Every finding on record at Greene Acres Rehabilitation and Nursing

Based on observation, resident interview, staff interview, and facility record review, the facility failed to maintain the functionality of essential equipment for one of two water heaters.The findings include:A resident interview was conducted with Resident #5 (R5) on 6/15/2026 at 12:48 PM. During this interview R5 stated that the water is not always hot. R5 stated that the water heater occasionally trips out and that the receptionist's husband has to be called to reset the water heater for hot water to be returned. R5 stated they were unsure of the duration this has been occurring, but it had been going on for a while. During this interview, the hot water was run in R5's room and was observed to be hot.An interview was conducted with the Maintenance Director on 6/16/2026 at 11:00 AM. The maintenance director stated that the water heater had been cleaned in early 2024. He stated that the water heater would frequently go into lockout and need to be manually reset. He stated that after cleaning the water heater the frequency of this occurring has decreased. Maintenance director presented temperature logs. No concerns were identified with the temperature logs. An interview was conducted with Other Staff #7 (Environmental Services) on 6/16/2026 at 11:38 AM. Other Staff #7 stated that the hot water will kick off occasionally and need to be reset and that several people know how to reset the water [NAME]. Other Staff #7 stated that the only way to know if the water heater had kicked off was to run the water. If the water stayed cold than the water heater needed to be reset. An interview was conducted with the Laundry Manager (Other staff #5) on 6/16/2026 at 11:58 AM. The Laundry Manager stated that the only times they would have issues with hot water in the laundry is when they are having trouble with the water heater. The Laundry Manager stated that the only way to know if the water heater needed to be reset was by running the water, like to wash hands, and observe the water not getting warm.An interview was conducted with the environmental services (EVS) manager on 6/16/2026 at 1:13 PM. The EVS manager believed this water heater supplied hot water to the 100, 200, 300 halls as well as the laundry and kitchen. The EVS manager stated the only way to know if the water heater has tripped is the absence of hot water such as if residents or staff wash their hands and the water is ice cold. The EVS manager stated that the water heater trips out about approximately every four to six hours and he or somebody else will go reset it. EVS manager stated that sometimes on the weekends they may not have hot water because not all of the Certified Nursing Assistants (CNAs) know how to reset the water heater. The EVS manager was not aware of any plans to replace or repair the water heater. A second interview was conducted with the Maintenance Director on 6/16/26 at 2:51 PM. The Maintenance Director stated that this water heater supplied hot water to the 100, 200, and 300 halls as well as the laundry and the kitchen. He stated that if not enough hot water is being pulled the water heater goes to standby and then when the demand for hot water increases it has to come back on. He stated that he believes the lack of hot water demand at times causes the water heater to trip out more frequently. When asked how residents and/or staff know if the water heater is not working, he stated that when they wash their hands if the water is not getting hot, staff can notify him and he will come to fix it. When he is not available, there are several others he has trained to reset the water heater including kitchen staff, some CNAs, and the EVS manager. On weekends the CNAs perform the reset and if they have an issue he only lives ten minutes away and can come. He stated it was happening frequently in 2024, but since they had the water heater cleaned it only has to be reset about once a week.An interview occurred with the Administrator on 6/17/2026 at 8:47 AM. The Administrator stated that when the water heater trips out, it takes about ten minutes for the hot water to return after the water heater is reset and that several people had been trained on how to reset the water heater. The Administrator was able to provide current inspection certificates for continued use of this water heater.During the survey process, several observations of water temperatures were made including in the resident rooms, showers, kitchen, and laundry. There were no identified issues with the water temperature noted during the survey. This information was made aware to the facility leadership staff on 6/17/2026 at 2:15 PM. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide education for the influenza vaccine for 5 of 5 residents (Residents # 7, #12, #57, #70 and #81), failed to provide education for the pneumonia vaccine for 2 of 5 residents (Residents #12 and #7), and failed to offer vaccines for 1 of 5 residents (Resident #7) sampled residents. The findings included:Five residents were chosen from the initial pool for review of vaccinations. Of these 5 residents, there was no evidence that Resident #7 had been offered either the flu or pneumonia vaccine or education provided related to these vaccines. Resident #12 had refused both the flu and pneumonia vaccine, and there was no evidence that education was provided for these vaccines. For Residents #57, #70, and #81, there was no evidence that education had been provided for flu vaccine. Surveyor spoke with vice-president of clinical operations (VPCO)on 06/17/26 at 11:40 am regarding education for vaccines for the sampled residents. VPCO stated, If you are not seeing it, I don't think we'll find it. Surveyor was provided with a facility policy entitled, Influenza Vaccination which read in part, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents annual immunization against influenza and providing vaccine education to staff including information about eligibility, timing, administration and monitoring. 4. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's (Center for Disease Control) current vaccine information statement relative to the influenza vaccination. 8. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal. Surveyor was provided with a facility policy entitled, Pneumococcal Vaccine (Series) which read in part, It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized .3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. 8. The resident's medical record shall include documentation that indicates at a minimum, the following: a. the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. The concern of not providing education related to immunizations and not offering immunizations was discussed with the director of nursing, regional director of clinical services, vice-president of clinical operations, and director of risk management on 06/17/26 at 1:10 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 4 of 19 residents, Resident's #1, #2, #7, and #22.The findings included: 1. For Resident #1 (R1), the facility failed to update the Comprehensive Care Plan to reflect changes regarding active infection and administration of supplemental oxygen. Diagnoses for R1 include dementia, chronic obstructive pulmonary disease (COPD), cerebral ischemia, and interstitial pulmonary disease. On the most recent Minimum Data Set (MDS) assessment, a quarterly assessment with an assessment reference date (ARD) of 3/28/2026, R1 scored a four out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. A care plan stating that R1 had pneumonia was developed for R1 on 1/19/2026. An additional care plan was created on 1/19/2026 stating that R1 has oxygen therapy. Both care plans contained an intervention to administer oxygen at two liters per minute via nasal cannula. Review of the clinical record for R1 revealed a physician's order to administer oxygen at two liters per minute via nasal cannula as needed to maintain oxygen saturation greater than 90 percent dated 1/11/2026. This order was discontinued on 1/25/2026. An additional physician's order was noted on 3/4/2026 for oxygen at three liters per minute via nasal cannula as needed to maintain oxygen saturation greater than 90 percent. This order was discontinued on 4/2/2026. There were no further orders for oxygen therapy noted in the clinical record. On 6/15/2026 during an initial walk through of the facility, there were no oxygen cannisters, condensers, or other oxygen supplies noted in R1's room. On 6/16/2026 R1 was observed in their room in the wheelchair. No oxygen was noted to be in use. R1 was observed again on 6/17/2026 in their wheelchair. No oxygen was noted to be in use. An interview was conducted with MDS coordinator on 6/17/2026 at 10:45 AM. MDS coordinator stated that care plans are reviewed quarterly, annually, and with any significant change(s). MDS coordinator stated that they will use diagnoses from hospital discharge summaries as well as History and Physical's when creating care plans. The care plans for R1 were reviewed with the MDS coordinator. MDS coordinator stated that the care plan for pneumonia and oxygen therapy should have been resolved. A facility policy stated Care Plan Revisions Upon Status Change demonstrated that care plans will be reviewed and revised as necessary when a resident experiences a status change and that the care plan will be updated with the new or modified interventions. The above information was presented to facility leadership at 2:15 PM on 6/17/2026. No further information was provided prior to exit. 2. For Resident #2 (R2) the facility failed to update the comprehensive care plan to reflect changes in R2's advanced directives. Diagnoses for R2 include Alzheimer's disease, dementia, bipolar disorder, hypertension, and surgical site infection. On the most recent Minimum Data Set (MDS) a quarterly assessment with an assessment reference date (ARD) of 4/13/2026, R2 scored a two out of 15 on the Brief Interview for Mental Status indicating that R2 has severe cognitive impairment. A care plan was created for R2 on 4/10/2025 stating that R2 was a full code. Review of the clinical record for R2 revealed an Advanced Directive dated 1/9/2026 stating that R2 was a Do Not Resuscitate (DNR). A corresponding physician order for DNR was noted with a most recent revision date of 5/8/2026. An interview was conducted with the social worker on 6/16/2026 at 3:58 PM. The social worker stated they were responsible for updating the care plans regarding advanced directives. The social worker stated that the care plan conference should have alerted them to change this care plan. Social worker confirmed that R2 had last had a care conference in March of 2026 which was during a transition period for social work which likely caused the change to be missed. The social worker stated that it is very important for the care plan to reflect the current advanced directive wishes of residents. A facility policy stated Care Plan Revisions Upon Status Change demonstrated that care plans will be reviewed and revised as necessary when a resident experiences a status change and that the care plan will be updated with the new or modified interventions. This information was presented to facility leadership on 6/16/2026 at 4:30 PM. No additional information was provided prior to exit. 3. The facility staff failed to review and revise Resident #7's comprehensive care plan (CCP) when their code status changed from a full code to a Do Not Resuscitate (DNR). Resident #7's diagnoses included surgical amputation, muscle weakness, cognitive communication deficit, myocardial infarction, and diabetes. Section C (cognitive patterns) of Resident #7's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/23/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #7 was severely impaired in cognitive skills for daily decision making. Resident #7's clinical record included the following: DNR Order form from the Virginia Department of Health dated 04/06/2026. DNR order dated 04/15/2026. Resident #7's comprehensive care plan (CCP) included the focus area Advanced Directives: Full Code, date initiated 02/24/2026. During an end of the day meeting on 06/16/2026 at 4:35 PM with the Administrator, Director of Risk Management, [NAME] President of Clinical Operations, Regional Director of Clinical Services, Regional Human Resource staff, and Director of Nursing the issue with Resident #7's CCP not being revised when their code status was updated was reviewed. On 06/17/2026, the facility staff provided the survey with a copy of their policy titled, Care Plan Revisions Upon Status Change effective date 12/01/2022. This policy read in part, The comprehensive care plan will be reviewed, and revised as necessary. Prior to the exit conference the facility staff provided the survey team with an updated CCP with a revision date of 06/16/2026. This CCP had been updated to reflect Resident #7's current DNR status. No additional information regarding this issue was provided to the survey team prior to the exit conference. 4. The facility staff failed to review and revise Resident #22's comprehensive care plan (CCP) when the anticoagulant medication Eliquis was discontinued. Resident #22's diagnoses included fracture of the left femur, bradycardia, atherosclerotic heart disease, and hypertension. Section C (cognitive patterns) of Resident #22's admission MDS assessment with an Assessment Reference Date (ARD) of 02/26/2026 included a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #22 was severely impaired in cognitive skills for daily decision making. Section N (medications) was coded to indicate Resident #22 was receiving an anticoagulant medication. The clinical record contained a provider's order dated 02/19/2026 for the anticoagulant medication Eliquis 2.5 mg 1 tablet twice a day for 42 days. This medication ended on 04/02/2026. Resident #22's CCP had not been revised when the medication had ended and still included the focus area anticoagulant therapy related to post surgical, date initiated 02/21/2026. Under interventions the CCP included avoid use of Aspirin. Resident #22 currently had an active order for Aspirin 81 mg in the morning that started when the Eliquis ended. Aspirin is classified as an antiplatelet medication. On 06/17/2026 at 10:30 AM, during an interview the MDS Coordinator stated she needed to revise the CCP. On 06/17/2026, the facility staff provided a copy of their policy titled, Care Plan Revisions Upon Status Change effective date 12/01/2022. This policy read in part, The comprehensive care plan will be reviewed, and revised as necessary. On 06/17/2026 at 1:10 PM, during a meeting with the Director of Nursing, Director of Risk Management, [NAME] President of Clinical Operations, and Regional Director of Clinical Services the issue with Resident #22's CCP not being reviewed and revised after the medication Eliquis had been discontinued was reviewed. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 3 of 19 residents, were free of significant medication errors, resident #4, #67, and #75. The findings included:1.For Resident #4 the facility staff failed to administer the medication levothyroxine on multiple occasions. Resident #4's clinical record listed diagnoses which included but not limited to hypothyroidism. Resident #4's most recent minimum data set with an assessment reference date of 06/02/26 assigned the resident a brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #4's comprehensive care plan was reviewed and contained a plan for . has hypothyroidism. Interventions for this care plan included Give thyroid replacement therapy as ordered . Resident #4's clinical record contained a physician's order summary which read in part, Levothyroxine Sodium Oral Tablet 50 MCG (Levothyroxine Sodium) give 1 tablet by mouth in the morning related to HYPTHYROIDISM, UNSPECIFIED. Resident #4's electronic medication administration records (eMAR) for the months of February 2026, March 2026, April 2026, and May 2026 were reviewed, and each contained an entry as above. The entry on the eMAR for February was blank on 02/08/26 and coded 9 on 02/28/26. The entry on the eMAR for March was coded 9 on 03/02/26, 03/04/26, 03/05/26, 03/30/26 and blank on 03/20/26. The entry on the eMAR for April was blank on 04/20/26, 04/29/26 and coded 9 on 04/23/26. The entry on the eMAR for May was coded 9 on 05/27/26. Chart code 9 is the equivalent of Other/See Nurse Notes. Resident #4's clinical record contained progress notes which read in part Effective Date: 02/28/2026 05:03. Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM, UNSPECIFIED, Effective Date: 03/02/2026 05:10 Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM< UNSPECIFIED. waiting on pharmacy, Effective Date: 03/04/2026 05:11. Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet in the morning related to HYPTHYROIDISM, UNSPECIFIED. waiting on pharmacy, Effective Date: 03/05/2026 05:06 Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM, UNSPECIFIED, Effective Date: 03/30/2026 04:38. Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM, UNSPECIFIED. waiting on pharmacy, Effective Date: 04/23/2026 05:02. Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM, UNSPECIFIED. waiting on pharmacy, and Effective Date: 05/27/2026 04:25. Note Text: Levothyroxine Sodium Oral Tablet 50 MCG. Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM, UNSPECIFIED. There are no corresponding notes for 02/08/26, 03/20/26, 04/20/26 or 04/29/26. Surveyor requested and was provided with a policy entitled, Preparation and General Guidelines which read in part, The facility may use automated dispensing machines (e.g., MEDBANK Pyxis, Omnicell, .) for the first dose and emergency medications, where permitted by regulation or law. Surveyor requested and was provided with a list of medications available in the facility Pyxis (automated medication dispensing machine). The medication levothyroxine 25 MCG was listed as available in the Pyxis. The concern on not ensuring Resident #4 was free of significant medication error was discussed with the administrator, director of nursing, regional director of clinical services, vice-president of clinical operations, director of risk management, and regional human resources manager on 06/16/26 at 4:35 pm. On 06/17/26 at 9:50 am, the director of nursing (DON) informed the survey team that education had been started with nursing staff regarding unavailable medications and use of the Pyxis. DON also stated that a list of medications available in the Pyxis was placed on each medication cart. No further information was provided prior to exit. 2. For Resident #67 the facility staff failed to administer the total doses of the antibiotic eye drops Resident #67's clinical record listed diagnoses which included but not limited to unspecified glaucoma. Resident #67's most recent minimum data set with an assessment reference date of 03/14/26 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #67's comprehensive care plan was reviewed and contained a plan for . has an eye infection, Conjunctivitis. Interventions for this plan included Give therapeutic ointments, drops as ordered by physician. Resident #67's clinical record contained a physician's order summary which read in part, Polymyxin B-Trimethoprim Solution 100000-0.1 UNIT/ML-%, Instill 1 drop in both eyes four times a day for conjunctivitis for 5 days-start date 05/06/2026. This indicates that the resident should receive a total of 20 doses. Resident #67's electronic medication administration record (eMAR) for the month of May 2020 was reviewed and contained an entry as above. This entry was coded 9 on 05/06/2026 at 4 pm and 9 pm. Chart code 9 is the equivalent of Other/See Nurse Note. The eMAR indicated the resident received a total of 18 doses, instead of 20 as ordered. Resident #67's progress notes were reviewed and contained notes which read in part, Effective Date: 05/06/2026 15:57 Note Text: Polymyxin B-Trimethoprim Solution 100000-0.1 UNIT/ML-%. Instill 1 drop in both eyes four times a day for conjunctivitis for 5 days (POLYTRIM). on ordered and Effective Date: 05/06/2026 20:55 Note Text: Polymyxin B-Trimethoprim Solution 10000-0.1 UNIT/ML-%. Instill 1 drop in both eyes four times a day for conjunctivitis for 5 Days (POLYTRIM). waiting on pharmacy none in pixis. The concern on not ensuring Resident #67 was free of significant medication error was discussed with the administrator, director of nursing, regional director of clinical services, vice-president of clinical operations, director of risk management, and regional human resources manager on 06/16/26 at 4:35 pm. On 06/17/26 at 9:50 am, the director of nursing (DON) informed the survey team that education had been started with nursing staff regarding unavailable medications and use of the Pyxis. DON also stated that a list of medications available in the Pyxis was placed on each medication cart. No further information was provided prior to exit. 3. For Resident #75 the facility staff failed to administer the medication phenytoin per the physician's order. Resident #75's clinical record listed diagnoses which included but not limited to generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus. Resident #75's most recent minimum data set with an assessment reference date of 03/06/26 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #75's comprehensive care plan was reviewed and contained a plan for . is LTC (long term care) she has Generalized Epilepsy . Resident #75's clinical record contained a physician's order summary which read in part, Phenytoin Sodium Extended Capsule 100 MG. Give 1 capsule by mouth three times a day for seizure disorder. Resident #75's electronic medication administration record for the month of April 2026 was reviewed and contained an entry as above. This entry was coded 9 on 04/22/26. Chart code 9 is equivalent to Other/See Nurse Note. Resident #75's progress notes were reviewed and contained a note which read in part, Effective Date: 04/22/2026 14:17 Note Text: Phenytoin Sodium Extended Capsule 100 MG. Give 1 capsule by mouth three times a day for seizure disorder. reorder. Surveyor requested and was provided with a policy entitled, Preparation and General Guidelines which read in part, The facility may use automated dispensing machines (e.g., MEDBANK Pyxis, Omnicell, .) for the first dose and emergency medications, where permitted by regulation or law. Surveyor requested and was provided with a list of medications available in the facility Pyxis (automated medication dispensing machine). The medication Phenytoin EX Cap 100 was listed as available in the Pyxis. The concern on not ensuring Resident #75 was free of significant medication error was discussed with the administrator, director of nursing, regional director of clinical services, vice-president of clinical operations, director of risk management, and regional human resources manager on 06/16/26 at 4:35 pm. On 06/17/26 at 9:50 am, the director of nursing (DON) informed the survey team that education had been started with nursing staff regarding unavailable medications and use of the Pyxis. DON also stated that a list of medications available in the Pyxis was placed on each medication cart. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, the facility staff failed to dispose of expired food in 2 of 2 facility pantries. The findings included:A facility policy entitled, Use and Storage of Food Brought in by Family or Visitors with a reviewed/revised date of 12/1/22 read in part, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Under the heading Policy Explanation and Compliance Guidelines the document read in part, 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. d. The facility will not be responsible for maintaining any reusable items. On 6/16/2026 at 10:59 AM in the 100-hall nourishment room refrigerator there was three boxes of Dairy Milk [NAME] with a best by date of 5/9/26. Each box was labeled with a resident name and room number. There was one 46-ounce box of prune juice with a sticker that read, discard 6/11. There was a container of yogurt with an expiration date of 6/11/26. There was a chafing pan with approximately 20 one half peanut butter and jelly sandwiches. Each sandwich had a sticker with a prep date of 5/8 and no discard date. The sandwiches were wrapped in plastic wrap and were hard to the touch. The Dining Services Manager was called to the room and interviewed. The Dining Services Manager stated, No, somebody wrote the wrong date on there, those were made and brought out on 6/8. When asked what date they should have been discarded with a prep date of 6/8 the Dining Services Manager stated, They should have been thrown out yesterday. On 6/16/26 at 11:13 AM the nourishment room on the 400/500 hall was observed. In the refrigerator had a prepackaged bag of mini cucumbers that did have a resident name on them but there was no visible expiration date. The cucumbers had white patches and were soft to the point of falling apart with light touch. The Dining Services Manager agreed that the cucumbers were bad. There were two plastic containers of food that were not labeled or dated and contained unidentifiable contents. Two fast food cups with only ice that were not labeled. The Dining Services Manager stated, The staff put their stuff in here to, so I don't always know what belongs to who. There was a large red cooler bag that was labeled with a resident name, all items were expired and are as follows; one container of Light and Fit yogurt with an expiration date of 10/14/25, one with an expiration date of 12/16/25, and one expired in September 2025. There was a total of 10 separate yogurt containers that were all expired and then another 4 pack that was also expired with a date of 12/17/25. The bottom of the bag was littered with food debris and an unknown sticky substance. On 6/17/26 at 1:00 PM the survey team met with the Administrator, Director of Nursing, [NAME] President of Clinical, Regional Director of Clinical Services and the Director of Risk Management. This concern was discussed with them at that time, No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide education for the COVID-19 vaccines for 2 of 5 residents (Residents #7 and #12) and failed to offer COVID-19 vaccine for 1 of 5 (Resident #7) sampled residents. The findings included: Five residents were chosen from the initial pool for review for COVID-19 vaccinations. Of these 5 residents, there was no evidence that Resident #7 had been offered a COVID-19 vaccine or that education was provided related to COVID-19 immunization. Resident #12 had refused the COVID-19 vaccination, and there was no evidence that education had been provided related to COVID-19 immunization. Surveyor spoke with vice-president of clinical operations (VPCO) on 06/17/26 at 11:40 am regarding education for COVID-19 immunization for Resident #7 and Resident #12. VPCO stated, If you are not seeing it, I don't think we'll find it. Surveyor requested and was provided with a facility policy entitled, Coronavirus Prevention and Response which read in part, 9. Vaccination Planning a. Residents will be assessed for Covid 19 immunization upon admission. Self-report of immunization will be accepted . b. Each resident will be offered a Covid 19 immunization unless itis medically contraindicated, or the resident has already been immunized. c. Prior to offering the Covid 19 immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization .f. The resident's medical record shall include documentation that indicates at a minimum, the following: The resident or resident's representative was provided education regarding the benefits and potential side effects of the Covid 19 immunization. b. The resident received the Covid 10 immunization or did not receive it due to medical contraindication or refusal. The concern of not providing education related to immunizations and not offering immunizations was discussed with the director of nursing, regional director of clinical services, vice-president of clinical operations, and director of risk management on 06/17/26 at 1:10 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to administer provider ordered medications for 1 of 19 residents, Resident #3. The findings included: The facility staff failed to administer Resident #3's provider ordered medication Pravachol on 05/22/2026. This medication was available in the back up medication supply at the facility (Pyxis).Resident #3's diagnoses included Alzheimer's disease, schizoaffective disorder, and aphasia.Section C (cognitive patterns) of Resident #3's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/03/2026 included a Brief Interview for Mental Status (BIMS) score of 1, indicating Resident #3 was severely impaired in cognitive skills for daily decision making.The clinical record included a provider order, originally dated 05/05/2025, for Pravachol 10 mg one tablet by mouth at bedtime for cholesterol. On 05/22/2026 this order was rewritten without any changes.Review of the Medication Administration Records (MARs) revealed that on 05/22/2026, nursing staff documented the code 9 for the Pravachol on the MARs for Other/See Nurses Notes.Corresponding nursing documentation read as follows, Pravachol Tablet 10 MG Give 1 tablet by mouth at bedtime for cholesterol waiting on pharmacy.A review of the backup medication supply list (Pyxis) confirmed that the Pravachol was available at the facility for administration. During an end of the day meeting on 06/16/2026 at 4:35 PM, with the Administrator, Director of Risk Management, [NAME] President of Clinical Operations, Regional Director of Clinical Services, Regional Human Resource staff, and Director of Nursing (DON) the failure to administer the medication as ordered on 05/22/2026 was reviewed.On 06/17/202t 6 9:04 AM, the DON stated that the nursing staff had been re-educated regarding medication availability. Additionally, a list of medications available in the Pyxis system was placed in the narcotic book on each medication cart.The facility policy titled, Preparation and General Guidelines read in part, .Automated dispensing machines (ADM) may be used by authorized facility staff to access first dose and emergency medications .No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, the facility staff failed to develop a comprehensive person-centered care plan for 1 of 19 residents, Resident #16. The findings inlcuded:A facility policy entitled, Comprehensive Care Plans with a reviewed/revised date of 12/1/22 read in part, It is the policy of this facility 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 are identified in the resident's comprehensive assessment. Under the heading Policy Explanation and Compliance Guidelines the document read in part, 2. The comprehensive care plan will be developed within 7 days after the comprehensive MDS (minimum data set) assessment. All care assessment areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. On page 2 of the document, 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. According to resident #16's demographic sheet, the facility admitted the resident on 12/7/23 with diagnoses that included cerebral palsy, muscle weakness, paraplegia and morbid (severe obesity). The quarterly MDS assessment with an assessment reference date of 5/20/26 assigned the resident a brief interview for mental status score of 15 indicating intact cognition. On 6/15/26 at 2:20 PM the comprehensive care plan was reviewed. There was no focus for activities included in the comprehensive person-centered care plan at that time. The CAA worksheet for the annual MDS assessment with an ARD of 2/3/26 was reviewed and indicated an activities focus would be included on the care plan. On 6/15/26 at 1:10 PM resident #16 was interviewed. They stated that no one from activities ever comes in the room. I listen to these audio books and I have my tablet, that's about it. When the resident was asked about attending out of room activities they stated, No, I'm not allowed to get up. They said it isn't safe and that the lift almost turned over so I stay in bed. I would love to get up and sit in the hall like I used to and go outside too. The resident denied wanting to participate in any structured group activities. On 6/16/26 at 8:40 AM the staff provided a copy of an activities care plan with a created date of 6/15/26. The Activities Director was interviewed on 6/16/26 at 10:00 AM. When asked about the activities care plan they stated, I don't know, I wasn't here yesterday. They went on to explain that the previous director had gotten behind, and she was still trying to catch up. On 6/17/26 at 1:00 PM the survey team met with the Administrator, Director of Nursing, Regional [NAME] President of Clinical, Regional Director of Clinical Services and Director of Risk Management. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication was safely stored for 1 of 19 residents, Resident #22. The findings included: Resident #22 was observed with a partially used tube of hydrocortisone in reach on their over the bed table, making the medication readily available. Resident #22's diagnoses included fracture of the left femur, bradycardia, atherosclerotic heart disease, and hypertension. Section C (cognitive patterns) of Resident #22's admission MDS assessment with an Assessment Reference Date (ARD) of 02/26/2026 included a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #22 was severely impaired in cognitive skills for daily decision making. On 06/15/2026 at 1:25 PM, during initial tour of the facility, the surveyor observed a partially used tube of Hydrocortisone on Resident #22's over the bed table. Review of the clinical record failed to identify a current provider order for Hydrocortisone. On 06/15/2026 at 3:50 PM, the Unit Manager removed the Hydrocortisone from Resident #22's room, reviewed the resident's medication orders, and confirmed that there was no current provider order for the medication. On 06/16/2026 at 4:35 PM, during an end of the day meeting with the Administrator, Director of Risk Management, [NAME] President of Clinical Operations, Regional Director of Clinical Services, Regional Human Resource staff, and Director of Nursing the issue with the Hydrocortisone being left at the resident's bedside and the resident not having an order for the Hydrocortisone was reviewed. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record facility, and facility document review, the facility staff failed to ensure medications were available for administration for 1 of 19 residents, Resident #67. The findings included:For Resident #67 the facility staff failed to ensure the medication Latanoprost was available for administration. Resident #67's clinical record listed diagnoses which included but not limited to unspecified glaucoma. Resident #67's most recent minimum data set with an assessment reference date of 03/14/26 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #67's comprehensive care plan was reviewed and contained a plan for . has impaired visual function r/t (related to) glaucoma. Interventions for this care plan included, administer eye gtts (drops) as ordered. Resident #67's clinical record contained a physician's order summary which read in part, Latanoprost Ophthalmic Solution 0.005 % (Latanoprost). Instill 1 drop in both eyes in the evening related to UNSPECIFIED GLAUCOMA. Resident #67's electronic medication administration record (eMAR) for the month of May 2026 was reviewed and contained an entry as above. This entry was coded 13 on 05/16/26 and 9 on 05/17/26. Chart coded 13 is equivalent to Partial Administration and chart coded 9 is equivalent to Other/See Nurse Notes. Resident #67 progress notes were reviewed and contained notes which read in part, Effective Date: 05/16/2026 19:04 Note Text: Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes in the evening related to UNSPECIFIED GLAUCOMA. Supply exhausted, awaiting pharmacy delivery and Effective Date: 05/17/2026 21:13. Note Text: Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes in the evening related to UNSPECIFIED GLAUCOMA. Surveyor requested and was provided with a list of medications available in the facility Pyxis (automated medication dispensing machine). The medication Latanoprost was not listed as available in the Pyxis. The concern on not ensuring Resident #67's medication was available for administration was discussed with the administrator, director of nursing, regional director of clinical services, vice-president of clinical operations, director of risk management, and regional human resources manager on 06/16/26 at 4:35 pm. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and failed to issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare Part A covered stay when Medicare benefit days had not been exhausted for 1 of 3 sampled residents, Resident #6. The findings include:The facility staff failed to provide Resident #6 with an SNF ABN and failed to provide the required two-day advance notice of benefits ending thereby limiting the resident and/or resident representative the opportunity to appeal the termination of Medicare covered services. Resident #6's diagnoses included encephalopathy, expressive language disorder, and muscle weakness. Section C (cognitive patterns) of Resident #6's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/06/2026 was coded 1/1/3, indicating impairment in both long- and short-term memory and severe impairment in cognitive skills for daily decision making. Resident #6's last covered day of Medicare Part A services was 03/03/2026. A NOMNC was issued and signed by the resident's representative on 03/02/26. The resident remained at the facility following the end of Medicare coverage. During an interview on 06/16/2026 at 11:00 AM, the Social Services Director acknowledged that Resident #6 did not receive an SNF ABN and had benefit days left. The Social Services Director stated that the facility has now implemented a process of issuing both a SNF ABN and NOMNC. The Administrator provided the surveyor with a copy of a document titled, Medicare Notices. This document read in part, NOMNC timing requirements Must be issued at least 2 calendar days before last covered day. On 06/16/2026 at 4:35 PM, during an end of the day meeting with the Administrator, Director of Risk Management, [NAME] President of Clinical Operations, Regional Director of Clinical Services, Regional Human Resource Staff, and Director of Nursing, the issue with Resident #6 and/or Resident Representative not receiving an SNF ABN and not being given two days to file an appeal was reviewed.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately completed for 2 of 19 residents, Resident #22 and #1. The findings included: 1. The facility staff failed to accurately code an admission minimum data set (MDS) assessment to indicate Resident #22 was receiving the antiplatelet medication, Aspirin. Resident #22's diagnoses included fracture of the left femur, bradycardia, atherosclerotic heart disease, and hypertension. Section C (cognitive patterns) of Resident #22's admission MDS assessment with an Assessment Reference Date (ARD) of 02/26/2026 included a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #22 was severely impaired in cognitive skills for daily decision making. Section N (medications) was not coded to indicate Resident #22 was receiving an antiplatelet medication. The clinical record contained a provider's order dated 02/20/2026 for Aspirin 81 mg, to be administered in the morning related to atherosclerotic heart disease. On 06/16/2026 at 3:35 PM, during an interview, the MDS Coordinator stated they had recently learned that Aspirin should be coded as an antiplatelet medication on the MDS assessment. On 06/16/2026 at 4:35 PM during an end of the day meeting with the Administrator, Director of Risk Management, [NAME] President of Clinical Operations, Regional Director of Clinical Services, Regional Human Resource staff, and Director of Nursing the failure to code Aspirin as an antiplatelet on the MDS assessment was reviewed. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #1 (R1) the facility failed to accurately code section I (active diagnoses) on the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2026. Diagnoses for R1 include dementia, chronic obstructive pulmonary disease (COPD), cerebral ischemia, and interstitial pulmonary disease. On the most recent MDS assessment, a quarterly assessment with an ARD of 3/28/2026, R1 scored a four out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of the clinical record demonstrated that a diagnosis of sepsis from streptococcus pneumoniae entered on 1/16/2026 upon readmission from the hospital. There was no indication of a later diagnosis of pneumonia or sepsis. Review of the quarterly MDS with an ARD of 3/28/26 indicated that R1 had an active diagnosis (within the last seven days of the ARD) of pneumonia and sepsis. An interview was conducted with MDS coordinator on 6/17/2026 at 10:45 AM. MDS coordinator stated that care plans are reviewed quarterly, annually, and with any significant change(s). MDS coordinator stated that they will use diagnoses from hospital discharge summaries as well as History and Physical's when completing the MDS. The MDS dated [DATE] was reviewed with the MDS coordinator. The MDS coordinator stated that the MDS should not have been marked for pneumonia and sepsis as these problems had been resolved and were not present in the seven day look back period for this assessment. The above information was presented to facility leadership on 6/17/2026 at 2:15 PM. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide Activities of Daily Living care for 1 of 19 residents, Resident's #11. The findings include: For Resident #11 the facility staff failed to ensure personal hygiene was maintained.Resident #11's clinical record listed diagnoses which include, but not limited to, type 2 diabetes mellitus with other skin complications, dysphagia, oropharyngeal phase muscle weakness (generalized), dysphagia following cerebral infraction.Resident #11's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/26 had a Staff Assessment of Mental Health Status coded as having both short- and long-term memory problems in section C, cognitive patterns. Section GG, functional abilities, indicated the resident is dependent with personal hygiene and shower/bathing activities of daily living (ADLs).Resident #11's comprehensive care plan was reviewed and contained a care plan for . 1. has an ADL self-care performance deficit r/t Confusion, Fatigue, Impaired balance, Limited Mobility. She will frequently refuse her showers. Interventions for this care plan include BATHING/SHOWERING . Avoid scrubbing & pat dry sensitive skin, Provide sponge bath when a full bath or shower cannot be tolerated, Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.2. Hospice, end stage diagnosis: TYPE 2 DIABETES MELLITUS WITH OTHER SKIN COMPLICATIONS: Interventions include Hospice CNA to supplement care as needed.Surveyor observed Resident #11 on 6/17/2026 at 9:30 AM, sitting in her wheelchair outside of her room. The resident was napping, had clean clothing with no major odors.An interview with certified nursing assistant (CNA) #6 on 6/17/2025 at 12:30 PM who reports having the same hall assignments most of the time. She conducts her ADL tasks as soon as she arrives for her morning shift. She tries to have everyone up, washed, toileted or changed and dressed before breakfast. She starts from the back hall and works her way to the front. There are generally two shower aides and residents rotate days based on shower times and chart. She reports the requirement is two showers or baths a week and try to accommodate the residents if they have any extra needs. Her ADL care is documented in the chart.An interview was completed with CNA #5 on 6/17/2025 at 12:35 PM, while assisting in the 500 hall. She reports there are supposed to be two shower aides scheduled, but some days the floor CNA may have to help. Showers and baths are expected to be twice a week. Surveyor reviewed Resident #11's ADL-bathing forms, located under the tasks section of the electronic clinical record. The bathing forms indicate that the resident went from having a bath on 5/26/26 to 6/4/26 when she received a shower. The resident went nine days without receiving a shower or bath.A phone interview with the director of policy for the hospice provider on 6/17/2026 at 2:24 PM, revealed that she had spoken with the clinical service manager who provided dates for showering/partial bathing that the CNA performed. She acknowledged that they dropped the ball on this and that it will be addressed.On 6/17/26 , a review of a facility policy titled, Activities of Daily Living (ADLs) Policy with a revision date of 12/01/2022, read in part, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Specified under the heading, Policy Explanation and Compliance Guidelines item #3 A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.The concern that the facility staff did not ensure personal hygiene was maintained for Resident #11 was discussed during a meeting with the administrator, director of nursing, and vice-president of clinical operations on 6/17/26 at 1:10 PM.No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to inspect a bed frame and mattress for one of twenty residents in the survey sample (Resident #43) and failed to implement a facility-wide program for inspecting bed frames, mattresses and bed rails for possible entrapment risks and bed/mattress compatibility for sixty-nine of sixty-nine beds currently in use by residents. The findings include: Resident #43 was admitted to the facility with diagnoses that included congestive heart failure, anxiety, dementia with behaviors, atrial fibrillation, mood disorder, deep tissue damage of right heel and depression. The MDS (minimum data set - cms assessment tool) dated 9/5/22 assessed Resident #43 with short and long-term memory problems and moderately impaired cognitive skills. Resident #43's clinical record documented a physician's order dated 8/31/22 for an air mattress to the bed for pressure ulcer treatment/prevention. On 10/26/22 at 10:21 a.m., accompanied by the licensed practical nurse unit manager (LPN #1), Resident #43's mattress was observed. Installed on the resident's bed was a low-air mattress that included bolsters along both sides of the mattress near the corners. LPN #1 stated this was a special mattress in use with the resident due to pressure ulcer treatment/prevention. On 10/26/22 at 2:11 p.m., the maintenance director (other staff #2) was interviewed about an inspection of Resident #43's bed with the low air loss mattress for compatibility and potential entrapment risks. The maintenance director replied that installed special mattresses and bed rails only when told to do so by therapy. The maintenance director stated that he performed monthly walk arounds but had nothing documented about bed and/or mattress inspections. The maintenance director stated that his inspections were focused on bed operation and condition. The survey team requested information from the maintenance director about a bed inspection program for the facility that included bed frames, mattress and/or bed rails for compatibility and potential entrapment risks. The maintenance director stated there was no formal program for checking side rails, mattresses or bed frames. The maintenance director stated only grab bars were used in the facility and these were not considered side rails. Concerning specialty air mattresses such as Resident #43's mattress, the maintenance director stated he installed the mattress and that's all. The maintenance director stated he did not keep up with which bed had what type of mattress and again stated there was no formal program for inspecting bed frames and/or mattresses. The maintenance director stated he had no inspection records or gap measurements related to potential entrapment zones. On 10/26/22 at 2:17 p.m., the facility's supply clerk (other staff #3) was interviewed about Resident #43's low-air mattress. The supply clerk stated Resident #43's mattress was a special alternating low-air pressure mattress ordered separately and installed on the existing bed frame. This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 10/26/22 at 4:15 p.m. On 10/27/22 at 8:00 a.m., the administrator presented a policy about bed maintenance and inspections. The administrator stated documented bed inspections had been done monthly and that the previous communication that the facility had no bed inspection program was inaccurate. The administrator presented a copy of their policy regarding bed maintenance and monthly inspection sheets. The facility's policy titled Bed Maintenance and Inspections (revised 9/1/21) documented, It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of possible entrapment .The Maintenance Director, or designee, is responsible for keeping records of bed inspections and maintenance .A list of bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each. The Maintenance Director shall be notified of any new equipment brought into the facility .When bed rails and mattresses are used and purchased separately from the bed frame, the facility will ensure that the bed rails, mattress, and bed frame are compatible .Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle according to the manufacturer's recommendations . Monthly inspection sheets from the facility's preventive maintenance system titled, Bed & Mattresses: Inspect Bed Rails were presented by the administrator. Each sheet documented the maintenance check procedure as, Inspect connectors on rails and tighten as necessary .Remove any burs or rough edges to prevent injury .Verify the function of the spring latch-knob assembly, if applicable. Ensure latch is free of dirt and/or foreign material .Ensure that the rails engage and lock as specified .Tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, etc. that are loose, show sign of wear or are missing . The monthly bed and mattress logbook sheets were reviewed for May 2022 through October 2022 and documented the following inspection results. 5/2/22 - no bed rails just grab bars 6/6/22 - no bed rail 7/4/22 - bed rails ok 8/3/22 - do not have bed rail we have grab bars 9/5/22 - no bed rails just grab bars 10/3/22 - do not have bed rail grab bars only The documented inspections included no list of bed frames, mattresses or bed rails for the facility. There was no documentation indicating which beds had rails and of any beds with specialty mattresses purchased separately from the bed frame. There was no documentation regarding the manufacturer of the bed frames, mattresses or bed rails. The inspection procedure and documented inspections made no reference to entrapment risks or bed frame/mattress compatibility. There was no documentation that Resident #43's bed/mattress was inspected for compatibility and safety when installed in August 2022. On 10/27/22 at 9:47 a.m., the maintenance director (other staff #2) was interviewed again by the survey team about bed/mattress/bed rail program for the facility. The maintenance director stated there was a program in the preventive maintenance system about bed. The maintenance director stated the interview provided yesterday stating there was no formal program was inaccurate because he did not feel well. The maintenance director stated the bed/mattress inspections were included in his preventive maintenance program. The maintenance director again stated the facility used only grab rails and he did not feel these were a safety problem. The maintenance director stated he did not have a list of bed frames, mattresses, beds with rails or bed frames with specialty mattresses. The maintenance director stated his monthly sheets documented that beds were checked but there was nothing documented by bed number or room number. The maintenance director stated he had no documentation that Resident #43's bed frame and air mattress were checked for compatibility when installed in August 2022. The maintenance director stated he had no documentation of any gap measurements for beds with rails as the facility only used grab bars. These findings were reviewed with the administrator, director of nursing and regional director of clinical services again on 10/27/22 at 11:55 a.m. No additional information was presented to the survey team prior to exiting at 12:15pm.

Based on observations, staff interview, record review and facility document review, the facility staff failed to properly place a catheter drainage bag below the bladder for one of 20 residents in the survey sample. Resident #31's catheter drainage bag was observed improperly positioned above the bladder level during the survey. The findings include: Resident #31 was admitted to the facility with diagnoses that included neuromuscular dysfunction of the bladder, contractures of the right hand, left and right knee, depression, hypothyroidism, osteoporosis, sacral pressure wound, and multiple sclerosis. The most recent MDS (minimum data set -cms assessment tool) dated 8/24/22 was a Quarterly, which assessed Resident #31 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating cognitively intact for daily decision making. Under Section H - Bladder and Bowel, the MDS assessed Resident #31 as having a catheter and a colostomy. Resident #31's clinical record was reviewed, which included physician's orders for the care and maintenance of Resident #31's suprapubic catheter. The Comprehensive Care Plans included a focus area for the care and maintenance of suprapubic catheter, with Goals that included: (Resident #31) will be/remain free from catheter-related trauma through review date Interventions included .check tubing for kinks Position catheter bag and tubing below the level of the bladder and away from the entrance room door . On 10/25/2022 at 1:50 p.m., Resident #31 was observed sitting in an electric wheelchair, in the facility's dayroom Although covered in a privacy bag, Resident #31's catheter drainage bag was positioned above the bladder, hooked onto the right upper side of the chair. Urine was observed in the tubing, which wound under the right arm of the electric wheelchair, towards the resident. On 10/26/2022 at 12:11 p.m., Resident #31 was again observed sitting in the electric wheelchair, eating lunch in the facility's dining room. The catheter drainage bag was observed in a privacy bag and positioned above the resident's bladder and attached onto the back of the electric wheelchair. The catheter tubing was observed winding under the right arm of the electric wheelchair. On 10/26/2022 at 3:12 p.m., a third observation of Resident #31 sitting in her electric wheelchair, while reading in her room. Again the catheter drainage bag was observed in a privacy bag and positioned above the resident's bladder, but attached to the back of the wheelchair. The catheter tubing remained winding under the right arm of the electric wheelchair. Resident #31 was asked if she had experienced any discomfort or problems with the catheter. Resident #31 stated, No, I've had this for quite sometime now. The girls know how take care of me. On 10/26/2022 at 3:20 p.m., along with the unit manager (LPN #1), Resident #31's catheter draining bag was observed in the same position, as last described. Upon observing , LPN #1 stated, Oh no, this is wrong! That bag is too high! When asked how was a catheter drainage bag supposed to be positioned, LPN #1 stated the catheter drainage bag was supposed to be positioned below the resident's bladder. LPN #1 explained that the positioning of the built-in hooks on the new electric wheelchair made it difficult to properly position the catheter drainage bag. LPN #1 added, I guess the staff were trying to be creative, but this bag is too high and the tubing is snaking under the chair arm. LPN #1 was asked if nurses and CNAs were trained and aware of the proper positioning of the drainage bag. LPN #1 replied, Yes, it's on the Kardex. So I know the CNAs know and I believe it is in our policy. LPN #1 was asked to provide a copy of the Kardex and policy for review. A review of Resident #31's Kardex (individualized care guide) documented the following under Bladder/Bowel, .Position catheter bag and tubing below the level of the bladder and away from the entrance room door The policy titled Catheter Care, Urinary (Revised September 2014) documented the following: .Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder On 10/26/2022 at 4:13 p.m., during a meeting with the administrator, director of nursing (DON) and corporate consultants the above findings were discussed. No additional information was received by the survey team prior to exit on 10/27/2022 at 12:15 p.m.

Based on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for two (Resident # 64 & #43) of twenty residents in the survey sample. Resident #64 was administered artificial tears solution instead of the physician ordered medicated eye drops (Refresh Optive solution). The medical devices (protective booties) were not applied to Resident #43's feet, as ordered by the physician. The findings include: 1. Facility staff failed to administer medication as ordered by the physician. Resident #64 was admitted to the facility with diagnoses that included cerebral infarction, hypertension, dry eyes, anxiety and seizures. The MDS (minimum data set - cms assessment tool) dated 10/6/22 assessed Resident #64 as being cognitively intact for daily decision making. A medication pass observation was conducted on 10/26/22 at 7:54 a.m. with licensed practical nurse (LPN) #3, administering medications to Resident #64. Among the medications administered was artificial tears labled 0.2%-0.2%-1% (glycerin-hypromellose-PEG 400), of which two drops were instilled in each eye. Resident #64's clinical record documented a physician's order dated 8/26/22 for Refresh Optive solution 0.5-0.9% (carboxymethylcellul-glycerin) with instructions to instill two drops in each eye four times per day for dry eyes. There was no order for the artificial tears that were administered during the medication pass observation. Neither was artificial tears listed on the MAR (medication administration record). On 10/26/22 at 8:35 a.m., LPN #3 was interviewed about the eye drops she had administered earlier to Resident #64's. When questioned about what eye drops were ordered by the physician, LPN #3 reviewed the orders and stated, The order says Optive. When questioned if the eye drops were interchangeable, LPN #3 stated that the Refresh Optive drops and artificial tears were not the same product. When questioned why had she administered the artificial tears, LPN #3 stated that eye drops were house stock items and the artificial tears were the only drops in the medication cart. On 10/26/22 at 10:16 a.m., the director of nursing (DON) was interviewed about Resident #64's eye drops. The DON stated the order should have been clarified and the prescription for Refresh Optive drops sent to the pharmacy. The DON stated the nurse administered the house stock artificial tears instead of the ordered Refresh Optive drops. The facility's policy titled Medication Reconciliation (revised 9/1/21) documented that medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay . The policy documented under daily processes, .Verify medication labels match physician orders and consider 'rights' of medication administration each time a medication is given . This finding was reviewed with the administrator, DON and regional director of clinical services during a meeting on 10/26/22 at 4:15 p.m. No additional information was presented to the survey team prior to exiting the facility on 10/27/22 at 12:15pm. 2. The facility staff failed to implement interventions for care and prevention of pressure ulcers, which were ordered for Resident #43. On 10/25/22 at 2:41 p.m., Resident #43 was observed seated in a reclining chair in her room. The resident had slipper socks on both feet. Resident #43 was observed again on 10/25/22 at 3:30 p.m. and on 10/26/22 at 10:00 a.m. seated in the reclining chair with slipper socks on both feet. During each of these observations, Resident #43's feet were elevated with heels resting directly on the footrests of the reclined chair, with no protective booties in use. On 10/26/22 at 10:02 a.m., Resident #43 was observed still seated in the reclined chair without protective booties in use, but was then accompanied by certified nurses' aide (CNA) #1. Interviewed about the protective booties, CNA #1 stated that she sent the booties to the laundry that morning (10/26/22) because they were dirty. CNA #1 was observed searching the room, but did not locate another pair of protective booties. On 10/26/22 at 10:26 a.m., the licensed practical nurse (LPN #3) caring for Resident #43 was interviewed. LPN #3 stated that the resident had a dressing to a pressure ulcer on the right heel. LPN #3 stated that the protective booties were soiled yesterday (10/25/22) and were sent to laundry for cleaning. Questioned further, LPN #3 responded that there was not another pair of booties to put on the resident, adding that she was not sure if the resident had a spare pair of booties. On 10/26/22 at 10:30 a.m., LPN #3 was accompanied to observe Resident #43's right heel pressure ulcer. The resident had a circular pressure ulcer on the right heel approximately the size of a 50-cent piece. The skin over the wound was dry, scaling with no surrounding redness or signs of infection. The clinical record documented that Resident #43 received daily treatment for an unstageable pressure ulcer on the right heel. A physician's order dated 8/31/22 documented, Maintain heel boots to bilat [bilateral] heels every shift. Last revised on 10/18/22, the Comprehensive Care Plan (CCP) documented that the Resident #43 had a right heel pressure ulcer, with interventions to heal and prevent ulcers, which included, .Administer treatments as ordered and monitor for effectiveness . The clinical record also documented that Resident #43 was admitted to the facility with diagnoses that included congestive heart failure, anxiety, dementia with behaviors, atrial fibrillation, mood disorder, deep tissue damage of right heel and depression. The MDS (Minimum Data Set - CMS assessment tool) dated 9/5/22 assessed Resident #43 with short and long-term memory problems, as well as moderately impaired cognitive skills. On 10/26/22 at 2:39 p.m., the unit manager (LPN #1) was interviewed about Resident #43 not having the ordered medical devices in place. LPN #1 stated that the booties were supposed to be on the resident's feet at all times for protection and prevention of ulcers. LPN #1 stated that if the booties were soiled, staff should have obtained another pair. LPN #1 added that additional booties were available and that the resident .should not have gone without . [the protective boots]. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as, localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device .The injury occurs as a result of intense and/or prolonged pressure . These findings were reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 10/26/22 at 4:15 p.m. No additional information was provided to the survey team prior to exit at 12:15pm on 10/27/22.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure a functioning call light system for two of 19 residents in the survey sample, Residents #12 and #35. The call light system for Residents #12 and #35 had been out of service for approximately three weeks. The findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses that included depression, dysphagia, flaccid left-side [CONDITION(S)], hypertension, [CONDITION(S)], cerebral infarction and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #35 as cognitively intact. Resident #12 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, history of [CONDITION(S)], cerebral infarction, hypertension, [CONDITION(S)] and dementia. The minimum data set (MDS) dated [DATE] assessed Resident #12 with moderately impaired cognitive skills. On 3/2/21 at 2:28 p.m., Resident #35 was interviewed about quality of care and life in the facility. When asked about her call light, Resident #34 stated her call light did not work and had been broken for about three weeks. Resident #35 stated when the call button was pushed, the light on the wall came on but the light in the hallway did not work. Resident #35 stated there was no buzzer or sound when the light was activated and she was not sure if the light was working at the nursing desk. Resident #35 stated staff members were aware the call light was not working because the shop worked on the light but did not fix it. Resident #35 was not sure when the light was going to be fixed. Resident #35 stated nursing gave her a small hand bell to ring in place of the corded call light. There was a small hand bell observed on the resident's bed table. On 3/2/21 at 2:33 p.m., Resident #35 was asked to demonstrate her corded call light. When Resident #35 pushed the call button, the light on the wall cover came on but the light in the hallway remained off. There was no sound associated with the call bell. On 3/2/21 at 2:42 a.m., Resident #35's roommate (Resident #12) was observed in bed. A corded call light button was positioned on her bed covers. There was no hand bell on the resident's bedside table or visible near the resident. Resident #12 was interviewed at this time about her call light. Resident #12 stated the call light worked on the wall but not in the hall. Resident #12 stated she did not have a hand bell. Resident #12 was asked to press her call button. Upon pressing the button, the wall light came on but the light indicator in the hall did not work. On 3/2/21 at 2:45 p.m., the licensed practical nurse (LPN #5) caring for Residents #12 and #35 was interviewed about the dysfunctional call light. LPN #5 stated she was aware the call light did not work and stated she knew Resident #35 was given a hand bell. LPN #5 stated she was not sure if Resident #12 had a hand bell. LPN #5 stated there was a call light display box at the nursing station that identified rooms with activated call lights. LPN #5 stated she was not sure if call lights for Residents #12 and #35 worked on the display box. LPN #5 stated she thought the call lights had been out of service for approximately three weeks. On 3/2/21 at 2:47 p.m., LPN #5 activated call lights for Resident #12 and #35 from their room. The wall light came on with each activation but there was no light on the hall indicator or on the display box at the nursing station. On 3/2/21 at 2:50 p.m., the director of nursing (DON) was interviewed about out of service call lights for Residents #12 and #35. The DON stated there was an electrical issue with the lights and they had been out of service for less than a month. The DON stated both the residents were provided a manual hand bell for use in place of the call light system. On 3/2/21 at 2:55 p.m., with the resident's permission, LPN #5 looked on and in Resident #12's bedside table, dresser drawers and the resident's closet. LPN #5 stated she did not find a manual bell accessible to Resident #12. On 3/3/21 at 8:41 a.m., the unit manager (LPN #3) was interviewed about the out of service call lights for Residents #12 and #35. LPN #3 stated she found out about the broken call lights last week. LPN #3 stated they were waiting for a vendor to come fix the call lights. LPN #3 stated she thought both the residents had manual hand bells to use in place of the call system. On 3/3/21 at 10:40 a.m., the maintenance director (other staff #3) was interviewed about the broken call lights for Resident #12 and #35. The maintenance director stated that approximately three weeks ago, a CNA (certified nurses' aide) told his assistant that the call lights for Residents #12 and #35 were not working. The maintenance director stated he was unable to fix the problem and contacted an outside electrical vendor. The maintenance director stated the original vendor was scheduled to come within a week and then postponed and referred him to another vendor. The maintenance director stated this vendor refused to come to the nursing facility due to COVID-19 and he had a hard time finding an electrical vendor to fix the call light. When asked when the work order originated for the call light repair, the maintenance director stated the dysfunctional call light was not entered into the facility's work order system but had been only communicated verbally to his staff. The maintenance director did not have a vendor scheduled for the repair at the time of this interview. This finding was reviewed with the administrator and director of nursing during a meeting on 3/3/21 at 11:30 a.m.

Based on staff interview and clinical record review, the facility staff failed to ensure a Level I PASRR (preadmission screening and resident review) was completed upon admission for two of 19 residents in the survey sample, Resident #25 and Resident #29. Findings include: 1. Resident #25 was admitted to the facility on [DATE]. The most current readmission was on 01/18/21. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with modified independence in daily decision making skills. In Section A1500. Preadmission Screening and Resident Review, it was documented that the resident had a serious mental illness. In Section A1510. Level II Preadmission Screening, it was documented that the resident had a serious mental illness and an intellectual disability. On 03/03/21 during Resident #25's clinical record review, a Level I PASRR was found. The Level 1 PASRR was dated 01/10/2019. The level 1 documented Resident #25 did not have a serious mental illness, but also documented that the resident did have a serious mental disorder that was diagnosable under the DSM (Diagnostic and Statistical Manual of Mental Disorders). On 03/03/21 at 1:55 PM, the SW (social worker) was interviewed regarding Resident #25's Level 1 PASRR. The SW stated that she did not completed the PASRR Level 1 for Resident #25 and that she has worked at the facility since December of 2020. The SW stated that Resident #25 does have a serious mental disorder and was not sure why the Level 1 PASRR was completed incorrectly. The SW stated, I don't know why it was completed on the date it was (as the resident was not out of the facility and did not have a significant change at that time) or why it completed the way it was. The SW stated, That isn't correct and stated that the Level 1 PASRR was contradicting itself. The SW stated she would find out what she could. On 03/03/21 at 2:40 PM, the SW returned with information regarding Resident #25. The SW stated that the resident was admitted on [DATE] and went out to the hospital on [DATE] and returned on 01/18/21. The SW stated that Resident #25 had not been out of the facility any other time since admission. The SW stated that she reviewed the resident's records and contacted the resident's RP (responsible party) and stated that Resident #25 has always had a mental illness. The SW stated that she did not know why a Level 1 wasn't done on her original admission and stated that Level II PASRR should have been completed. The SW that there was no other Level 1 found and that Resident #25 did not have a Level II. The administrator, DON (director of nursing) and corporate staff were made aware on 03/04/21 at approximately 10:40 AM. No further information and/or documentation was provided prior to the exit conference on 03/04/21 to explain why Resident #25 did not have a Level 1 PASRR on admission to the facility. 2. Resident #29 was admitted to the facility on [DATE]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment review date) of 1/12/2021. Resident #29 was assessed with [REDACTED]. [DIAGNOSES REDACTED]. A review of Resident #29's most recent MDS documented that a PASRR had been completed. On 3/3/2020, Resident #29's clinical record review was reviewed, and did not include a preadmission screening (PASRR). On 3/3/21 at 1:30 P.M. the Social Worker (SW) was asked to present evidence that a PASRR was completed for Resident #29 at the time of admission. On 3/4/21 at 8:15 A.M., the SW returned and stated she was unable to locate a PASRR for Resident #29. When asked why a PASRR had not been completed for Resident #29, the SW stated it makes no sense why a Pre-admission screening wasn't done, and that one should have been done because of the [MEDICAL CONDITION] diagnosis. These findings were discussed with the Administrator and DON during a meeting held on 3/4/2021 at 10:30 A.M. No other information was provided prior to exit conference on 3/4/2021.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS regarding PASRR (preadmission screening and resident review) status for one of 19 residents in the survey, Resident #25. Findings include: Resident #25 was admitted to the facility on [DATE]. The most current readmission was on 01/18/21. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with modified independence in daily decision making skills. In Section A1500. Preadmission Screening and Resident Review, it was documented, YES that the resident had a serious mental illness and/or intellectual disability and to continue to Section A1510. for the Level II PASRR. In Section A1510. Level II Preadmission Screening and Resident Review (PASRR) Condition, it was documented that the resident had a serious mental illness and an intellectual disability. On 03/03/21 during Resident #25's clinical record review, a Level I PASRR was found. The Level 1 PASRR was dated 01/10/2019. The level 1 documented that Resident #25 did not have a serious mental illness, but also documented that the resident had a major mental illness diagnosable under the DSM (Diagnostic and Statistical Manual of Mental Disorders). On 03/03/21 at 1:55 PM, the SW (social worker) was interviewed regarding Resident #25's Level 1 PASRR. The SW stated that she did not complete the PASRR for Resident #25, but stated that the resident does have a serious mental disorder. The SW was asked if a Level II had been completed on Resident #25 as indicated on the MDS. The SW stated that she did have a PASRR Level II for Resident #25. On 03/03/21 at 2:40 PM, the SW stated that she reviewed the resident's records and contacted the resident's RP (responsible party) and stated that the resident has always had a mental illness. The SW was asked if this resident could have used a Level II PASRR. The SW stated, Yes. On 03/04/21 at 9:00 AM, RN (Registered Nurse) #3 (corporate MDS) was interviewed regarding the above significant change assessment for Resident #25 concerning the PASRR. RN #3 stated that she signed off that the MDS was completed on 02/28/21, but stated that LPN (licensed practical nurse) #7 (a nurse from a sister facility) was the one who actually completed that section of the MDS for Resident #25. RN # 3 stated that this was an MDS error and could not provide any additional information. The administrator, DON (director of nursing) and corporate staff were made aware on 03/04/21 at approximately 10:40 AM. No further information and/or documentation was provided prior to the exit conference on 03/04/21 to evidence that this MDS assessment was an accurate assessment for Resident #25.

Based on observation, resident interview, and staff interview, the facility failed to ensure assistive devices were in good repair for one of 19 residents in the survey sample, Resident #7. Resident #7's wheelchair arm pad was ripped and had jagged edges. The Findings Include: Resident #7 was admitted to the facility on [DATE]. Diagnoses for Resident #4 included: [CONDITION(S)], urine retention with catheter, contractors, and neuromuscular dysfunction of bladder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/19/20. Resident #7 was assessed with a cognitive score of 15 indicating cognitively intact. On 03/02/21 at 11:17 AM, Resident #7 was interviewed. During the interview Resident #7's wheelchair armrest was observed torn with jagged edges. Resident #7 was asked if that bothered him or irritated his skin. Resident #7 stated that it does scratch his forearm some but has not caused any abrasions. Resident #7 then lifted his right arm which didn't indicate any skin tears. On 03/03/21 at 2:50 PM, the maintenance director (other staff, OS #3) was interviewed. OS #3 stated that he had not been made aware that the armrest of Resident #7's wheelchair was torn. OS #3 said that the facility had plenty of replacement parts and he would repair it. On 03/03/21 at 3:00 PM, licensed practical nurse (LPN #4) observed Resident 7's torn wheelchair armrest and said that it should be replaced because of potential for skin tears. LPN #4 said that anyone could put in a work order for maintenance for repairs, and staff on night shift should be assessing wheelchairs when cleaning them. On 03/04/21 at 10:30 AM, the above finding was brought to the attention of the administrator and director of nursing. No other information was provided prior to exist conference on 3/4/20.

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensue one of 19 residents was free from significant medication errors, Resident #16. The facility staff did not properly identify Resident #16 before administering fourteen unprescribed medications to him, which resulted in harm. Resident #16 was administered another resident's medications in error on June 10, 2016. The following erroneous medications were administered PO (by mouth) to Resident #16: [MEDICATION NAME] 400 mg (milligrams), Dexilant 60 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] HCL ([MEDICATION NAME]) 10 mg, Aspirin 81 mg, Quetiapine [MEDICATION NAME] 75 mg, one Thera vitamin tablet, Lispril 2.5 mg, Magnesium Oxide 500 mg, [MEDICATION NAME] HCL 1000 mg, Oyster shell calcium plus Vitamin D 250-125, [MEDICATION NAME] 17 gm (grams) mixed with 8 ounces of fluid, and Pro-stat s/f (sugar free) Wild Cherry (flavor) 30 ml (milliliters); also administered were Artificial Tears 1 drop into each eye. These medications were in addition to Resident #16's regularly scheduled medications of [MEDICATION NAME] 200 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 5 mg that had already been administered to him that morning (06/10/2016). Resident #16 became increasingly lethargic throughout the day with decreased blood pressure, decreased responsiveness and decreased respirations. Resident #16 was sent to the emergency roiagnom on the evening of June 10, 2016 and was admitted to the hospital due to accidental drug ingestion. Resident #16 was hospitalized for [REDACTED]. Findings were: Resident #16 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. The yearly MDS (minimum data set) with an assessment reference date of 05/25/2016, assessed Resident #16 as having a cognitive summary score of 12, indicating moderate impairment with his cognitive status. On 03/29/2017 at approximately 8:00 a.m., all information pertaining to the incident on 06/10/2016 with Resident # 16 was requested from the administrator. At approximately 8:15 a.m., the administrator presented a binder containing a plan of correction developed by the facility, as well as a folder containing all information related to the Facility Reported Incident. Review of the information revealed that newly licensed (05/12/2016) LPN (licensed practical nurse) # 8 was hired by the facility on 06/08/2010. Her account of the incident included the following information: While administering morning medication, I, (LPN #8's name) drew up all morning medications for (Resident name). Went to (room on the 200 hall where the intended resident resided) and a gentleman (Resident #16) was in the bathroom. I asked twice are you (Intended resident's name) and he said yes. I told him I had his medication and administered it to the gentleman (Resident #16). This happened at 8:30 am (sic). At 8:55 am (sic) another gentleman came to the medication cart and asked if I had any medicine for him to take. I asked him his name and he identified himself as (resident's name who the medications were intended for) in room (room number on 200 hall). I immediately stopped my medication pass to find my orienting nurse to tell her my concern of giving (Resident name) medication to the wrong resident. She and I walked the facility to identify the resident I gave (intended resident) medications to . Further review of the information showed that LPN #9 who was orienting LPN #8 was not with her at the time of the medication error. Also observed in the facility information was a Personnel Consultation conducted with LPN #9 regarding the orientation process. The subject content was: On the morning of 6-10-16 you had a new nurse orienting with you on the 100 hall. You were nor present with nurse when she made a significant med error. You are always to remain with orienting staff during a med pass unless they have been deemed competent in doing this independently. Once they have been deemed competent I will instruct the orienting nurse of this. Had you been at the nurses side, the med error would not have occurred. The consultation was presented by the Staff Development Coordinator, LPN #1. LPN #8 and LPN #9 were no longer employed at the facility and were not available for interview. A timeline of events developed and presented by the facility was reviewed. The following is a summary of the timeline: The physician was notified of the error at 9:00 a.m. and orders were). given to obtain vital signs every hour for 24 hours and to provide the MD on call with updates. Oxygen was also started at 2 liters via nasal cannula. Vital signs for Resident #16 were: BP (blood pressure): 92/50; Pulse: 60; Respirations: 16. Resident #16 was closely monitored 1:1 at the nursing station by staff. A message was left with the RP (responsible party). At 10:00 a.m., Resident #16's BP was 88/48, Pulse 60, respirations were 24. Resident #16 was lethargic, but aroused by verbal stimuli. Oxygen sats were 77% on 2 liters of oxygen. Resident #16 was mouth breathing. He was placed on a face mask and his oxygen sats increased to 92%. At 11:00 a.m., BP was 90/60, pulse 56, respirations 16 and oxygen sats were 92%. Blood sugar was 112. The physician was updated on the resident's progress. At 11:39 a.m., an IV was started of .5 Normal Saline at 100 cc/hr for one liter due to Resident #16's low blood pressure. Facility staff continued to monitor Resident #16, updating the physician and attempting to contact the RP. By 3:00 p.m., Resident #16 was becoming more difficult to arouse. At 5:15 p.m. Resident #16's respirations were becoming shallow and he had a non-responsive episode. The physician was notified and an order was obtained to send the resident to the emergency room . Vital signs at that time were BP 111/66, pulse: 79, Oxygen saturation was 95 % on 2 liters of oxygen. The clinical record was reviewed. Nurse's notes and physician orders [REDACTED]. The discharge summary from the local hospital was reviewed and included the following: Discharge [DIAGNOSES REDACTED]. Hospital Course: The gentleman (Resident #16) was admitted to the hospital in the lethargic state with acute [MEDICAL CONDITION] and dehydration. Apparently he was accidentally given another patients (sic) medications including sedatives and [MEDICATION NAME] and [MEDICATION NAME] and [MEDICATION NAME]. We found him to be in acute kidney injury that improved with gentle IV fluids. We gave him his fluids gently because he has a history of [MEDICAL CONDITION] and although he did not have a frank [MEDICAL CONDITION] in house, an echocardiogram did show evidence of a low ejection fraction at 45%. He does have a known history of [MEDICAL CONDITION]/defibrillator/[MEDICAL CONDITION]. He also has a history of [MEDICAL CONDITION] and a distant history of stroke . The plan of correction created by the facility was reviewed. The plan of correction titled (Name of Facility) ALLEGATION OF COMPLIANCE WITH RESIDENTS AT RISK FOR MEDICATION ERRORS 6/10/2016 included the following: Resident: (Initials of Resident #16) received medications that was (sic) subscribed for another resident. Immediate Actions taken for the resident identified as receiving the incorrect medications: [REDACTED]. The physician was notified requested V/S (vital signs) and hourly updates. At 10am (sic) the physician was given an update by the charge nurse and orders were received for IV fluids 1000 cc at 80 cc per hour and to continue to monitor with hourly updates. The resident was lethargic but aroused on verbal command. (See notebook for timeliness and process for assessment, orders and treatment for [REDACTED]. At 5:30 p.m. the physician was notified of the resident continuing to be lethargic and order was received to transport the resident to the hospital for evaluation. Nurse #1 (LPN #8) received one to one education from the DON (Director of Nursing) on the medication administration policy and identifying residents prior to giving them medication by at least 2 identifiers-name band, photo or second person. The nurse was also suspended pending an investigation. If the nurse returns to duty she will receive to (sic) orientation with direct oversight with a second nurse until competency in medication administration is demonstrated Identifying other residents at risk: 1. All residents will be reviewed to assure they have identifiers in place such as a photo and name bracelet, by DON and charge nurse by 6/11/2016 2. Residents identified as needing photo or bracelet will have replacements made by medical records or designee. Residents that refuse to wear the bracelet or is known to remove them will have it noted in the medication book to have the second person to confirm the resident's identity by 6/11/2016 3. Care plans will be reviewed and updated for residents that remove the name bracelet by 6/11/2016. System changes: 1. The Director of Nursing or designee will do education with all licensed nursing on medication administration starting 6/10/2016. After the initial nurses on duty are trained the remaining licensed nurses will receive the education prior to starting a medication pass. The education will be ongoing until all current licensed nurses receive the education prior to doing a medication pass and will be completed by 6/17/2016. All newly licensed nurses will receive the medication administration education during orientation and prior to passing medications. 2. Medication Pass Observations will be started 6/10/2016 by the DON and unit managers. Medication Pass Observations will be completed daily by the DON/designee daily for seven days than (sic) three times per for (sic) two weeks then two times per week for two weeks then weekly for three weeks then monthly and any concern with the observation will be documented and the nurse educated as indicated at the time of the observation. 3. Skills checklist using the Medication Pass Observation will be completed on all licensed nursing staff by 6/17/2016. 4. The residents will be audited weekly for four weeks then every other week for four weeks then monthly by the medical record {sic) to assure photos and name bracelets are in place. The DON or Assistant Director of Nursing will be notified of residents as identified as removing bracelets in order to place notices to nurses to use a different identifier if bracelet is not on the resident. 5. Develop and implement a nurse mentor program for newly hired licensed nurses. Nurse Mentors will be selected using the mentor selection rating system. The SD (staff developer) and Unit will develop a training notebook with the outline for the selected nurse mentors education by 6/17/2016. 6. All newly hired nurses on their first day after general orientation will attend orientation with the SDC (staff development coordinator) or designee for clinical training on their responsibilities in the roles they are going (sic) assuming. The new nurses will be assigned a designated mentor on their first day of duty and will work with the mentor during their first few days of employment. New nurses, who are working their first two days of employment, should not be in the floor without their mentor. Monitoring of Process: 1. Interdisciplinary team consisting of the Director of Nursing, Unit Mangers, Assistant Director of Nursing and the Administrator meeting will be conducted on 6/13/2016 to review that residents identifiers are in place, the progress of the medication administration education of the licensed nurses and the outcomes of the Medication Pass Observations. 2. The DON will be responsible for oversight and ongoing compliance. 3. Results of the Medication Pass Observations will be reviewed at the facility Quality Assurance and Performance Improvement committee for further recommendations by the Director of Nursing. 4. Results of the medical record audits will be reported to the facility Quality Assurance and Performance Improvement Committee for review and further recommendations. 5. The DON/designee will audit the Licensed Nursing Staff Orientation checklist for completion on all newly hired nurses monthly and report her findings to the facility Quality Assurance and Performance Improvement Committee for review and further recommendations. 6. The facility Quality Assurance and Performance Improvement committee consists of the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, rehab director, activities, social services, dietary, Medical Director and maintenance director. A copy if the facility policy and procedure regarding medication administration was requested and obtained. The policy titled, Medication Administration and Medication Room, Storage, Security was obtained. The policy was used as a training tool for all newly hired licensed staff. The policy included an area for the name, title, date and time that the policy was presented and used for training to new licensed staff. The policy also contained an area for the newly hired nurse to sign, acknowledging the training. Included in the policy was the following: patient identified using (2) identifiers: picture and another nurse identifying, arm bands 'Five Rights' of medication pass are followed: right patient, right dose/form, right time, right route, right drug Included in the facility Inservice Education Report was an inservice Proper Identification of Residents w/ID (with identification) bands and pictures before your medication administration, attached to the inservice was a white piece of paper that contained the following information: ****ALERT*** RESIDENT IS KNOWN TO REMOVE/REFUSE TO WEAR ARM IDENTIFICATION PLEASE REFER TO PICTURE IDENTIFICATION, VERBAL AND SECOND EMPLOYEE IDENTIFICATION AS NEEDED! Per the administrator the Alert was printed on bright yellow paper and placed on the MAR for staff to see. She stated, The use of that is part of the POC (plan of correction) .it should be on every resident MAR indicated [REDACTED]. Also included in the IN-SERVICE EDUCATION REPORTS was the following: All Residents must be properly identified before administering meds. Identify by name badge. Identify by picture on front of MAR/TAR or electronic record. Ask Resident their name. Never ask if they are a certain person. If two identifiers are not present you may ask two other staff members to identify them The administrator, the DON and the Regional Director of Clinical Services were notified during a meeting on 03/29/2017 at approximately 2:30 p.m. that although the deficient practice would be recommended at a harm level deficiency, the survey team would also recommend that it be cited as past non-compliance. No further information was obtained prior to the exit conference on 03/29/2016. This is a complaint deficiency. This is Past- noncompliance.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to follow professional standards of nursing practice for two of 19 residents, Resident #16 and Resident #1, with resulting harm for Resident #16. 1. The facility staff did not properly identify Resident #16 before administering fourteen unprescribed medications to him, which resulted in harm. Resident #16 was administered another resident's medications in error on June 10, 2016. The following erroneous medications were administered PO (by mouth) to Resident #16: [MEDICATION NAME] 400 mg (milligrams), Dexilant 60 mg, Cocaine 25 mg, [MEDICATION NAME] HCL ([MEDICATION NAME]) 10 mg, Aspirin 81 mg, Quetiapine [MEDICATION NAME] 75 mg, one Thera vitamin tablet, Lispril 2.5 mg, Magnesium Oxide 500 mg, [MEDICATION NAME] HCL 1000 mg, Oyster shell calcium plus Vitamin D 250-125, [MEDICATION NAME] 17 gm (grams) mixed with 8 ounces of fluid, and Pro-stat s/f (sugar free) Wild Cherry (flavor) 30 ml (milliliters); also administered were Artificial Tears 1 drop into each eye. These medications were in addition to Resident #16's regularly scheduled medications of [MEDICATION NAME] 200 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 5 mg that had already been administered to him that morning (06/10/2016). Resident #16 became increasingly lethargic throughout the day with decreased blood pressure, decreased responsiveness and decreased respirations. Resident #16 was sent to the emergency roiagnom on the evening of June 10, 2016 and was admitted to the hospital due to accidental drug ingestion. Resident #16 was hospitalized for [REDACTED]. 2. During a medication pass and pour observation on 03/28/2017, Resident #1 was not identified using two methods of identification per facility policy, prior to receiving morning medications during a medication pass and pour observation on 03/28/2017, nor was the resident care planned and identified as a resident who did not wear an identification bracelet. Findings were: 1. Resident #16 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. The yearly MDS (minimum data set) with an assessment reference date of 05/25/2016, assessed Resident #16 as having a cognitive summary score of 12, indicating moderate impairment with his cognitive status. On 03/29/2017 at approximately 8:00 a.m., all information pertaining to the incident on 06/10/2016 with Resident # 16 was requested from the administrator. At approximately 8:15 a.m., the administrator presented a binder containing a plan of correction developed by the facility, as well as a folder containing all information related to the FRI. Review of the information revealed that newly licensed (05/12/2016) LPN (licensed practical nurse) # 8 was hired by the facility on 06/08/2010. Her account of the incident included the following information: While administering morning medication, I, (LPN #8's name) drew up all morning medications for (Resident name). Went to (room on the 200 hall where the intended resident resided) and a gentleman (Resident #16) was in the bathroom. I asked twice are you (Intended resident's name) and he said yes. I told him I had his medication and administered it to the gentleman (Resident #16). This happened at 8:30 am (sic). At 8:55 am (sic) another gentleman came to the medication cart and asked if I had any medicine for him to take. I asked him his name and he identified himself as (resident's name who the medications were intended for) in room (room number on 200 hall). I immediately stopped my medication pass to find my orienting nurse to tell her my concern of giving (Resident name) medication to the wrong resident. She and I walked the facility to identify the resident I gave (intended resident) medications to . Further review of the information showed that LPN #9 who was orienting LPN #8 was not with her at the time of the medication error. Also observed in the facility information was a Personnel Consultation conducted with LPN #9 regarding the orientation process. The subject content was: On the morning of 6-10-16 you had a new nurse orienting with you on the 100 hall. You were not present with nurse when she made a significant med error. You are always to remain with orienting staff during a med pass unless they have been deemed competent in doing this independently. Once they have been deemed competent I will instruct the orienting nurse of this. Had you been at the nurses side, the med error would not have occurred. The consultation was presented by the Staff Development Coordinator, LPN #1. LPN #8 and LPN #9 were no longer employed at the facility and were not available for interview. A timeline of events developed and presented by the facility was reviewed. The following is a summary of the timeline: The physician was notified of the error at 9:00 a.m. and orders were given to obtain vital signs every hour for 24 hours and to provide the MD on call with updates. Oxygen was also started at 2 liters via nasal cannula. Vital signs for Resident #16 were: BP (blood pressure): 92/50; Pulse: 60; Respirations: 16. Resident #16 was closely monitored 1:1 at the nursing station by staff. A message was left with the RP (responsible party). At 10:00 a.m., Resident #16's BP was 88/48, Pulse 60, respirations were 24. Resident #16 was lethargic, but aroused by verbal stimuli. Oxygen sats were 77% on 2 liters of oxygen. Resident #16 was mouth breathing. He was placed on a face mask and his oxygen sats increased to 92%. At 11:00 a.m., BP was 90/60, pulse 56, respirations 16 and oxygen sats were 92%. Blood sugar was 112. The physician was updated on the resident's progress. At 11:39 a.m., an IV was started of .5 Normal Saline at 100 cc/hr for one liter due to Resident #16's low blood pressure. Facility staff continued to monitor Resident #16, updating the physician and attempting to contact the RP. By 3:00 p.m., Resident #16 was becoming more difficult to arouse. At 5:15 p.m. Resident #16's respirations were becoming shallow and he had a non-responsive episode. The physician was notified and an order was obtained to send the resident to the emergency room . Vital signs at that time were BP 111/66, pulse: 79, Oxygen saturation was 95 % on 2 liters of oxygen. The clinical record was reviewed. Nurse's notes and physician orders [REDACTED]. The discharge summary from the local hospital was reviewed and included the following: Discharge [DIAGNOSES REDACTED]. Hospital Course: The gentleman (Resident #16) was admitted to the hospital in the lethargic state with acute [MEDICAL CONDITION] and dehydration. Apparently he was accidentally given another patients (sic) medications including sedatives and [MEDICATION NAME] and [MEDICATION NAME] and [MEDICATION NAME]. We found him to be in acute kidney injury that improved with gentle IV fluids. We gave him his fluids gently because he has a history of [MEDICAL CONDITION] and although he did not have a frank [MEDICAL CONDITION] in house, an echocardiogram did show evidence of a low ejection fraction at 45%. He does have a known history of [MEDICAL CONDITION]/defibrillator/[MEDICAL CONDITION]. He also has a history of [MEDICAL CONDITION] and a distant history of stroke . The plan of correction created by the facility was reviewed. The plan of correction titled (Facility Name) ALLEGATION OF COMPLIANCE WITH RESIDENTS AT RISK FOR MEDICATION ERRORS 6/10/2016 included the following: Resident: (Initials of Resident #16) received medications that was (sic) subscribed for another resident. Immediate Actions taken for the resident identified as receiving the incorrect medications: When the error was noted the resident was assessed, vital signs obtained by the charge nurse, O2 sat was 90% and oxygen was started. The physician was notified requested V/S (vital signs) and hourly updates. At 10am (sic) the physician was given an update by the charge nurse and orders were received for IV fluids 1000 cc at 80 cc per hour and to continue to monitor with hourly updates. The resident was lethargic but aroused on verbal command. (See notebook for timeliness and process for assessment, orders and treatment for [REDACTED]. At 5:30 p.m. the physician was notified of the resident continuing to be lethargic and order was received to transport the resident to the hospital for evaluation. Nurse #1 (LPN #8) received one to one education from the DON (Director of Nursing) on the medication administration policy and identifying residents prior to giving them medication by at least 2 identifiers-name band, photo or second person. The nurse was also suspended pending an investigation. If the nurse returns to duty she will receive to (sic) orientation with direct oversight with a second nurse until competency in medication administration is demonstrated Identifying other residents at risk: 1. All residents will be reviewed to assure they have identifiers in place such as a photo and name bracelet, by DON and charge nurse by 6/11/2016 2. Residents identified as needing photo or bracelet will have replacements made by medical records or designee. Residents that refuse to wear the bracelet or is known to remove them will have it noted in the medication book to have the second person to confirm the resident's identity by 6/11/2016 3. Care plans will be reviewed and updated for residents that remove the name bracelet by 6/11/2016. System changes: 1. The Director of Nursing or designee will do education with all licensed nursing on medication administration starting 6/10/2016. After the initial nurses on duty are trained the remaining licensed nurses will receive the education prior to starting a medication pass. The education will be ongoing until all current licensed nurses receive the education prior to doing a medication pass and will be completed by 6/17/2016. All newly licensed nurses will receive the medication administration education during orientation and prior to passing medications. 2. Medication Pass Observations will be started 6/10/2016 by the DON and unit managers. Medication Pass Observations will be completed daily by the DON/designee daily for seven days than (sic) three times per for (sic) two weeks then two times per week for two weeks then weekly for three weeks then monthly and any concern with the observation will be documented and the nurse educated as indicated at the time of the observation. 3. Skills checklist using the Medication Pass Observation will be completed on all licensed nursing staff by 6/17/2016. 4. The residents will be audited weekly for four weeks then every other week for four weeks then monthly by the medical record {sic) to assure photos and name bracelets are in place. The DON or Assistant Director of Nursing will be notified of residents as identified as removing bracelets in order to place notices to nurses to use a different identifier if bracelet is not on the resident. 5. Develop and implement a nurse mentor program for newly hired licensed nurses. Nurse Mentors will be selected using the mentor selection rating system. The SD (staff developer) and Unit will develop a training notebook with the outline for the selected nurse mentors education by 6/17/2016. 6. All newly hired nurses on their first day after general orientation will attend orientation with the SDC (staff development coordinator) or designee for clinical training on their responsibilities in the roles they are going (sic) assuming. The new nurses will be assigned a designated mentor on their first day of duty and will work with the mentor during their first few days of employment. New nurses, who are working their first two days of employment, should not be in the floor without their mentor. Monitoring of Process: 1. Interdisciplinary team consisting of the Director of Nursing, Unit Mangers, Assistant Director of Nursing and the Administrator meeting will be conducted on 6/13/2016 to review that residents identifiers are in place, the progress of the medication administration education of the licensed nurses and the outcomes of the Medication Pass Observations. 2. The DON will be responsible for oversight and ongoing compliance. 3. Results of the Medication Pass Observations will be reviewed at the facility Quality Assurance and Performance Improvement committee for further recommendations by the Director of Nursing. 4. Results of the medical record audits will be reported to the facility Quality Assurance and Performance Improvement Committee for review and further recommendations. 5. The DON/designee will audit the Licensed Nursing Staff Orientation checklist for completion on all newly hired nurses monthly and report her findings to the facility Quality Assurance and Performance Improvement Committee for review and further recommendations. 6. The facility Quality Assurance and Performance Improvement committee consists of the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, rehab director, activities, social services, dietary, Medical Director and maintenance director. A copy if the facility policy and procedure regarding medication administration was requested and obtained. The policy titled, Medication Administration and Medication Room, Storage, Security was obtained. The policy was used as a training tool for all newly hired licensed staff. The policy included an area for the name, title, date and time that the policy was presented and used for training to new licensed staff. The policy also contained an area for the newly hired nurse to sign, acknowledging the training. Included in the policy was the following: patient identified using (2) identifiers: picture and another nurse identifying, arm bands 'Five Rights' of medication pass are followed: right patient, right dose/form, right time, right route, right drug Included in the facility Inservice Education Report was an inservice Proper Identification of Residents w/ID (with identification) bands and pictures before your medication administration, attached to the inservice was a white piece of paper that contained the following information: ****ALERT*** RESIDENT IS KNOWN TO REMOVE/REFUSE TO WEAR ARM IDENTIFICATION PLEASE REFER TO PICTURE IDENTIFICATION, VERBAL AND SECOND EMPLOYEE IDENTIFICATION AS NEEDED! Per the administrator the Alert was printed on bright yellow paper and placed on the MAR for staff to see. She stated, The use of that is part of the POC (plan of correction) .it should be on every resident MAR that is not wearing an arm band. Also included in the IN-SERVICE EDUCATION REPORTS was the following: All Residents must be properly identified before administering meds. Identify by name badge. Identify by picture on front of MAR/TAR or electronic record. Ask Resident their name. Never ask if they are a certain person. If two identifiers are not present you may ask two other staff members to identify them The administrator, the DON and the Regional Director of Clinical Services were notified during a meeting on 03/29/2017 at approximately 2:30 p.m. that the past non-compliance would not an option due to current issues during the survey of patient identification during medication pass. Questions from the administrative staff were fielded by the survey team. The facility staff were asked if there was any additional information regarding the identification of residents to ensure the right resident received the right medication to be presented. The DON stated there was no additional information. The DON, the administrator and Regional Director of Clinical Services were informed that the survey team would recommend the facility be cited at a harm level with a complaint deficiency. No further information was obtained prior to the exit conference on 03/29/2016. This is a harm deficiency. This is a complaint deficiency. 2. During a medication pass and pour observation on 03/28/2017, Resident #1 was not identified using two methods of identification per facility policy, prior to receiving morning medications during a medication pass and pour observation on 03/28/2017, nor was the resident care planned and identified as a resident who did not wear an identification bracelet. Resident #1 was most recently admitted to the facility on [DATE] with the following diagnoses, but not limited to: Pathological Fracture, age related [MEDICAL CONDITION], symbolic dysfunction, hypertension, dysphagia, CKD ([MEDICAL CONDITION]) Stage II, protein/calorie malnutrition, [MEDICAL CONDITIONS] and heart failure. The most recent MDS (minimum data set) was a quarterly assessment with an assessment reference date of 1/25/2017. Resident #1 was assessed as having a cognitive summary score of 15, indicating she was cognitively intact. On 03/28/2017 at approximately 7:45 a.m., LPN (licensed practical nurse) #7 was observed on the 200 hall going in and out of patient rooms. She referred to each resident as Beautiful or Lovely. She did not use the resident's name while interacting with them. This surveyor stopped LPN #7 and asked for information regarding a resident in the hallway. She answered the question and then stated, I think that's right .I normally work the other hall. I don't know these patients as well as I know the others over there. At approximately 8:10 a.m., LPN #7 was observed giving medications. This surveyor approached her and asked if she could observe her giving medications. LPN #7 was observed preparing medications for Resident #1. The [MEDICATION NAME] Inhalation ordered to be given twice daily for [MEDICAL CONDITION] was not on the medication cart. LPN #7 stated, I'll call the pharmacy and get that .it should be here by ten o'clock this morning. A large black and white picture of Resident #1 was observed in the MAR (Medication Administration Book). When LPN #7 completed preparing the medications she entered Resident #1's room. She stated, Good morning beautiful .I have your medications for you. LPN #7 did not call Resident #1 by name, nor did she check her arm band for identification. The medications were administered, however, the [MEDICATION NAME] was not administered per order. The order was [MEDICATION NAME] 18 mcg (micrograms) cap .Inhale contents of one cap orally once every day for [MEDICAL CONDITION] (by taking two separate inhalations via handihaler device). LPN #7 handed the [MEDICATION NAME] to Resident #1 and after she took one inhalation, LPN #7 popped the capsule out of the device into the trash can. After the medication administration was complete this surveyor told LPN #7 about the observation of the resident only taking one inhalation of the [MEDICATION NAME] instead of two. She stated, Okay. LPN #7 was asked to come get this surveyor to observe the [MEDICATION NAME] administration when the medication arrived from the pharmacy. At approximately 2:30 p.m., this surveyor went to see if the [MEDICATION NAME] had arrived from the pharmacy. This surveyor was told that LPN #7 had not been feeling well and had already left for the day. The DON (director of nursing) was asked if the [MEDICATION NAME] had arrived from the pharmacy and if so what time had it been given. She returned and stated, She got it at 1:30 p.m. During an end of the day meeting on 03/28/2017 the DON (director of nursing), the administrator and the Regional Director of Clinical Services were notified of the above medication errors. The DON was asked how staff were to identify residents prior to medication administration. She stated, There are to be two forms of identification . they can look at the arm band, the picture on the MAR, ask the resident their name, or get another staff person to identify them. The DON was informed that LPN #7 had not looked at the resident's arm band or called her by name, or asked another staff person. Also reviewed were the medication administration policy and procedure, as well as inservices to staff regarding medication administration were reviewed. Per the facility policy titled, Medication Administration and Medication Room, Storage, Security was obtained. The policy was used as a training tool for all newly hired licensed staff. The policy included an area for the name, title, date and time that the policy was presented and used for training to new licensed staff. The policy also contained an area for the newly hired nurse to sign, acknowledging the training. Included in the policy was the following: patient identified using (2) identifiers: picture and another nurse identifying, arm bands 'Five Rights' of medication pass are followed: right patient, right dose/form, right time, right route, right drug Included in the facility Inservice Education Report was an inservice Proper Identification of Residents w/ID (with identification) bands and pictures before your medication administration, attached to the inservice was a white piece of paper that contained the following information: ****ALERT*** RESIDENT IS KNOWN TO REMOVE/REFUSE TO WEAR ARM IDENTIFICATION PLEASE REFER TO PICTURE IDENTIFICATION, VERBAL AND SECOND EMPLOYEE IDENTIFICATION AS NEEDED! Per the administrator the Alert was printed on bright yellow paper and placed on the MAR for staff to see. She stated, The use of that is part of the POC (plan of correction) .it should be on every resident MAR that is not wearing an arm band. Also included in the IN-SERVICE EDUCATION REPORTS was the following: All Residents must be properly identified before administering meds. Identify by name badge. Identify by picture on front of MAR/TAR or electronic record. Ask Resident their name. Never ask if they are a certain person. If two identifiers are not present you may ask two other staff members to identify them This surveyor went to Resident #1's room and asked her if she was wearing an arm band/identification bracelet. She stated, No, I don't wear them .my skin is easy to tear and they hurt my arms .I have one on my wheelchair here and I think there's one on my bed. This surveyor then went to the MAR book. There was no alert on the MAR for Resident #1 that she did not wear an arm band. The care plan was reviewed. The care plan had not been updated to include information that Resident #1 did not wear an arm band. LPN #7 was interviewed on 03/29/2017 at approximately 11:00 a.m. regarding Resident #1. The MAR book was observed with LPN #7. LPN #7 was asked about the alert that should be on her MAR since she was not wearing an arm band. She stated, I don't know anything about that .maybe she had one and it got frayed or fell out. LPN #7 was asked how she knew who Resident #1 was since she was not wearing an arm band. She stated, I've worked here for three months, I know who she is. LPN #7 was reminded that prior to medication pass on 03/28/2017 she had told this surveyor that she did not work that hall as much and did not know those residents as well. She stated, I can make it happen (referring to obtaining an alert for the MAR). At approximately 1:30 p.m., the administrator was informed of the above information. She stated, (Name of staff development coordinator) said that the alert is on the MAR, she checked them last night. The administrator was again informed that the alert was not present on the MAR that morning (03/29/2017) or the previous morning during medication pass and pour observation. At approximately 1:55 p.m., Other staff #2 from medical records was interviewed by this surveyor. She stated that she audited weekly to ensure that photos were on the MARS, as well as armbands on residents and alerts on the MARS if the resident was not wearing an arm band. She presented the audit conducted on 03/28/2017. She stated, All I looked at last night was the arm bands and the pictures .I checked the MARS last week I did check the MARS today (03/29) when (name of staff development coordinator) told me to. She was asked if the Alert had been on Resident #1's MAR when she checked. She stated, No, there wasn't one on there, I put it on there today. During an end of the day meeting on 03/29/2018 the DON, the administrator and the Regional Director of Clinical Services were informed that during the medication pass and pour observation, LPN #7 had not used two forms of identification to identify Resident #1 prior to administering her morning medications. They were also informed that Resident #1 was not wearing an arm band, and per the facility policy and plan of correction for a complaint being investigated that information should be on the MAR and the care plan. Any additional information regarding this was requested and per the DON there was no additional information to be presented. No further information was obtained prior to the exit conference on 03/29/2017.