marked. Resident #1's History and Physical dated 09/20/11 reflected she had a history of [REDACTED]. Resident #1's past surgery history was a Left [MEDICAL CONDITION]. Resident #1's current [DIAGNOSES REDACTED]. The section for "Pain" was marked "yes" to Resident #1's arms bilaterally. Resident #1 was transferred to and was admitted to the hospital on [DATE], per the hospital History and Physical that was dictated on 09/23/11. The History and Physical reflected Resident #1 was admitted to the hospital with [REDACTED]. Resident #1's re-admission orders [REDACTED]. Resident #1's "Admission Nursing Evaluation" dated 09/30/11 reflected, "Rarely" was checked on pain frequency. Resident #1 was seen by her Attending Physician on 10/02/11, according to a physician's progress note and there was no information regarding pain. The Progress Note reflected she continued to have [MEDICAL CONDITION], Urosepsis, Dementia, and Sacrum/Lower Extremity Wounds. Resident #1's 09/30/11 admission orders fever." There were no orders for any pain medication. Interviews on 10/03/11 at 8:38 p.m. and 10/06/11 (approximately 1:00 p.m.) with Resident #1's responsible party revealed, Resident #1 was ambulatory using a walker on the patio in August 2011 before her recent illness and prior admission on 09/19/11 to the facility. Resident #1's current October 2011 MAR indicated fever." Resident #1's Daily Skilled Nurse's Note dated 10/02/11 on the day shift reflected: "Alert Oriented times one to person. Appears to be in pain while repositioning. Tylenol 650 mg given times one as needed. Turn and reposition every two hours and as needed...." This entry was signed by LVN U. Resident #1's Daily Skilled Nurse's Note dated 10/05/11 reflected no documentation for the reason Tylenol 650 mg was given. Observation on 10/04/11 at 4:10 p.m. revealed CNA N was repositioning Resident #1 after providing incontinent care. Resident #1 was moaning and repeatedly saying "ouch" while her lower extremities were being moved. On 10/05/11 at 11:00 a.m. Resident #1 was observed moaning and saying "Ouch" as she was turned to her left side for the wound care physician to assess her coccyx wound. Resident #1 continued moaning and saying "ouch" when LVN V was moving her lower extremities. Resident #1 was observed with facial grimacing upon movement by the physician and LVN V. Review of Resident #1's entire clinical record revealed there was no pain evaluation completed after she was readmitted to the facility, on 09/30/11, following a hospital admission. In an interview on 10/06/11 at 1:45 p.m., the surveyor asked CNA N and CNA O if Resident #1 was ever in pain. CNA N stated, "(Resident #1) has pain every time you turn her in her legs and arms. CNA O stated, "(Resident #1) yells every time you turn her." In an interview on 10/06/11 at 2:35 p.m., the surveyor asked OTR Q if Resident #1 was ever in pain. OTR Q stated, "There is some level of pain or discomfort. Even when you sit her up or move her arms or legs she is having pain or discomfort. I think she could do it (therapy) if she didn't have Dementia and pain." In an interview on 10/06/11 at 2:45 p.m., the surveyor asked PTA P if Resident #1 was ever in pain. PTA P stated, "With any kind of movement she is hollering and yelling out, mostly in her legs and knees. But, from supine to sitting she yelled. I asked her to point to where it hurt. She pointed to her knees and legs." In an interview on 10/06/11 at 3:00 p.m., LVN V stated, "You can't tell if (Resident #1) is in pain or just afraid. She hollers if you slightly touch her." On 10/06/11 at 3:25 p.m., the DON stated to the surveyor that she had asked the Medical Director (MD) to assess Resident #1 for pain. During an observation on 10/06/11 at 3:30 p.m., the MD, DON, and LVN V were present in Resident #1's room. The MD moved Resident #1's upper extremities and asked if they hurt. Resident #1 stated, "No." The MD slightly moved Resident #1's lower extremities and Resident #1 yelled "Ouch." The MD asked Resident #1 if it hurt. Resident #1 stated "yes." The MD moved Resident #1's lower extremities again and Resident #1 yelled "Ouch." The MD stated, "She has pain on moving her lower extremities." In an interview on 10/06/11 at 5:05 p.m. with CNA N, the surveyor asked if Resident #1's pain was reported to the nurse. CNA N stated, "I told the nurse. She knows about it because she was with me, working together. She knows when she is hollering." In an interview on 10/06/11 at 5:40 p.m. with PTA P, the surveyor asked if Resident #1's pain was reported to the nurse. PTA P stated, "Everybody pretty much knew about her pain because she yelled out in pain. (LVN W) was here today and yesterday. I'm sure everyone was aware of it." Review on 10/07/11 at approximately 10:00 a.m. of Resident #1's Telephone physician's orders [REDACTED]. In an interview on 10/07/11 at 2:20 p.m. with OTR Q, the surveyor asked if Resident #1's pain was reported to the nurse. OTR Q stated, "I talked to (LVN W) about her. I told her (Resident #1) is in discomfort." In an interview on 10/07/11 at 4:00 p.m. with CNA O, the surveyor asked if Resident #1's pain was reported to the nurse. CNA O stated, "When (Resident #1) is in pain we let the nurses know. It hurts her arms and her legs. I worked this weekend and I let (LVN U) know. We tell (LVN W) any time the resident has pain. (LVN W) knows about the pain. (LVN W) goes right away to check on her." An undated current Pain Management Policy was given to the surveyor on 10/05/11 by the DON. The policy reflected: "Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort...Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life...It is important, therefore, that a resident's report of pain, or nonverbal signs suggesting pain, be evaluated... ...8. Patient/Resident should be evaluated for any needed pain medication prior to treatments (wounds) or care." The Roster/Sample Matrix CMS-802, provided to the survey team on 10/04/11, reflected 68 residents who were identified as being on a pain management program.