Every finding on record at Hawthorne Center for Rehabilitation and Healing of

Based on interview and record review, the facility failed to review and revise, based on changing goals, preferences and needs of the residents, the comprehensive care plans for 3 of 4 residents, Resident #1, #3, and #4, reviewed for ADL (Activities of Daily Living) care needs.Findings include:Review of Resident #1's MDS (Minimal Data Set) assessment dated [DATE] did not document a BIMS (Brief Inventory of Mantal Status) Score. She required partial to moderate assistance for eating and required substantial to maximal assistance or was dependent for all other self-care activities.Review of Resident #1's Care Plan read, Focus - The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) syncope, history of falls, dementia. Date Initiated 6/16/2026. Interventions included - Bathing/showering: The resident requires moderate assist x1 (times [with] 1 person); Eating: The resident requires setup and encouragement; Toilet use: The resident requires moderate assist x1. Date initiated: 6/16/2026.Review of Resident #1's Task List documentation from 6/15/2026 through 6/23/2026 revealed documentation that Resident #1 was dependent for eating for eight meals. She was dependent or required substantial to maximal assistance for all of her toileting activities.Review of Resident #1's medical record documented the resident was admitted on [DATE] with medical diagnoses to include syncope and collapse (primary); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; altered mental status, unspecified. Resident #1 was discharged on 6/23/2026.2) Review of Resident #3's MDS assessment dated [DATE] documented a BIMS Score as a 7 out of 15 which indicated she had significant cognitive impairment. She required supervision or touching assistance with eating and was dependent on staff for all other self-care activities.Review of Resident #3's Care Plan read, Focus - The resident has an ADL self-care performance deficit r/t Activity Intolerance. Interventions included - EATING: The resident requires setup by 1 staff to eat.Review of Resident #3's Task List documentation from 8/01/2026 through 8/24/2026 documented Resident #3 was dependent on staff for feeding assistance or required substantial to maximal assistance from staff for 35 out of 42 meals documented.Review of Resident #3's medical record documented the resident was admitted on [DATE] with medical diagnoses to include heart failure, unspecified (primary); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified protein-calorie malnutrition; weakness.3) Review of Resident #4's MDS Assessment, an annual assessment, dated 7/21/2026 documented 0 out of 15 for the BIMS Score which indicated she was significantly cognitively impaired. She was dependent on staff for all self-care activities.Review of Resident #4's Care Plan read, Focus - [Resident #4's name] has an ADL self-care performance and Mobility deficits r/t dementia, generalized weakness, impaired balance, limited mobility, muscle weakness and osteomyelitis of sacral wound. Interventions included - EATING: The resident requires Supervision/touching assist of 1 staff to eat.Review of Resident #4's Task List documentation from 8/01/2026 through 8/24/2026 documented Resident #4 was dependent on staff for feeding assistance or required substantial to maximal assistance from staff for 39 out of 43 meals documented.During an interview at approximately 12:15 PM Staff C, LPN (Licensed Practical Nurse) stated that right now, Resident #3 and Resident #4 were their [nurses and CNAs (Certified Nursing Assistants)] focus, because they required staff assistance with all activities. During an interview at 12:45 PM Staff B, CNA stated that she was not sure what it meant if a resident required partial to moderate assistance with eating. She had to feed Resident #4 and Resident #3.During an interview at 2:52 PM Staff A, LPN - MDS Nurse stated to complete the MDS Assessment, it required looking at the CNA documentation for care and services provided, seeing what therapy was saying about the resident's abilities and needs, and interviewing the CNAs and the nurses. Resident #1's care plan should have been updated to accurately reflect her needs and the services she required. Resident #3's task list documentation conflicted with her MDS assessment and her care plan. The process was when an MDS Assessment was completed, they were to review the task list documentation to see what support the resident required. Resident #4's Care Plan needed to be updated because it did not reflect the MDS Assessment that documented the resident as being dependent for eating and other self-care activities. When an MDS Assessment was completed, the resident's care plan should be updated. During an interview at 3:26 PM the Director of Nursing stated that the expectation was the MDS Assessments and residents' care plans should be updated and accurate.Review of the policy and procedure titled, Comprehensive Resident Centered Care Plans, read, Intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Procedure: 2. The facility must develop and implement A comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being as required. 5. The planning process will: b. Include an assessment of the residents strengths and needs. Developing the Care Plan: 1. A comprehensive care plan will be: b. Prepared by an interdisciplinary team, that includes but is not limited to: ii. A registered nurse with responsibility for the resident. iii. A nurse aide with responsibility for the resident. c. Reviewed and revised by the interdisciplinary team after each assessment. 3. Each discipline will check and/or add interventions/approaches to include but not limited to: a. The intervention statements describe those measures performed by staff to help the resident achieve the expected outcomes. b. Interventional entries reflect activities that incorporate observations, assessments, management and teaching components that will restore, maintain and/or promote the resident's well-being. c. Each planned intervention will be specific and include parameters for frequency and time schedule. Updating Care Plans: 1. Care plans are modified between care plan conference when appropriate to meet the residents current needs, problems and goals. 3. The Care Plan will be updated and/or revised for the following reasons: b. A change in planned interventions. c. Goals are obtained new goals established to meet current resident needs and/or goals. CAA's (Care Area Assessments - a structured framework used after an MDS evaluation to interpret resident data and guide individualized care planning) provide further assessment of triggered MDS areas and enable staff to further analyze assessment findings to develop a comprehensive plan of care.

Based on observation interview and record review the facility failed to ensure food was stored and served in a sanitary manner. Findings include: Observation of the walk in freezer on 5/26/2026 at 9:34 AM showed there was no stand alone thermometer in the walk-in freezer. During interview on 5/26/2026 at 9:35 AM, the Certified Dietary Manager confirmed there was no stand alone thermometer in the walk-in freezer. Service of the midday meal was observed on 5/29/2026 beginning at 11:20 AM. The cook was observed using a gloved hand to scoop and place meal items onto plates and touching the counter top. The cook was then observed lifting a cheese slice from a stack of cheese with her same gloved hand and placing the slice of cheese onto a hamburger bun for service to a resident. Throughout the meal service, while plating meal items to be served to residents, the cook was observed placing her hand on the food contact surface of 4 plates. The cook was also observed doffing used gloves and donning new gloves without washing her hands after doffing gloves. During interview on 5/29/2026 beginning 11:30 AM, the Certified Dietary Manager agreed dietary staff should not touch food items or the food contact surfaces of plates with their hands. She stated staff were expected to wash their hand after doffing gloves and before donning clean gloves. Review of the policy titled Food Handling, last reviewed 1/22/2026, read Food shall be handled in a proper method to ensure retention of flavor, appearance, quality, nutrients, and to safeguard against contamination. The policy specified 3. When it is necessary for staff to touch food during preparation, they must wash their hands immediately before beginning the process. Disposable gloves are used. Review of policy titled Storage of Perishable Goods, last reviewed 1/22/2026, 1. Freezer temperatures are maintained at a level to keep frozen food solid. Stored frozen foods shall be maintained frozen.

Based on observation, interview and record review the facility failed to administer oxygen at the correct flow rate according to physician orders for 2 residents ( Resident #58 and #116) and failed to have physician orders documenting the prescribed flow rate for 1 resident ( Resident #130) of 5 residents reviewed for oxygen therapy. Findings include: During an observation on 5/26/2026 at 10:49 AM Resident #58 was observed with oxygen at 3 liters via a nasal cannula. During and observation on 5/27/2026 at 7:26 AM Resident #58 was observed with oxygen at 3 liters via a nasal cannula. Review of Resident #58's admission record document diagnosis that include unspecified diastolic congestive heart failure, morbid severe obesity due to excess calories, protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, asthma, cardiomegaly, atherosclerotic heart disease of native coronary artery without angina pectoris, age-related osteoporosis without current pathological fracture, anxiety disorder, hyperlipidemia, insomnia, essential primary hypertension and major depressive disorder recurrent moderate. Review of Resident #58's physician order dated 3/16/2026 read, Oxygen @ 2 L/Min continuous inhalation via nasal cannula. During an interview on 5/27/2026 at 2:28 PM, Staff M, Licensed Practical Nurse (LPN) stated, Her (Resident #58) oxygen should be at 2 liters, we check it every shift usually when we are finished with meds. We should follow the orders for the rate. During an interview on 5/28/2026 at 6:29 AM, the Director of Nursing (DON) stated, Oxygen should be running at the ordered rate and we should follow doctors orders. During an observation on 5/26/2026 at 10:07 AM Resident #116 was sitting at bedside, oxygen was being administered via nasal cannula at 4 liters per minute. During an interview on 5/26/2026 at 11:43 AM Resident #116 was sitting on a chair in her room Oxygen was being administered at 4 liters per minute via nasal cannula. During an interview on 5/26/2026 at 11:43 AM Resident #116 stated, The oxygen the nurses are the ones that will touch it, I never touch it. The machine is only assigned to me. During an observation on 5/27/2026 at 8:15 AM Resident #116 sitting up at bedside eating breakfast oxygen running at 4 liters per minute. Review of Resident #116 physician order dated 5/14/2026 read, Oxygen @ [at] 2 L/Min [liters per minute] via NC [nasal cannula] inhalation as needed as needed. During an interview on 5/28/2026 at 8:29 AM with the Director of Nursing (DON) stated, Nurses are to check orders prior to administering oxygen if the order says two liters the oxygen concentrator should read 2 liters. The orders should be followed. During an observation on 5/28/2026 at 8:37 AM the DON confirmed Resident #116 oxygen was being administered at 4 liters per minute. During an observation on 5/26/2026 at 10:37 AM Resident #130 was lying in bed oxygen was being administered at 1.5 liters per minute via nasal cannula. There was no date on tubing. During an observation on 5/26/2026 at 12:10 PM Resident #130 was sitting up in a wheelchair. Oxygen was being administered at 1.5 liters per minute via nasal cannula. Oxygen tubing was dated 5/26. Review of Resident #130's physician orders did not document oxygen orders. During an interview on 5/27/2026 at 11:46 AM, Staff D, Licensed Practical Nurse stated, I do not see an order for oxygen. She [Resident #130] would need one for the nasal cannula and the liters of oxygen. I will have to contact the provider and get an order. During an interview on 5/27/2026 at 11:46 AM, Staff D, LPN, confirmed Resident #130 was resting in bed with eyes closed, oxygen at 2 liters per minute via nasal cannula. During an interview on 5/27/2026 at 8:28 AM, the Director of Nursing stated, Doctors orders need to be in place for oxygen. Review of the facility policy and procedure titled, Oxygen Administration, last approval date of 1/22/2026 read, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 7. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. 9. Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered.

Based on observation, interview and record review the facility failed to perform hand hygiene to prevent the possible spread of infection during medication administration in 6 of 9 observations of medication administration.Findings include: During an observation of medication administration on 5/27/2026 at 8:04 AM for Resident #111, Staff D. Licensed Practical Nurse (LPN) did not perform hand hygiene, retrieved keys from their uniform pocket, unlocked the medication cart, activated and typed on the computer. Staff D, LPN donned gloves without performing hand hygiene, locked the medication cart, placed keys in pocket, and closed the computer. Staff D. LPN picked up medication cards and a glass of water and the medication cup, placed their thumb in the inside of the medication cup touching the medications and entered the residents room, administered the medications without changing gloves or performing hand hygiene. During an observation of medication administration on 5/27/2026 at 8 :12 AM Staff D, LPN returned to the medication cart and began to prepare medications for Resident #133, Staff D. LPN retrieved keys from their uniform pocket, unlocked the medication cart, opened up, activated and typed on the computer without performing hand hygiene, Staff D,LPN prepared medications, locked the medication cart and entered the resident room without performing hand hygiene, administered the medications after touching the bed controls and the resident while assisting the resident reposition in the bed without performing hand hygiene. During an observation of medication administration on 5/27/2026 at 8:18 AM Staff D, LPN returned to the medication cart and began to prepare medications for Resident #32. Staff D , LPN staff retrieved keys from their uniform pocket, unlocked the medication cart, opened, activated and typed on computer without performing hand hygiene. Staff D. LPN entered the residents room without performing hand hygiene and administered the medications.During an interview on 5/27/2026 at 8:25 AM Staff D, LPN stated, I should have used more hand sanitizer before I poured the meds(medications) and when I entered the room or touched the resident. During an observation of medication administration on 5/27/2026 at 8:29 AM Staff M, LPN began to prepare medications for Resident #40 without performing hand hygiene. Staff retrieved keys from their uniform pocket, unlocked the medication cart opened the computer activated the computer and typed on the keyboard. Staff M, LPN poured 3 medications into the medication bottle cap, Staff M,LPN placed their thumb over 2 medications and let the extra 1 medication fall into the medication cup and then placed the 2 tablets back into the bottle of medications. Staff M, LPN placed on gloves without performing hand hygiene, touched the stethoscope hanging round their neck and their hair with their gloved hand, entered the residents room, administered medications and removed gloves without performing hand hygiene. Staff M. LPN then returned to medication cart without performing hand hygiene, retrieved the keys from their uniform pocket unlocked the medication cart, opened, activated and typed on the computer keyboard. Staff M, LPN returned to the residents room, without performing hand hygiene inquired about pain level and asked if she wanted medication for pain without performing hand hygiene, Staff M, LPN was observed touching the bed side table. Staff M, LPN exited the room without performing hand hygiene, retrieved the keys from their uniform pocket, unlocked the medication cart, activated and typed on the computer keyboard without performing hand hygiene, poured medication, locked the medication cart closed computer and entered resident room without performing hand hygiene and administered the medication. During an observation of medication administration on 5/27/2026 at 8:42 AM Staff M, LPN returned to the medication and began preparing medications for Resident #12. Staff M, LPN retrieved the keys from their uniform pocket, unlocked the medication cart, activated and typed on the computer keyboard, staff poured medications into the medication cap, placed their ungloved hand over 2 medications covering them with their by thumb and placed 1 medication into the medication cup. Staff M, LPN then placed the 2 remaining medications back in the medication bottle and placed the cap back on, Staff M, LPN entered the resident room without performing hand hygiene and administered the medication. During an interview on 5/27/2026 at 9:02 AM Staff M, LPN stated, I should have used hand sanitizer before and after I put on gloves. I should not have put my hands on the medications and then let them go back in the medication bottle. During an interview on 5/28/2026 at 06:42 AM the Director of Nursing (DON) stated, All nurses should follow all infection control policies during medication pass.Review of the policy and procedure titled, Medication Administration General Guidelines last approval; date of 1/22/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. Procedure: A). Preparation: 2. Handwashing and hand sanitization: The person administering medications adheres to good hand hygiene, which includes sanitizing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. B. Administration: 2). Medications are administered in accordance with written orders of the prescriber. 9). Hands are sanitized before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal, and vaginal medications. Review of the policy and procedure titled, Handwashing/Hand Hygiene last approval date of 1/22/2026 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non anti-microbial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with residents intact skin; m. After removing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections.

Based on observation, interview, and record review the facility to ensure complete and accurate records were provided for 2 (Residents #8 and #32) of 6 residents, reviewed for skin conditions. Findings include: During an observation on 5/26/2026 at 10:14 AM Resident #32 was lying in bed PICC [peripherally inserted central catheter] line dressing dated 5/6/2026. There was no redness or swelling at the site. During an interview on 5/26/2026 at 10:14 AM Resident #32 stated she was getting antibiotics for wound infection of a wound in her back which she was admitted with. She was unable to recall when was the last time they change dressing. Resident #32 denied any discomfort with her arm at this time. During an interview on 5/6/2026 at 11:54 AM, Staff C, Licensed Practical Nurse (LPN) stated, IVs [intravenous] dressing are to be changed every 7 days. During an interview on 5/26/2026 at 12:22 PM, Staff C, LPN, confirmed Resident #32's dressing was dated 5/6/2026 and needed to be changed. Review of Resident #32 physician order dated 5/6/2026 read, IV: PICC Line: Change transparent dressing every 7 day (s) for preventative care and as needed for soiling or dislodgment. Review of Resident #32 Treatment Administration Record for the Month of April 2026 documented change transparent dressing on 5/13/2026 and on 5/20/2026 {initial by Staff D, LPN] During an interview on 5/28/2026 at 8:13 AM with the Director of Nursing stated, IV Dressing should be changed every 7 days. There should be flush orders in the system if resident has a PICC line. During an interview on 5/27/2026 at 3:00PM Staff D, LPN, stated, I cannot recall why I checked off as completing the dressing changes. Normally they need to be done every week. During an interview on 5/28/2026 at 8:13 AM with the Director of Nursing stated, Staff should follow physician orders and make sure documentation is complete and accurate. Review of Resident #8's physician order dated 05/08/2026 read, Wound: Sacral wound cleanser, pat dry and apply zinc to peri wound, apply collagen/silver alginate then silicone bordered gauze every shift for pressure ulcer AND as needed for wound maintenance. Review of Resident #8's TAR [treatment administration record] for May 2026 showed wound care was not documented on 05/16/2026, 05/22/2026 and 05/26/2026 on 7AM-7 PM shift. During an interview on 05/29/2026 at 8:21 AM, Staff I, LPN stated, I have always done [Resident #8's name]'s wound care when it was on my shift. I must have forgotten to check it off after I did it. That is my mistake. During an interview on 05/29/2026 at 8:26 AM, the Administrator stated, When a nurse is doing wound care, I expect them to document that it was completed. Review of the facility policy and procedure titled Documentation with a last review date 1/22/2026 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all the interdisciplinary team members. Review of the facility policy and procedure titled Ongoing Assessment, Site Care, and Dressing Change with a last review date 1/22/2026 read, Policy: Transparent semipermeable membrane (TSM) dressing are changed every 5-7 days.

Based on record review and interview, the facility failed to ensure the resident's medication regimen remained free from unnecessary medications by administering midodrine outside of physician ordered parameters for 1 (Resident #108) of 7 residents reviewed for unnecessary medications. Findings include: Review of Resident #108's physician order dated 03/13/2026 read, Midodrine HCl [hydrochloride] Oral Tablet 5 MG [milligrams] (Midodrine HCl) [medication used to increase blood pressure] Give 1 tablet by mouth three times a day for hypotension [low blood pressure] Hold for SBP [systolic blood pressure] greater than 120. Review of Resident #108's physician order dated 05/20/2026 read, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for Hypotension Hold for SBP greater than 120. Review of Resident #108's MAR [medication administration record] for May 2026 read, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for hypotension Hold for SBP greater than 120 D/C [discontinue] Date 05/20/2026 2135 [9:35 PM].Review of Resident #108's MAR for May 2026 revealed that on 05/01/2026, Resident #108's Blood Pressure (B/P) was documented as 132/84 and midodrine was administered at 1400 [2:00 PM], on 05/03/2026, B/P was 130/81 and midodrine was administered at 1400, on 05/06/2026, B/P was documented as 130/72 and midodrine was administered at 0600 [6:00 AM], on 05/10/2026, B/P was documented as 140/72 and midodrine was administered at 2200 [10:00 PM], on 05/11/2026, B/P was documented as 132/70 and midodrine was administered at 0600, on 05/11/2026, B/P was documented as 121/61 and midodrine was administered at 1400, on 05/11/2026, B/P was documented as 126/74 and midodrine was administered at 2200, on 05/12/2026, B/P was documented as 122/70 and midodrine was administered at 0600, on 05/12/2026, B/P was documented as 129/68 and midodrine was administered at 1400, on 05/13/2026, B/P was documented as 122/75 and midodrine was administered at 2200, on 05/14/2026, B/P was documented as 131/73 and midodrine was administered at 1400, on 05/15/2026, B/P was documented as 136/69 and midodrine was administered at 1400, on 05/17/2026, B/P was documented as 134/72 and midodrine was administered at 2200, on 05/18/2026, B/P was documented as 134/70 and midodrine was at 2200, on 05/21/2026, B/P was documented as 130/70 and midodrine was administered at 1400, 05/21/2026, B/P was documented as 145/78 and midodrine was administered at 2200, on 05/23/2026, B/P 145/65 and midodrine was administered at 1400, on 05/23/2026, B/P was 126/62 and midodrine was administered at 2200, on 05/24/2026, B/P was documented as 121/66 and midodrine was administered at 0600, on 05/24/2026, B/P was documented as 121/66 and midodrine was administered at 1400, on 05/27/2026, B/P was documented as 124/62 and midodrine was administered at 0600,During an interview on 05/28/2026 at 3:10 PM, Staff K, RN (Registered Nurse) stated, A check mark on the MAR means that a medication was administered. I don't know why there is a checkmark. I always check the parameters for medications. If I hold a medication, I document a number in the MAR and a nursing note. I am not sure what happened with [Resident #108's Name]'s midodrine. During an interview on 05/28/2026 at 12:55 PM, the Director of Nursing stated, The checkmark on the MAR means that a medication was given. When a nurse is holding midodrine per parameters they should document a number in the MAR, not a checkmark. The nurses should not have administered the medication if the blood pressure is outside of parameters. Review of policy and procedure titled, Nursing Policies- Medication Administration Guidelines reviewed on 01/22/2026 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration 1) Medications are administered in accordance with written orders of the prescriber.

Based on observations, interviews, and record review the facility failed to provide dressing changes and have orders for flushing of intravenous catheters for 1 (Resident#32) of 3 residents reviewed for intravenous infusions, the facility failed to perform weekly skin observations for 1 (Resident #50) of 6 residents reviewed for skin conditions, the facility failed to provide daily weights for 1 Resident (Resident #45) out of 4 Residents reviewed for weights and failed to administer medication appropriately for 1 (Resident #103) of 7 residents reviewed for medication management. Findings include: During an observation on 5/26/2026 at 10:14 AM, Resident #32 was lying in bed PICC [peripherally inserted central catheter] line dressing dated 5/6/2026. The dressing was intact. The site was not red or swollen. During an interview on 5/26/2026 at 10:14 AM, Resident #32 stated she was getting antibiotics for wound infection of a wound in her back which she was admitted with. She was unable to recall when the last time was that they changed the dressing. During an interview on 5/26/2026 at 11:54 AM, Staff C, Licensed Practical Nurse (LPN) stated, IV (intravenous) dressing changes are done every 7 days. During an interview on 5/26/2026 at 12:22 PM, Staff C, LPN confirmed the dressing was dated 5/6/2026 and needed to be changed. Review of Resident #32's physician order dated 5/6/2026 read, IV: PICC Line: Change transparent dressing every 7 day (s) for preventative care and as needed for soiling or dislodgment. Review of Resident #32's physician orders did not document orders for flushing the PICC line for patency. During an interview on 5/28/2026 at 8:13 AM, the Director of Nursing stated, IV dressings should be changed every 7 days. There should be flush orders in the system if resident has a PICC line. During an interview on 5/29/2026 at 11:14 AM, the Advanced Practice Registered Nurse #1 stated, The dressing should have been changed. The facility has not called me with any concerns regarding the site. Review of the facility policy and procedure titled Ongoing Assessment, Site Care, and Dressing Change with a last review date of 1/22/2026 read, Policy: Transparent semipermeable membrane (TSM) dressing are changed every 5-7 days. Review of the facility policy and procedure titled Flushing Midline and Central Line IV Catheters with a last review date 1/22/2026 read, Policy: Midline and Central Line IV catheters (CVADS) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. Review of Resident #50's physician order dated 4/24/2026 read, Weekly Skin Observation every day shift every Fri [Friday] for weekly skin check. Review of Resident #50's Skin Sweep Weekly dated 4/25/2026 read, 2. Is skin impaired? Yes. 3. Observations: 12. Chest. Description: Surgical incision. Review of Resident #50's evaluations did not document weekly skin observations. During an interview on 5/29/2026 at 10:11 AM, Staff G, Licensed Practical Nurse [LPN} stated, Nurses are the ones responsible for doing the weekly skin assessments. We will fill out a form under evaluations. During an interview on 5/29/2026 at 10:12 AM, the Director of Nursing stated, The nurses are the ones who do the skin assessments. If there is an order the nurses should follow the order and do the skin assessments weekly. Review of the facility policy and procedure titled Regular skin inspections and prompt interventions to address changes with a last review date of 1/22/2026 read, Policy: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. Procedure: Skin inspections will be conducted by the licensed nurse using the Skin Sweep form for documentation at the time of admission and weekly. Record review revealed that Resident #45 was admitted to the facility on [DATE] with diagnoses that included pleural effusion, chronic kidney disease, stage 3B and hypertensive heart disease with heart failure. During an observation on 05/28/2026 at 8:15 AM, Resident #45 was noted to have +1 pitting edema to bilateral ankles. Review of Resident #45's physician order dated 05/15/2026 read, Weight: Daily every shift. Start date 05/15/2026. Review of Resident #45's TAR [treatment administration record] for May 2026 showed weight was documented as 5 (hold/see progress notes) on 05/15/2026, NA on 05/16/2026, 9 (other, see progress notes) on 05/17/2026 on the 7a-7p shift, 9 on 05/18/2026 on the 7a-7p shift, NA on 05/19/2026 on the 7a-7p and 7p-7a shifts, NA on 05/20/2026 on 7a-7p shift, not documented on 05/20/2026 7p-7a shift, 9 on 05/22/2026 and 9 on 05/24/2026. Review of Resident #45's nursing note dated 05/17/2026 read, Weight: Daily every shift restorative to complete. Review of Resident #45 nursing note dated 05/18/2026 read, Weight: Daily every shift restorative to complete. Review of Resident #45's physician order dated 05/21/2026 read, Weight: Daily every day shift. Start date 05/21/2026. Review of Resident #45's nursing note dated 05/22/2026 read, Weight: Daily every day shift. restorative to complete. During an interview on 05/28/2026 at 8:33 AM, Staff J, LPN stated, The restorative aide is responsible for doing the daily weights. Restorative is here Monday through Friday, and if restorative is not here, the nurse is responsible. During an interview on 05/28/2026 at 8:26 AM, Staff F, LPN Unit Manager stated, Restorative is responsible for daily weights, and they should be documented in the chart every day. During an interview on 05/28/2026 at 8:30 AM, Staff L, Restorative CNA stated, I do the daily weights, write them down and put them in the computer, the ones I am aware of. The nurses tell me who is a daily weight, and I do the admission weights. I am not here on weekends. Sometimes I have an assignment, and the CNA responsible for that hall does the daily weight. I am not aware of whether [Resident #45's name] is a daily weight. During an interview on 05/28/2026 at 8:40 AM, Staff J, LPN stated, I am not sure whether [Resident #45's name] is a daily weight or not. I will have to check. I don't think she is. During an interview on 05/28/2026 at 8:45 AM, Resident #45 stated, They have not been checking my weight every day. During an interview on 05/28/2026 at 12:57 PM, the Director of Nursing stated, If daily weights are ordered, I expect the nurse and the CNA to check the weight every day and document it. During an interview on 05/29/2026 at 11:31 AM, the Administrator stated, We do not have a policy specifically about following physician orders. Review of Resident #103's admission record documented diagnoses that include generalized anxiety disorder, solitary pulmonary nodule, dementia severe with behavioral disturbance psychotic disturbance mood disturbance and anxiety, type 2 diabetes mellitus, systemic inflammation response syndrome or non-infectious origin, and hypertension. Review of Resident #103's physician order dated 1/27/2025 read, CloNIDine HCl Oral Tablet 0.1 MG (Clonidine HCl) Give 1 tablet by mouth every 8 hours as needed for HTN (hypertension) GIVE for SBP [systolic blood pressure] greater than 160 or DBP [diastolic blood pressure greater than 90. Review of Resident #103's physician order dated 1/16/2025 read, Blood Pressure every 8 hours see PRN (as needed) CLONIDINE for SBP greater than 160 or DBP greater than 90. Review of Resident #103's May 2026 medication administration record (MAR) documented on 5/1/2026 at 2200 a blood pressure (B/P) of 188/93, on 5/2/2026 at 0600 a B/P of 116/99, on 5/10/2026 at 2200 a B/P of 175/76, on 5/11/2026 at 0600 a B/P of 162/76, on 5/13/26 at 1400 a B/P of188/90,on 5/14/26 at 1400 a B/P of 175/49, on 5/17 at 1400 a B/P of 178/63, on 5/21/26 at 1400 a B/P of 161/80 , on 5/23/26 at 0600 a B/P of 178/88 and on 5/24/2026 at 1400 a B/P of 164/83 and at 2200 a B/P of 168/79 and on 5/25/26 at 0600 a B/P of 168/79, no clonidine was administer every 8 hours as ordered on these dates. Review of Resident #103 April MAR documented on 4/1/26 a B/P of 168/82 at 1400 on 4/6/26 at 1400 a B/P of 168/76 , on 4/7/26 at 0600 a B/P of 168/78 and at 1400 a B/P of 165/82, on 4/10/26 at 1400 a B/P of 157/98, on 4/14/26 at 1400 a B/P of 179/97 on 4/24/26 at 1400 a B/P of 153/93, on 4/25/26 at 0600 a B/P of 180/91 on 4/28/26 at 2200 a B/P of 164/97 and on 4/29/26 at 0600 a B/P of 182/101 and at 1400 a blood pressure of 182/80, no clonidine was administered as ordered on these dates. Review of Resident #103 March MAR documented a B/P of 173/85 at 2200, on 3/3/2026 a B/P of 163/88 at 1400, on 3/6/26 at 1400 a B/P of 167/84, on 3/12/26 at 1400 a B/P of 164/91, on 3/13/26 at 1400 a B/P of 151/93, on 3/17/26 at 1400 a B/P of 171/93, on 3/20/26 at 2200 a B/P of 147/91, no clonidine was administered as ordered on these dates. During an interview on 5/27/2026 at 1:55 PM Staff M, Licensed Practical Nurse (LPN) stated, He does have that order for clonidine. No, I don't see that I did administer it. I should have. During an interview on 5/28/2026 at 6:45 AM the Director of Nursing (DON) stated, All orders should be followed. Review of the policy and procedure titled, Medication Administration General Guidelines approval date of 1/22/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. Procedure: B. Administration: 2). Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #14) of 7 residents reviewed for medication management and for 1 (Resident #58) of 5 residents reviewed for respiratory services. Findings include: Review of Resident #14's care plan did not document a focus for anxiety or antianxiety medication. Review of Resident #14's medical record resident was admitted on [DATE] with diagnoses including but not limited to major depressive disorder [onset date 4/28/2026], anxiety disorders [onset date 4/28/2026], and bipolar disorder [onset date 4/28/2026]. Review of Resident #14's physician order dated 4/28/2026 read, Clonazepam Oral Tablet 1 MG [milligram] give 1 tablet by mouth one time a day for severe anxiety. Review of Resident #14's physician order dated 5/1/2026 read, Clonazepam Oral Tablet 0.5 MG give 0.5 mg by mouth in the morning for anxiety. Review of Resident #14's physician order dated 5/11/2026 read, Clonazepam Oral Tablet 0.5 MG give 1 tablet mouth in the morning for anxiety Hold for sedation. Review of Resident #14's physician order dated 5/19/2026 read, Hydroxyzine HCl [hydrochloride] Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 14 Days. During an interview on 5/28/2026 at 8:47 AM with Staff H, Minimum Data Set Lead stated, We will have a morning meeting where we go over new orders, and the care plan will be revised. In looking at her [Resident #14's Name] care plan, you are correct; anxiety is not a focus, and it should be since she is on medication for anxiety. Review of Resident #58's comprehensive care plan did not document a focus for oxygen use or respiratory care. Review of Resident #58 admission record document diagnoses that include unspecified diastolic congestive heart failure, morbid severe obesity due to excess calories, protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, asthma, cardiomegaly, atherosclerotic heart disease of native coronary artery without angina pectoris, age-related osteoporosis, anxiety disorder, insomnia, essential primary hypertension and major depressive disorder recurrent moderate. Review of Resident #58 physician order dated 3/16/2026 read, Oxygen @ 2 L(liters)/Min(minute) continuous inhalation via nasal cannula. During an interview on 5/28/2026 at 6:44 AM the Director of Nursing stated, We go over residents and orders in our morning meetings. We should have implemented a care plan for her. During an interview on 5/28/2026 at 9:47 AM with Staff H, Minimum Data Set Lead stated, We will have a morning meeting where we go over new orders, and the care plan will be revised. I do not see any care plan related to oxygen use. Review of the facility policy and procedure titled Summit Care Resident Assessment Instrument Comprehensive Care Plan Policy with a last review date of 1/22/2026 read, Policy Statement. Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI), and to comply with state and federal regulations. Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes.

Based on record review and interview the facility failed to ensure assessments were accurately and completely documented for 3 residents (Resident #7, #129, and #14) of 10 sampled for preadmission screening and resident review. Findings include: Review of Resident #7's admission record documented diagnoses that include non-ST elevation myocardial infarction, chronic obstructive pulmonary disease with acute exacerbation, pneumonia, protein calorie malnutrition, chronic respiratory failure with hypoxia, chronic pain syndrome, and idiopathic peripheral autonomic neuropathy. Review of Resident #7's physician order dated 4/24/2026 read, psych consult. Review of Resident #7's physician order dated 3/19/2026 read, Amitriptyline HCl Oral Tablet 25 MG (Amitriptyline HCl) Give 25 mg by mouth at bedtime for Mdd (major depressive disorder). Review of Resident #7's psychiatric note dated 5/8/2026 read, Note Type: Balanced Wellbeing Psychiatry Subsequent Note. Patient admit date : [DATE] Chief Complaint: Depression, anxiety and nicotine dependence disorder. Review of Resident #7's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) dated 3/13/2026 showed there was no anxiety disorder or depressive disorder documented under Section 1A. Review of Resident #129's admission record documented diagnoses including Chronic obstructive pulmonary disease with acute exacerbation, bacteremia, pneumonia, Parkinson's disease with dyskinesia, chronic combined systolic congestive and diastolic congestive heart failure, atherosclerotic heart disease of native coronary artery, gastroesophageal reflux disease, depression, essential primary hypertension, hyperlipidemia, hypothyroidism, diaphragmatic hernia without obstruction or gangrene and anxiety disorder. Review of Resident #129's physician order dated 5/25/2026 read, RisperiDONE Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth two times a day for anxiety. Review of Resident #129's physician order dated 5/25/2026 read, HydrOXYzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet by mouth two times a day for anxiety. Review of Resident #129's physician order dated 5/25/2026 read, Psych consult Review of Resident #129's physician order dated 5/25/2026 read, Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth two times a day for anxiety. Review of Resident #129's PASSAR dated 5/20/2026 does not include anxiety disorder as a diagnosis. During an interview on 5/28/2026 at 6:35 AM the Director of Nursing (DON) stated, Their PASSAR's do not include the appropriate diagnosis and they should. During an interview on 5/28/2026 at11:42 AM, the Nursing Home Administrator (NHA) stated, I have no additional PASSAR for them. They are not correct. Usually the DON completes them, but I see that they have either been incorrect on admission or if they were admitted and got a new diagnosis from psych the IDT (interdisciplinary) team is not updating them and they should. Review of Resident #14's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) dated 4/27/2026 documented bipolar disorder as a mental illness or suspected mental illness. Review of Resident #14's medical admission record resident was admitted on [DATE] with diagnosis including but not limited to major depressive disorder recurrent [onset date 4/28/2026], other specified anxiety disorders [onset date 4/28/2026], and other bipolar disorder [onset date 4/28/2026]. Review of Resident #14's physician order dated 4/28/2026 read, Clonazepam oral tablet 1 MG [milligram] (Clonazepam) give 1 tablet by mouth one time a day for severe anxiety. Review of Resident #14's physician order dated 4/28/2026 read, Bupropion HCI [hydrochloride] ER [extended release] (XL) Oral Tablet Extended Release 24 Hour 150 MG [milligram] (Bupropion HCI) Give 1 tablet by mouth one time a day for MMD [Major Depressive Disorder] Do not crush, chew, or split. During an interview on 5/29/2026 at 8:30 AM, the Director of Nursing stated, [Resident #14's Name]'s PASSAR should have been reviewed and corrected to reflect all the diagnoses. Review of the policy and procedure titled Pre-admission Screening and Resident Review (PASRR) last approval date of 1/22/2026 read, The Admissions Coordinator/Designee is responsible for ensuring that the Level I PASRR Screen and Level II PASRR Evaluation and Determination, if applicable, are completed prior to admission. Procedure: 2. A level I PASRR must be fully and accurately complete and distributed in accordance with Rule 59G-1.040,F.A.,C. Upon or prior to admission, if the facility finds the Level I to be incomplete or inaccurate, a corrected Level I PASRR must be completed by hospital staff or appropriate Nursing Facility staff (physician, RN, MSW, or LCSW) or KEPRO staff.

Based on interview and record review the facility failed to ensure assessments were updated following documentation of a new diagnosis for 4 Residents (Resident #2, 5, 70, and 119) out of 10 Residents sampled for preadmission screening and resident reviews (PASARR). Findings include: Review of Resident #119's admission record showed Resident #119 diagnoses included altered mental status (onset date 4/3/2025), depression (onset date 4/8/2025), anxiety disorder (onset date 4/8/2025), brief psychotic disorder (onset date 4/8/2025) and major depressive disorder (onset date 4/3/2025). Review of Resident #119's Level I Preadmission Screening and Resident Review (PASARR), dated 4/2/2026, showed no entry in section A. MI [mental illness] or suspected MI [mental illness]. During interview on 5/28/2026 at 11:43 AM, the Administrator confirmed Resident #119's Level I PASARR had not been updated to include mental health diagnoses. Review of Resident # 70's admission record showed a diagnosis of Dementia with other diseases classified elsewhere mild, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety onset date 2/13/2026. Review of Resident 70's PASARR dated 1/8/2026 was not revised to document a diagnosis of Dementia. Record review of Resident #2s admission record showed diagnoses including vascular dementia onset date 5/09/2025 and major depressive disorder onset date 2/4/2026. Review of Resident #2's Level I PASARR screening dated 5/08/2025 identified Resident #2 as diagnosed with Vascular dementia, the PASARR was not revised to reflect a diagnosis of major depressive disorder. Review of Resident #5's admission record showed a diagnosis of PTSD (Post Traumatic Stress Syndrome) onset date 6/24/2022. Review of Resident #5's Level I PASARR screening dated 2/16/2026 showed no documentation of PTSD. During an interview on 5/27/2026 at 11:32 am, the Social Services Director stated, I don't sign the PASARR's, but do review them when directed to do so. When a resident is first admitted , the Director of Nursing is the responsible one for the PASARR's. During interview on 5/28/2026 at 11:43 am, the Administrator stated, The PASARR process should be an IDT (Interdisciplinary Team) approach. Previously the Director of Nursing was responsible. During interview on 5/29/2026 at 11:05 am, the Director of Nursing stated, I saw the issues with the PASARRs.

Based on interviews, record reviews, and review of policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical wellbeing of each resident by failing to implement policy and procedures for medication administration. The facility failed to ensure residents with prescribed controlled medications were administered the medications per the physician order when failing to contact the physician when prescriptions were needed and the medications were not administered for three of three residents reviewed( Residents #7, #9, and #10). Resident #7, with a history of prescribed Alprazolam use, was admitted into the facility on 6/11/2025 and had been prescribed Alprazolam four times a day. Resident #7 suffered withdrawal symptoms of sweating, shaking, insomnia, and increased pain. There was a delay in administering Alprazolam until 6/13/2025 at 9:00 PM resulting in nine missed doses. Resident #9, with a history of prescribed Alprazolam use, was admitted into the facility on 5/20/2025 and was prescribed Alprazolam once a day. Resident #9 was not administered Alprazolam until 5/24/2025 resulting in three missed doses. Resident #10, a long-time resident of the facility, with a history of prescribed Alprazolam use, was prescribed Alprazolam twice a day and missed three doses. The facility's failure to implement the policy and procedure for medication administration to ensure residents who required Alprazolam received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy at a scope and severity of pattern (K). The Nursing Home Administrator was notified of the Immediate Jeopardy on June 17, 2025, at 4:44 PM. Findings include: Review of the document titled, Nursing Home Job Description Administrator, read, Job function: responsible for directing the overall operation of the facility's activities with current federal, state, local and corporate standards, guidelines and regulations ensuring the highest degree of quality resident care is provided at all times. Supervises: Department Heads and Office staff. Primary Responsibilities: 1. Assure that the goals of the Nursing Home are being met-the provision of quality resident care in a highly respectful, highly regulated, well managed, and caring environment and billing and collection for these services. 2. Complete other duties as assigned by supervisor. Specific Duties: .4. Personnel b. Participate in orientation training program for new employees and monitor training including, but not limited to, OJT (on the job training), and in-services. C. Monitor staff training period for all employees. Review of the document titled, Nursing Home Job Description Director of Nursing, read, Job Function: coordinate and direct all health care services provided to the Resident. Supervises: Shift Coordinators, CNA's (Certified Nursing Assistants), MDS (minimum data set) Coordinators, Shift Nurses, Medical Services, Medical Records, Pharmacist. Report to: Administrator. Primary responsibilities: 1. Implement and monitor facility policies and procedures to ensure that the facility is in compliance with all Federal and State Minimum Standards as they apply to nursing and medical services. 3. Supervise all documentation of services provided to residents. 9. Interview, hire, train and supervise all employees under your supervision and review staff competency in dealing with medical issues and provide training on a regular and as needed basis. 10. Perform other duties as assigned by the Administrator. Specific duties: 2. Final responsibility for interviewing, hiring, scheduling and supervising all staff that work under your supervision .18. Spot check all nurses' documentation by randomly auditing charts daily. 19. Coordinate review of Physician Order Sheets on a monthly basis for accuracy. 21. Monitor eMAR (electronic Medication Administration Record) compliance reports, routinely observe medication administration. Investigate medication errors and follow up with any corrective action. Review of the document titled, Medical Director Services Agreement, read, Recitals: Now therefore, in consideration of the covenants and agreements herein contained and the moneys to be paid here under, the parties agree upon the following terms and conditions: 3 Medical Director of Facility: During the term, Physician agrees to serve as Medical Director for Facility. Physician agrees to perform the services identified on Exhibit A attached hereto and incorporated herein by reference. Exhibit A: Associate Medical Director Services: Physician shall provide these services in conjunction with the Facility Medical Director and Facility. 2. Develop, implement, and evaluate resident care policies, procedures and guidelines, based on the current standards of practice, and collaborate with Facility leadership, including the Facility Medical Director, staff, and other practitioners and consultants regarding the following: b. accidents and incidents, use of medications, use and release of clinical information, ancillary services such as laboratory, radiology, and pharmacy and overall quality of care. d. the safe and effective use of medications to meet the needs of residents, j. the contents of the Facility's emergency medication kit and k. medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed health care practitioners. 5. Advise and consult with the Facility Administrator and Medical Director regarding: a. Facility's ability to meet the residents' needs and opportunities for future resident care programs, b. the adequacy and appropriateness of Facility's scope of services, medical equipment, and its professional and support staff; d. the staffing, operational, and other needs of the facility; 6. Direct and Coordinate: a. the medical care in Facility and ensure Facility is providing appropriate care as required; e. In-service education by providing information for Facility personnel as may be required by accrediting bodies and facility, including pertinent education regarding existing and proposed procedures within Facility. Review of the admission Record for Resident #9 documented an admission date of 5/20/2025 with medical diagnoses that include anxiety disorder unspecified, depression unspecified, essential (primary) hypertension (high blood pressure), unspecified fracture of right pubis (break in the bone of the pelvis) subsequent encounter for fracture with routine healing, fall on same level from slipping tripping and stumbling without subsequent striking against object subsequent encounter, gastroesophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease unspecified. Review of hospital Discharge summary dated [DATE] for Resident #9 read, New medications included Alprazolam 0.5 mg (milligrams) daily next dose tomorrow (05/21/25) morning. Review of Resident #9's physician orders dated 5/20/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth in the morning for anxiety. Review of Resident #9's May medication administration record (MAR) on 5/21, 5/22 and 5/23/2025 Alprazolam is documented as 9 [chart code for other/see nurses notes]. Review of Resident #9's progress notes from 5/20/2025 through 5/23/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. Review of Resident #9's Specialty Rx [a symbol that primarily refers to a prescription in the medical context] form titled, Medication Monitoring/Control Record, with a date received as 5/23/2025 documented the first dose of Alprazolam administered to Resident #9 was on 5/24/2025 at 0900 [9:00 AM]. Review of Resident #9's comprehensive care plan with an implementation date of 5/20/2025 read, Focus: [Resident #9's name] uses anti-anxiety medications. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift. During an interview on 6/16/2025 at 10:13 AM Resident #9 stated, I do take medication for my anxiety. I am getting my medicine now, but when I was first admitted , it took a long time for them to get it. I think it was three days before they got it from the pharmacy. They [the nurses] kept saying they were waiting on the pharmacy. I don't really know why it would take so long, they knew I was coming, and they knew what I needed to take when I got here. It is upsetting to think they can't get the medicines you need. During an interview on 6/16/2025 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN) stated, I did take care of [Resident #9's name] and I did not give her the Alprazolam on 5/23, it wasn't in yet. I do think I called and made sure it was ordered. I think I called the pharmacy. I didn't know that we could get it out of the [name of the automated medication dispensing system]. During an interview on 6/16/2025 at 1:30 PM the Advanced Practice Registered Nurse (APRN) stated, I was not notified that [Resident #9's name] also did not receive her Xanax [Alprazolam] when she was admitted . I'm not sure why that happened. It should not take three days to receive medication for a resident. She [Resident #9] would be at risk for withdrawal symptoms. This is a problem that nurses are not aware of what is available to them and what they need to do. During an interview on 6/17/2025 at 7:30 AM Staff C, LPN stated, I was not aware that there was Alprazolam in the [name of the automated medication dispensing system] machine. I did not give her [Resident #9] her Alprazolam, it was ordered, and a prescription had been sent to pharmacy, so we were just waiting for it to get in. 2. Review of the admission Record for Resident #10 documented an admission date of 8/27/2024 with medical diagnoses that include chronic obstructive pulmonary disease unspecified, major depressive disorder recurrent unspecified, peripheral vascular disease (reduced circulation of blood to a body part) unspecified, atherosclerotic heart disease of native coronary arteries (heart disease) without angina pectoris (chest pain), essential (primary) hypertension, anxiety disorder unspecified, and other chronic pain. Review of Resident #10's physician orders dated 5/26/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth every 12 hours for Anxiety. Review of Resident #10's May MAR, Alprazolam was documented as 9 [chart code for other/ see nurses notes] for 5/31/2025 at 2100 [9:00 PM]. Review of Resident #10's Specialty Rx form titled, Medication Monitoring/Control Record documented the last dose of Alprazolam 0.5 mg was administered to Resident #10 on 5/31/2025 at 9:21 AM. Review of Resident #10's June MAR alprazolam 0.5 mg documented as 9 [chart code other see nurses] for 6/1/2025 at 0900 [9:00 AM] and 2100 [9:00 PM]. Review of Resident #10's Specialty Rx form titled Medication Monitoring/Control Record date received of 6/2/25 documented the next dose of Alprazolam 0.5 mg was administered to Resident #10 on 6/2/2025 at 0900 (9:00 AM). Review of Resident #10's progress notes from 5/31/2025 through 6/4/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not give [Resident #10's name] her Alprazolam either. I did call pharmacy on her [Resident #10], and they needed a prescription, and I think I called and got it. Like I told you, I had no idea we could get it from the [name of the automated medication dispensing system]. 3. Review of the admission Record for Resident #7 documented an admission date of 6/11/2025 with medical diagnoses that include fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, unspecified fracture of sacrum, subsequent encounter for fracture with routine healing, unstable burst fracture of T5-T6 [thoracic, upper back between the neck and lumbar spine] vertebra, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter, unspecified fracture of T11-T12 vertebra, chronic obstructive pulmonary disease with (acute) exacerbation, peripheral vascular disease, unspecified, age-related osteoporosis without current pathological fracture, chronic systolic (congestive) heart failure, unspecified osteoarthritis, unspecified site, acute and chronic respiratory failure with hypoxia, hypothyroidism, unspecified, displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, diverticulitis of both small and large intestine without perforation or abscess without bleeding, nondisplaced comminuted [type of bone fracture where the bone breaks in three or more pieces] fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified fracture of unspecified thoracic vertebra, sequela, unspecified fracture of first lumbar vertebra, sequela, hyperlipidemia, unspecified, iron deficiency anemia secondary to blood loss (chronic), personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, anxiety disorder, unspecified, personal history of other venous thrombosis and embolism, and chronic atrial fibrillation, unspecified. Review of hospital Discharge summary dated [DATE] for Resident #9 read, Continued Medications: 8. Alprazolam 1 mg oral four times a day. Review of Resident #7's physician orders dated 6/11/2025 read, Alprazolam Oral Tablet 1 MG Give 1 tablet by mouth four times a day for anxiety. Review of Resident #7's June MAR Alprazolam 1 mg documented as 9 [chart code other/see nurses notes] on 6/11/2025 at 1700 [5:00PM], 2100 [9:00 PM], on 6/12/2025 at 0900, 1200, 1700 [5:00 PM] and 2100 [9:00 PM], on 6/13/2025 at 0900, 1200, and 1700. Review of Resident #7's Specialty Rx form titled, Medication Monitoring/Control Record documented that Alprazolam tab 1 mg 1 tablet by mouth four times daily for 30 days was received at the facility on 6/13/2025. The first dose of Alprazolam 1 mg was administered to Resident #7 on 6/13/2025 at 2100 [9:00 PM]. A total of nine doses were not administered. Review of Resident #7's progress notes from 6/11/2025 through 6/14/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an observation on 6/15/2025 at 1:20 PM, Resident #7's spouse was assisting her with meal at bedside. An interview with the spouse, [Resident Representative's name] stated It took them four days to get a medication she has taken for years. She takes Xanax [Alprazolam] 1 mg 4 times a day and they didn't give it to her. She was just having a terrible time, sweating, shaking, not sleeping good, and having just an awful time of it. Her pain was worse, and she wouldn't let them do things to her. I tried telling them, but they wouldn't listen. She has taken this medication for years now. During an interview on 6/15/2025 at 1:30 PM, Resident #7 stated, I was feeling awful, in so much pain, sweating, aching all over and just couldn't do anything because I felt so awful. I asked everyday about my medication, and they just told me it wasn't here. I felt awful, I think I was more anxious, couldn't sleep right, was sweaty and miserable. I did start feeling better after I got the medication. It came and I think it was four days before they got it, but I can't say for sure now. It was the one nurse here for a few days, she just kept saying pharmacy hadn't sent it. I don't know why they didn't have it. Then one day they told me the doctor needed to order it, but I was taking it in the hospital. I know I have a lot of broken bones, but when I didn't get the medicine, I feel like I was in a lot more pain, everything hurt worse. I asked every nurse when they gave medicine where it was and how long before it got here, none of them could say. I don't understand why they didn't get the medicine. I don't understand why the pharmacy doesn't deliver medicine faster. They should have made sure the prescription was there when I first got here. I can't understand why they [the nurses] didn't call for the prescription sooner, why did it take so long. I asked every time a nurse came in if my medicine was here yet. They did not care or really listen to me. They should make sure that medicine is here when someone is admitted . We told the nurses every day. During an interview on 6/15/2025 at 1:58 PM, the Director of Nursing (DON) stated, It is a standard of care that nurses call the doctors and let them know that medications are not available to administer. The staff should have called the doctor and documented that in the chart. The 9 chart code is other/see nurses notes. There are no notes in the chart telling me why the [Alprazolam] wasn't given. I don't think we have policies for med [medication] administration that state when to call the doctor, that is a standard if residents refuse or meds [medications] are not available, we give them [the physician] a call. During an interview on 6/16/2025 at 10:45 AM, the DON stated, The process is that we admit patients and fax the prescriptions to pharmacy from the hospital, sometimes they don't come with the resident, and we will need to call the doctor or nurse practitioner and have them provide a prescription to the pharmacy. This was not done for her [Resident #7], they did not call the provider until the 13th, they should have. I don't know if it is available in the EDK (Emergency Drug Kit) [also known as the automated medication dispensing system]. During an observation on 6/16/2025 at 10:45 AM, with the DON and the Administrator of the supply room where the automated medication dispensing machine was located, there was a printed handout that provided a list of all medications that were available to be taken from the machine. On page one of the document titled, [the name of the automated medication dispensing system] inventory is Alprazolam 0.25 mg Par [periodic automatic replenishment] 20. During an interview on 6/16/2025 at 10:45 AM, the DON stated, Well, the [Alprazolam] were in the [name of the automated medication dispensing system] and we should have been able to call the provider, get a script (prescription) and then call pharmacy for the code to administer the medication. The [Alprazolam] were available the entire time she [Resident #7] went without them. I guess the nurses did not know they were available for them [Residents #7, #9, and #10]. Each nurse should have called the doctor or nurse practitioner, asked them to get a script to pharmacy and asked pharmacy to let them get the med (medication) from the [name of the automated medication dispensing system]. I guess they all need training on everything that's available in it [ the automated medication dispensing system]. I was not aware that this was happening, none of the nurses came to me or a supervisor and let them know about this. It is a professional standard of practice to notify a doctor when medication can't be administered. I will have to check, but I don't think anyone documented that they did any type of notification to a doctor or nurse practitioner. During an interview on 6/16/25 at 11:30 AM, Staff A, LPN stated, I called [the pharmacy] on the 13th to get her [Resident #7] medication. I didn't know that Xanax [Alprazolam] was available in the machine at that time. We are supposed to notify the doctor when we are unable to administer any medications. We need to let the doctor know with one missed dose. I did not call the doctor or nurse practitioner. I didn't know what was in the machine [the automated medication dispensing system] or that narcotics were in there. When we don't have a medicine we need to get a script (prescription) and call the pharmacy to get an authorization code to get the medicine. She didn't complain about anything to me except not having the medicine for a few days. Her husband was there [on 6/13] and he did say, she needs it she takes it all the time and she's hurting without it. I explained that I needed to get the prescription from the doctor and there wasn't anything I could do until I got the prescription and sent it. I feel badly; I really don't know anything about the withdrawal symptoms. I don't think that [what is available in the automated medication dispensing system] was covered when I oriented. I don't think they went over what was in the machine [the automated medication dispensing system].I did not document in the progress notes that I couldn't administer the medication. I really should have done that. I did not call pharmacy every day or with every dose she missed, I should have. During an interview on 6/16/2025 at 1:30 PM, the APRN stated, I was called on I think it was the 13th for a prescription for her [Resident #7] Xanax (Alprazolam). I can't tell you exactly when she [the nurse] contacted me. I think that some of the problems are the hospitals sometimes don't send prescriptions with the patients when they get discharged . I do think I should have been contacted for both of the patients [Resident #7 and #9] when they couldn't administer the medications when ordered. [Resident #7's name] has taken 1 mg of Xanax for a long time. She could have had withdrawal symptoms starting within the 24 hours, irritability, sweating, sleeplessness, heightening pain and discomfort. There absolutely is the risk of withdrawal with abrupt stopping of benzodiazepines [a class of central nervous system depressants used to treat anxiety, insomnia and seizures]. She would likely, most people would likely, begin to feel the effects within 24 hours and it would worsen. There is a likelihood of a seizure. It would be harmful for anyone who was on benzodiazepines to suffer withdrawal when they aren't administered the medication and abruptly stopped. They should have called me. I would have provided the pharmacy with the script. I would not know what is in the [name of the automated medication dispensing system], but if Xanax is in it I could have provided a script for a limited number of doses until the correct dose was available from pharmacy. I would say that anyone could possibly suffer harm from this [not being administered Alprazolam]. I do expect to be notified if nursing can't administer ordered medications, if vitals are abnormal and meds don't have parameters. I want to be notified with any changes in the resident's condition. This is a problem that nurses are not aware of what is available to them and what they need to do. During an interview on 6/17/2025 at 7:10 AM, Staff B, LPN stated, I took care of [Resident #7's name] and did not have the medication to administer on the night of her admission. I was waiting on the medication to get here. I can't remember but I think I called pharmacy that night and they said they were working on getting her meds (medications) in. I have been a nurse for a long time, and I know each place has an EDK [Emergency Drug Kit], whether it's a [name of the automated medication dispensing system] or a box. But I didn't realize we should call and get another one-time order for the medication. I should have done that. I didn't know that we could get the Xanax [Alprazolam]. I did not get any orders and did not call the pharmacy or the nurse practitioner. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not do any medication orders for her [Resident #7], that was completed by another staff, [Staff E, LPN's name], on the day she was admitted . I got involved when my father [Staff C is Resident #7's daughter] came and told me she still didn't have her medication. He told me this every day and finally on the 13th I found out it was because she didn't have a prescription with the pharmacy, and I called [APRN's name] and got that taken care of. She [Resident #7] has been taking this medication for at least eight years now, at that dose and really she is dependent on it. I do think she [Resident #7] was experiencing withdrawal symptoms. Finally on the 13th at some time she finally got the medicine. I don't take direct care of her ever and I try not to interfere with her [Resident #7] care, but I needed to make sure she had her medicine. During a telephone interview on 6/17/2025 at 8:47 AM, the Registered Pharmacist, RPhD [doctorate] stated, We receive orders and e [electronic] scripts daily for all residents from this facility. All prescribers have access to Escribe [an electronic record to prescribe medications electronically] and can send orders at any time of the day and night. Typically, medications will go out at 2 PM and 2 AM but the facilities can ask for a stat [Latin word STATim which translates to immediately] run at any time. If the orders are received prior to 1-1:30 PM, they will go out with the afternoon run and will be at the facility between 5-7 PM depending on traffic and if received prior to 1:30 AM, it would arrive between 5-7 AM. We do have Alprazolam on PAR (periodic automatic replacement) in the [name of the automated medication dispensing system]. I can't say for sure, but I think it's a PAR of 20 at all times. I would say there is a huge problem if this medication is stopped abruptly, a large risk of withdrawal, this would begin with 16-24 hours after the last dose and would continue up to 5-10 days and with extended use, people can have a longer more extensive withdrawal time. Most commonly people develop nausea, vomiting, restlessness, irritability, agitation sleep disturbances, shakes and tremors. The most severe would be seizures and that generally occurs with higher doses at longer duration of exposure. At 1 mg four times a day it is likely that the patient began to experience one or more of these symptoms. I would say that withdrawal is not physically or mentally comfortable. The medication was always available to be administered to the patient until her medication arrived had someone called and notified us that she did not have the medication. We could have told them that we needed the prescription before the 13th. During an interview on 6/17/2025 at 9:11 AM, Staff D, LPN stated, I didn't realize that we could pull the medicine from the machine [the automated medication dispensing system]. I didn't know it [Alprazolam] was in there. I just thought it was like antibiotics and things like that. I should have asked someone about it. I should have called the doctor to get more orders, and I didn't. During an interview on 6/17/2025 at 9:50 AM, the Medical Director stated, I am the Medical Director and have been notified of the concerns that you have brought. I understand this impacted three residents, one taking Xanax once a day, one twice a day, and one four times a day. We do have some concerns with really newly admitted patients not coming with prescriptions for medications and here with some on-call providers not being able to escribe meds. But as Medical Director I am always available. There would be concerns with stopping this [Alprazolam] for long periods of time. We have more problems with opioids and returning patients to hospital because they have not come with a prescription and a provider who doesn't want to prescribe without first seeing the patient. I think this was caused when the nurses did not know that it [Alprazolam] was available and is always available. I am not their doctor so I can't really say if it would have caused any harm. During an interview on 6/17/2025 at 11:17 AM Staff E, LPN stated, I didn't actually do anything with [Resident #7's name] except fax the orders to pharmacy. I didn't see a prescription for the Xanax [Alprazolam] and the nurse coming on, I told that to her. I told her that I didn't do that [send the order for Xanax [Alprazolam]]. I did not call the nurse practitioner for the prescription. I did not know that the medication was in the [name of the automated dispensing system] machine. I don't remember any training on that. During an interview on 6/17/2025 at 3:05 PM, the DON stated, I should have been more involved and made sure that the nurses were aware of the process. I handed this to the Educator, who no longer works here, and I should have made sure that all staff were trained. It is my responsibility. No one told me that anyone had concerns about their medications. I do not audit medication administration. I just wasn't aware that this was a concern. I do expect all staff to follow doctor's orders for medications and call when they cannot give the med [medication]. Staff should all know what medications are available to them in the [name of the automated medication dispensing system]. During an interview on 6/17/2025 at 3:30 PM, the Administrator stated, Well, I would have to defer any nursing questions to the Director of Nursing, I am not clinical. Ultimately, I do expect staff to follow the policies and procedures for medication administration and any other we have. Review of the policy and procedure titled Medication Administration General Guidelines last approval date of 01/2025 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedure: A. Preparation . 11.) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g.,) are searched , if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. B. Administration .2) Medications are administered in accordance with written orders of the prescriber 6) Medications are administered without unnecessary interruptions. D. Documentation (including electronic) .6) If a dose of regularly scheduled medication is withheld, refused, not available or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of an antibiotic is needed), the space provided in [name of clinical software] is coded with appropriate code. An explanatory note is entered in nurses notes/progress note. If a dose of vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. The Immediate Jeopardy (IJ) was removed onsite on June 17,2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On June 17, 2025, an Ad Hoc [Latin meaning 'for this'] QAPI [Quality Assurance and Performance Improvement] was completed in the presence of the Nursing Home Administrator, the Director of Nursing, and the Medical Director to identify the root cause analysis. It was determined that the facility failed to ensure residents were free from medication errors and missed controlled prescription medications when facili[TRUNCATED]

Based on interviews, record reviews, and review of policy and procedures, the facility failed to ensure residents with prescribed controlled medications were administered the medications per the physician order when failing to contact the physician when prescriptions were needed and the medications were not administered for three of three residents reviewed for medication administration (Residents #7, #9, and #10). Resident #7, with a history of prescribed Alprazolam use, was admitted into the facility on 6/11/2025 and had been prescribed Alprazolam four times a day. Resident #7 suffered withdrawal symptoms of sweating, shaking, insomnia, and increased pain. There was a delay in administering Alprazolam until 6/13/2025 at 9:00 PM resulting in nine missed doses. Resident #9, with a history of prescribed Alprazolam use, was admitted into the facility on 5/20/2025 and was prescribed Alprazolam once a day. Resident #9 was not administered Alprazolam until 5/24/2025 resulting in three missed doses. Resident #10, a long-time resident of the facility, with a history of prescribed Alprazolam use, was prescribed Alprazolam twice a day and missed three doses. Abruptly stopping Alprazolam can be dangerous and lead to a range of severe, potentially life-threatening complications. These dangers can include tremors and seizure, nausea, vomiting, diarrhea, muscle pain and stiffness, heart palpitations, headaches, irritability and agitation, confusion and delirium, hallucinations and psychosis, and suicidal thoughts or actions. The facility's failure to implement the policy and procedures for medication administration and failure to ensure residents who required Alprazolam received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy at a scope and severity of pattern (K). The Nursing Home Administrator was notified of the Immediate Jeopardy on June 17, 2025, at 4:44 PM. Findings include: Review of the admission Record for Resident #9 documented an admission date of 5/20/2025 with medical diagnoses that include anxiety disorder unspecified, depression unspecified, essential (primary) hypertension (high blood pressure), unspecified fracture of right pubis (break in the bone of the pelvis) subsequent encounter for fracture with routine healing, fall on same level from slipping tripping and stumbling without subsequent striking against object subsequent encounter, gastroesophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease unspecified. Review of hospital Discharge summary dated [DATE] for Resident #9 read, New medications included Alprazolam 0.5 mg (milligrams) daily next dose tomorrow (05/21/25) morning. Review of Resident #9's physician orders dated 5/20/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth in the morning for anxiety. Review of Resident #9's May medication administration record (MAR) on 5/21, 5/22 and 5/23/2025, Alprazolam was documented as 9 [chart code for other/see nurses notes]. Review of Resident #9's progress notes from 5/20/2025 through 5/23/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. Review of Resident #9's Specialty Rx [a symbol that primarily refers to a prescription in the medical context] form titled, Medication Monitoring/Control Record, with a date received as 5/23/2025 documented the first dose of Alprazolam administered to Resident #9 was on 5/24/2025 at 0900 [9:00 AM]. Review of Resident #9's comprehensive care plan with an implementation date of 5/20/2025 read, Focus: [Resident #9's name] uses anti-anxiety medications. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift. During an interview on 6/16/2025 at 10:13 AM, Resident #9 stated, I do take medication for my anxiety. I am getting my medicine now, but when I was first admitted , it took a long time for them to get it. I think it was three days before they got it from the pharmacy. They [the nurses] kept saying they were waiting on the pharmacy. I don't really know why it would take so long, they knew I was coming, and they knew what I needed to take when I got here. It is upsetting to think they can't get the medicines you need. During an interview on 6/16/2025 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN) stated, I did take care of [Resident #9's name] and I did not give her the Alprazolam on 5/23, it wasn't in yet. I do think I called and made sure it was ordered. I think I called the pharmacy. I didn't know that we could get it out of the [name of the automated medication dispensing system]. During an interview on 6/16/2025 at 1:30 PM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified that [Resident #9's name] did not receive her Xanax [Alprazolam] when she was admitted . I'm not sure why that happened. It should not take three days to receive medication for a resident. She [Resident #9] would be at risk for withdrawal symptoms. This is a problem that nurses are not aware of what is available to them and what they need to do. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I was not aware that there was Alprazolam in the [name of the automated medication dispensing system] machine. I did not give her [Resident #9] her Alprazolam, it was ordered, and a prescription had been sent to pharmacy, so we were just waiting for it to get in. 2. Review of the admission Record for Resident #10 documented an admission date of 8/27/2024 with medical diagnoses that include chronic obstructive pulmonary disease unspecified, major depressive disorder recurrent unspecified, peripheral vascular disease (reduced circulation of blood to a body part) unspecified, atherosclerotic heart disease of native coronary arteries (heart disease) without angina pectoris (chest pain), essential (primary) hypertension, anxiety disorder unspecified, and other chronic pain. Review of Resident #10's physician orders dated 5/26/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth every 12 hours for Anxiety. Review of Resident #10's May MAR, Alprazolam was documented as 9 [chart code for other/see nurses notes] for 5/31/2025 at 2100 [9:00 PM]. Review of Resident #10's Specialty Rx form titled, Medication Monitoring/Control Record documented the last dose of Alprazolam 0.5 mg was administered to Resident #10 on 5/31/2025 at 9:21 AM. Review of Resident #10's June MAR Alprazolam 0.5 mg documented as 9 [chart code for other/see nurses notes] for 6/1/2025 at 0900 [9:00 AM] and 2100 [9:00 PM]. Review of Resident #10's Specialty Rx form titled Medication Monitoring/Control Record, date received 6/2/25 documented the next dose of Alprazolam 0.5 mg was administered to Resident #10 on 6/2/2025 at 0900 (9:00 AM). Review of Resident #10's progress notes from 5/31/2025 through 6/4/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not give [Resident #10's name] her Alprazolam either. I did call pharmacy on her [Resident #10], and they needed a prescription, and I think I called and got it. Like I told you, I had no idea we could get it from the [name of the automated medication dispensing system]. 3. Review of the admission Record for Resident #7 documented an admission date of 6/11/2025 with medical diagnoses that include fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, unspecified fracture of sacrum, subsequent encounter for fracture with routine healing, unstable burst fracture of T5-T6 [thoracic, upper back between the neck and lumbar spine] vertebra, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter, unspecified fracture of T11-T12 vertebra, chronic obstructive pulmonary disease with (acute) exacerbation, peripheral vascular disease, unspecified, age-related osteoporosis without current pathological fracture, chronic systolic (congestive) heart failure, unspecified osteoarthritis, unspecified site, acute and chronic respiratory failure with hypoxia, hypothyroidism, unspecified, displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, diverticulitis of both small and large intestine without perforation or abscess without bleeding, nondisplaced comminuted [type of bone fracture where the bone breaks in three or more pieces] fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified fracture of unspecified thoracic vertebra, sequela, unspecified fracture of first lumbar vertebra, sequela, hyperlipidemia, unspecified, iron deficiency anemia secondary to blood loss (chronic), personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, anxiety disorder, unspecified, personal history of other venous thrombosis and embolism, and chronic atrial fibrillation, unspecified. Review of the hospital Discharge summary dated [DATE] for Resident #9 read, Continued Medications: 8. Alprazolam 1 mg oral four times a day. Review of Resident #7's physician orders dated 6/11/2025 read, Alprazolam Oral Tablet 1 MG Give 1 tablet by mouth four times a day for anxiety. Review of Resident #7's June MAR Alprazolam 1 mg was documented as 9 [chart code other/see nurses notes] on 6/11/2025 at 1700 [5:00PM], 2100 [9:00 PM], on 6/12/2025 at 0900, 1200, 1700 [5:00 PM] and 2100 [9:00 PM], on 6/13/2025 at 0900, 1200, and 1700. Review of Resident #7's Specialty Rx form titled, Medication Monitoring/Control Record documented that Alprazolam tab 1 mg 1 tablet by mouth four times daily for 30 days was received at the facility on 6/13/2025. The first dose of Alprazolam 1 mg was administered to Resident #7 on 6/13/2025 at 2100 [9:00 PM]. A total of nine doses were not administered. Review of Resident #7's progress notes from 6/11/2025 through 6/14/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an observation on 6/15/2025 at 1:20 PM, Resident #7's spouse was assisting her with meal at bedside. An interview with the spouse, [Resident Representative's name] stated It took them four days to get a medication she has taken for years. She takes Xanax [Alprazolam] 1 mg 4 times a day and they didn't give it to her. She was just having a terrible time, sweating, shaking, not sleeping good, and having just an awful time of it. Her pain was worse, and she wouldn't let them do things to her. I tried telling them, but they wouldn't listen. She has taken this medication for years now. During an interview on 6/15/2025 at 1:30 PM, Resident #7 stated, I was feeling awful, in so much pain, sweating, aching all over and just couldn't do anything because I felt so awful. I asked everyday about my medication, and they just told me it wasn't here. I felt awful, I think I was more anxious, couldn't sleep right, was sweaty and miserable. I did start feeling better after I got the medication. It came and I think it was four days before they got it, but I can't say for sure now. It was the one nurse here for a few days, she just kept saying pharmacy hadn't sent it. I don't know why they didn't have it. Then one day they told me the doctor needed to order it, but I was taking it in the hospital. I know I have a lot of broken bones, but when I didn't get the medicine, I feel like I was in a lot more pain, everything hurt worse. I asked every nurse when they gave medicine where it was and how long before it got here, none of them could say. I don't understand why they didn't get the medicine. I don't understand why the pharmacy doesn't deliver medicine faster. They should have made sure the prescription was there when I first got here. I can't understand why they [the nurses] didn't call for the prescription sooner, why did it take so long. I asked every time a nurse came in if my medicine was here yet. They did not care or really listen to me. They should make sure that medicine is here when someone is admitted . We told the nurses every day. During an interview on 6/15/2025 at 1:58 PM, the Director of Nursing (DON) stated, It is a standard of care that nurses call the doctors and let them know that medications are not available to administer. The staff should have called the doctor and documented that in the chart. The 9 chart code is other/see nurses notes. There are no notes in the chart telling me why the [Alprazolam] wasn't given. I don't think we have policies for med [medication] administration that state when to call the doctor, that is a standard if residents refuse or meds [medications] are not available, we give them [the physician] a call. During an interview on 6/16/2025 at 10:45 AM, the DON stated, The process is that we admit patients and fax the prescriptions to pharmacy from the hospital, sometimes they don't come with the resident, and we will need to call the doctor or nurse practitioner and have them provide a prescription to the pharmacy. This was not done for her [Resident #7], they did not call the provider until the 13th, they should have. I don't know if it is available in the EDK (Emergency Drug Kit) [also known as the automated medication dispensing system]. During an observation on 6/16/2025 at 10:45 AM, with the DON and the Administrator of the supply room where the automated medication dispensing machine was located, there was a printed handout that provided a list of all medications that were available to be taken from the machine. On page one of the document titled, [the name of the automated medication dispensing system] inventory is Alprazolam 0.25 mg Par [periodic automatic replenishment] 20. During an interview on 6/16/2025 at 10:45 AM, the DON stated, Well, the [Alprazolam] were in the [name of the automated medication dispensing system] and we should have been able to call the provider, get a script (prescription) and then call pharmacy for the code to administer the medication. The [Alprazolam] were available the entire time she [Resident #7] went without them. I guess the nurses did not know they were available for them [Residents #7, #9, and #10]. Each nurse should have called the doctor or nurse practitioner, asked them to get a script to pharmacy and asked pharmacy to let them get the med (medication) from the [name of the automated medication dispensing system]. I guess they all need training on everything that's available in it [ the automated medication dispensing system]. I was not aware that this was happening, none of the nurses came to me or a supervisor and let them know about this. It is a professional standard of practice to notify a doctor when medication can't be administered. I will have to check, but I don't think anyone documented that they did any type of notification to a doctor or nurse practitioner. During an interview on 6/16/25 at 11:30 AM, Staff A, LPN stated, I called [the pharmacy] on the 13th to get her [Resident #7] medication. I didn't know that Xanax [Alprazolam] was available in the machine at that time. We are supposed to notify the doctor when we are unable to administer any medications. We need to let the doctor know with one missed dose. I did not call the doctor or nurse practitioner. I didn't know what was in the machine [the automated medication dispensing system] or that narcotics were in there. When we don't have a medicine we need to get a script (prescription) and call the pharmacy to get an authorization code to get the medicine. She didn't complain about anything to me except not having the medicine for a few days. Her husband was there [on 6/13] and he did say, she needs it she takes it all the time and she's hurting without it. I explained that I needed to get the prescription from the doctor and there wasn't anything I could do until I got the prescription and sent it. I feel badly; I really don't know anything about the withdrawal symptoms. I don't think that [what is available in the automated medication dispensing system] was covered when I oriented. I don't think they went over what was in the machine [the automated medication dispensing system].I did not document in the progress notes that I couldn't administer the medication. I really should have done that. I did not call pharmacy every day or with every dose she missed, I should have. During an interview on 6/16/2025 at 1:30 PM, the APRN stated, I was called on I think it was the 13th for a prescription for her [Resident #7] Xanax (Alprazolam). I can't tell you exactly when she [the nurse] contacted me. I think that some of the problems are the hospitals sometimes don't send prescriptions with the patients when they get discharged . I do think I should have been contacted for both of the patients [Resident #7 and #9] when they couldn't administer the medications when ordered. [Resident #7's name] has taken 1 mg of Xanax for a long time. She could have had withdrawal symptoms starting within the 24 hours, irritability, sweating, sleeplessness, heightening pain and discomfort. There absolutely is the risk of withdrawal with abrupt stopping of benzodiazepines [a class of central nervous system depressants used to treat anxiety, insomnia and seizures]. She would likely, most people would likely, begin to feel the effects within 24 hours and it would worsen. There is a likelihood of a seizure. It would be harmful for anyone who was on benzodiazepines to suffer withdrawal when they aren't administered the medication and abruptly stopped. They should have called me. I would have provided the pharmacy with the script. I would not know what is in the [name of the automated medication dispensing system], but if Xanax is in it I could have provided a script for a limited number of doses until the correct dose was available from pharmacy. I would say that anyone could possibly suffer harm from this [not being administered Alprazolam]. I do expect to be notified if nursing can't administer ordered medications, if vitals are abnormal and meds don't have parameters. I want to be notified with any changes in the resident's condition. This is a problem that nurses are not aware of what is available to them and what they need to do. During an interview on 6/17/2025 at 7:10 AM, Staff B, LPN stated, I took care of [Resident #7's name] and did not have the medication to administer on the night of her admission. I was waiting on the medication to get here. I can't remember but I think I called pharmacy that night and they said they were working on getting her meds (medications) in. I have been a nurse for a long time, and I know each place has an EDK [Emergency Drug Kit], whether it's a [name of the automated medication dispensing system] or a box. But I didn't realize we should call and get another one-time order for the medication. I should have done that. I didn't know that we could get the Xanax [Alprazolam]. I did not get any orders and did not call the pharmacy or the nurse practitioner. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not do any medication orders for her [Resident #7], that was completed by another staff, [Staff E, LPN's name], on the day she was admitted . I got involved when my father [Staff C is Resident #7's daughter] came and told me she still didn't have her medication. He told me this every day and finally on the 13th I found out it was because she didn't have a prescription with the pharmacy, and I called [APRN's name] and got that taken care of. She [Resident #7] has been taking this medication for at least eight years now, at that dose and really she is dependent on it. I do think she [Resident #7] was experiencing withdrawal symptoms. Finally on the 13th at some time she finally got the medicine. I don't take direct care of her ever and I try not to interfere with her [Resident #7] care, but I needed to make sure she had her medicine. During a telephone interview on 6/17/2025 at 8:47 AM, the Registered Pharmacist, RPhD [doctorate] stated, We receive orders and e [electronic] scripts daily for all residents from this facility. All prescribers have access to Escribe [an electronic record to prescribe medications electronically] and can send orders at any time of the day and night. Typically, medications will go out at 2 PM and 2 AM but the facilities can ask for a stat [Latin word STATim which translates to immediately] run at any time. If the orders are received prior to 1-1:30 PM, they will go out with the afternoon run and will be at the facility between 5-7 PM depending on traffic and if received prior to 1:30 AM, it would arrive between 5-7 AM. We do have Alprazolam on PAR (periodic automatic replacement) in the [name of the automated medication dispensing system]. I can't say for sure, but I think it's a PAR of 20 at all times. I would say there is a huge problem if this medication is stopped abruptly, a large risk of withdrawal, this would begin with 16-24 hours after the last dose and would continue up to 5-10 days and with extended use, people can have a longer more extensive withdrawal time. Most commonly people develop nausea, vomiting, restlessness, irritability, agitation sleep disturbances, shakes and tremors. The most severe would be seizures and that generally occurs with higher doses at longer duration of exposure. At 1 mg four times a day it is likely that the patient began to experience one or more of these symptoms. I would say that withdrawal is not physically or mentally comfortable. The medication was always available to be administered to the patient until her medication arrived had someone called and notified us that she did not have the medication. We could have told them that we needed the prescription before the 13th. During an interview on 6/17/2025 at 9:11 AM, Staff D, LPN stated, I didn't realize that we could pull the medicine from the machine [the automated medication dispensing system]. I didn't know it [Alprazolam] was in there. I just thought it was like antibiotics and things like that. I should have asked someone about it. I should have called the doctor to get more orders, and I didn't. During an interview on 6/17/2025 at 9:50 AM, the Medical Director stated, I am the Medical Director and have been notified of the concerns that you have brought. I understand this impacted three residents, one taking Xanax once a day, one twice a day, and one four times a day. We do have some concerns with really newly admitted patients not coming with prescriptions for medications and here with some on-call providers not being able to escribe meds. But as Medical Director I am always available. There would be concerns with stopping this [Alprazolam] for long periods of time. We have more problems with opioids and returning patients to hospital because they have not come with a prescription and a provider who doesn't want to prescribe without first seeing the patient. I think this was caused when the nurses did not know that it [Alprazolam] was available and is always available. I am not their doctor so I can't really say if it would have caused any harm. During an interview on 6/17/2025 at 11:17 AM Staff E, LPN stated, I didn't actually do anything with [Resident #7's name] except fax the orders to pharmacy. I didn't see a prescription for the Xanax [Alprazolam] and the nurse coming on, I told that to her. I told her that I didn't do that [send the order for Xanax [Alprazolam]]. I did not call the nurse practitioner for the prescription. I did not know that the medication was in the [name of the automated dispensing system] machine. I don't remember any training on that. During an interview on 6/17/2025 at 3:05 PM, the DON stated, I should have been more involved and made sure that the nurses were aware of the process. I handed this to the Educator, who no longer works here, and I should have made sure that all staff were trained. It is my responsibility. No one told me that anyone had concerns about their medications. I do not audit medication administration. I just wasn't aware that this was a concern. I do expect all staff to follow doctor's orders for medications and call when they cannot give the med [medication]. Staff should all know what medications are available to them in the [name of the automated medication dispensing system]. During an interview on 6/17/2025 at 3:30 PM, the Administrator stated, Well, I would have to defer any nursing questions to the Director of Nursing, I am not clinical. Ultimately, I do expect staff to follow the policies and procedures for medication administration and any other we have. Review of the policy and procedure titled Medication Administration General Guidelines last approval date of 01/2025 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedure: A. Preparation . 11.) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g.,) are searched , if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. B. Administration .2) Medications are administered in accordance with written orders of the prescriber 6) Medications are administered without unnecessary interruptions. D. Documentation (including electronic) .6) If a dose of regularly scheduled medication is withheld, refused, not available or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of an antibiotic is needed), the space provided in [name of clinical software] is coded with appropriate code. An explanatory note is entered in nurses notes/progress note. If a dose of vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. The Immediate Jeopardy (IJ) was removed onsite on June 17,2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On June 17, 2025, an Ad Hoc [Latin meaning 'for this'] QAPI [Quality Assurance and Performance Improvement] was completed in the presence of the Nursing Home Administrator, the Director of Nursing, and the Medical Director to identify the root cause analysis. It was determined that the facility failed to ensure residents were free from medication errors and missed controlled prescription medications when facility staff did not know what was available in the [name of the automated medication dispensing system]. A performance improvement plan was developed and implemented for medication management and clinical communication processes. On June 17, 2025 the Director of Nursing developed a 'Missed Dose Escalation Protocol' that requires immediate notification to the charge nurse and Director of Nursing if any scheduled medication that is not administered and documentation of physician notification within one hour. On June 17, 2025, 47 of 47 licensed staff received training and education on medication administration, [name of the automated medication dispensing system] medication availability, location of the [name of the automated medication dispensing system] inventory sheets, staff [name of the automated medication dispensing system] log in, following physician orders, Missed Dose Escalation Protocol and medical doctor and family notification. On June 17, 2025, the Director of Nursing completed a full house audit of all residents receiving Alprazolam. On June 17,2025, the Regional Director of Clinical Services reviewed the facility medication administration policy and procedures and changes were made to include steps for medication escalation protocol, procedures to address missed doses, notification requirements and documentation requirements for missed doses. On June 17, 2025, the Regional Director of Operations provided training and education to the Administrator, Director of Nursing, Unit Manager and assistant Director of Nursing on facility administration, job descriptions, on medication administration, [name of the automated medication dispensing system] medication availability, location of the [name of the automated medication dispensing system] inventory sheets, staff [name of the automated medication dispensing system] log in, following physician orders, missed dose escalation protocol and medical doctor and family notification. Review of the facility records documented that there were seven residents receiving Alprazolam and the additional four residents had no concerns with medication administration and no missed doses. Review of the facility records beginning 6/16/2025 and completed on 6/17/2025 documented that 47 out of 47 licensed nursing staff received training and education on medication administration, [name of the automated medication dispensing system] medication availability, location of the [name of the automated medication dispensing system] inventory sheets, staff [name of the automated medication dispensing system] log in, following physician orders, missed dose escalation protocol and medical doctor and family notification. Review of the facility records dated 6/17/2025 documented that four out of four administrative staff received training and education on facility administration, job descriptions, on medication administration, [name of the automated medication dispensing system] medication availability, location of the [name of the automated medication dispensing system] inventory sheets, staff [name of the automated medication dispensing system] log in, following physician orders, missed dose escalation protocol and medical doctor and family notification. Review of the policy and procedure titled Medication Administration General Guidelines updated on 6/17/2025, read, If a dose of regularly schedule medication is withheld, refused, not available, or given at a time other than scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of an antibiotic is needed) the space provided in [name of the electronic medical record software] is coded with appropriate code. An explanatory note is entered in the nurses/note/progress note. If a dose of medication is refused the physician is notified. If dose of a medication is withheld or not available the Missed Dose Escalation Protocol will be followed. The protocol includes the following information. The DON and physician are notified. The physician will determine if the medication is needed to be provided at the time. In the event the medication is required the nurse will retrieve medication from the emergency medication dispensing system. In the event the medication is a controlled substance, the nurse will contact pharmacy to ask to obtain the medication from the emergency medication dispensing system. If the medication is not available in the emergency medication dis[TRUNCATED]

Based on interviews, record reviews and policy and procedure review, the facility failed to maintain a complete and accurate medical record when it failed to document within the medical record the reason medications were not administered for three of three residents reviewed for medication administration (Residents #7,#9 and #10). Findings include: Review of the admission record for Resident #9 documented an admission date of 5/20/2025 with medical diagnoses that include anxiety disorder unspecified, depression unspecified, essential (primary) hypertension (high blood pressure), unspecified fracture of right pubis (break in the bone of the pelvis) subsequent encounter for fracture with routine healing, fall on same level from slipping tripping and stumbling without subsequent striking against object subsequent encounter, gastroesophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease unspecified. Review of Resident #9's physician orders dated 5/20/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth in the morning for anxiety. Review of Resident #9's May medication administration record (MAR) on 5/21, 5/22 and 5/23/2025 Alprazolam was documented as 9 [chart code for other/see nurses notes]. Review of Resident #9's progress notes from 5/20/2025 through 5/23/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an interview on 6/16/2025 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN) stated, I did take care of [Resident #9's name] and I did not give her the Alprazolam on 5/23, it wasn't in yet. I did not document why. We should document in the progress notes or on the MAR that we don't have the med (medication) and we called the doctor. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not give her [Resident #9] her Alprazolam, it was ordered, and a prescription had been sent to pharmacy, so we were just waiting for it to get in. I did not write a note about why I didn't give the med; I should have. 2. Review of the admission Record for Resident #10 documented an admission date of 8/27/2024 with medical diagnoses that include chronic obstructive pulmonary disease unspecified, major depressive disorder recurrent unspecified, peripheral vascular disease (reduced circulation of blood to a body part) unspecified, atherosclerotic heart disease of native coronary arteries (heart disease) without angina pectoris (chest pain), essential (primary) hypertension, anxiety disorder unspecified, and other chronic pain. Review of Resident #10's physician orders dated 5/26/2025 read, Alprazolam Oral Tablet 0.5 MG Give 1 tablet by mouth every 12 hours for Anxiety. Review of Resident #10's May MAR, Alprazolam was documented as 9 [chart code for other/ see nurses notes] for 5/31/2025 at 2100 [9:00 PM]. Review of Resident #10's June MAR, Alprazolam 0.5 mg was documented as 9 [chart code other see nurses] for 6/1/2025 at 0900 [9:00 AM] and 2100 [9:00 PM]. Review of Resident #10's progress notes from 5/31/2025 through 6/4/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an interview on 6/17/2025 at 7:30 AM, Staff C, LPN stated, I did not give [Resident #10's name] her Alprazolam. I did not write a note about why I didn't give the med; I should have. 3. Review of the admission Record for Resident #7 documented an admission date of 6/11/2025 with medical diagnoses that include fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, unspecified fracture of sacrum, subsequent encounter for fracture with routine healing, unstable burst fracture of T5-T6 [thoracic, upper back between the neck and lumbar spine] vertebra, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter, unspecified fracture of T11-T12 vertebra, chronic obstructive pulmonary disease with (acute) exacerbation, peripheral vascular disease, unspecified, age-related osteoporosis without current pathological fracture, chronic systolic (congestive) heart failure, unspecified osteoarthritis, unspecified site, acute and chronic respiratory failure with hypoxia, hypothyroidism, unspecified, displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, diverticulitis of both small and large intestine without perforation or abscess without bleeding, nondisplaced comminuted [type of bone fracture where the bone breaks in three or more pieces] fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified fracture of unspecified thoracic vertebra, sequela, unspecified fracture of first lumbar vertebra, sequela, hyperlipidemia, unspecified, iron deficiency anemia secondary to blood loss (chronic), personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, anxiety disorder, unspecified, personal history of other venous thrombosis and embolism, and chronic atrial fibrillation, unspecified. Review of Resident #7's physician orders dated 6/11/2025 read, Alprazolam Oral Tablet 1 MG Give 1 tablet by mouth four times a day for anxiety. Review of Resident #7's June MAR Alprazolam 1 mg documented as 9 [chart code other/see nurses notes] on 6/11/2025 at 1700 [5:00PM], 2100 [9:00 PM], on 6/12/2025 at 0900, 1200, 1700 [5:00 PM] and 2100 [9:00 PM], on 6/13/2025 at 0900, 1200, and 1700. Review of Resident #7's progress notes from 6/11/2025 through 6/14/2025, documented no progress notes related to Alprazolam and no notification to the physician that the medication was unavailable. During an interview on 6/15/2025 at 1:58 PM, the Director of Nursing (DON) stated, The staff should have called the doctor and documented that in the chart. The 9 chart code is other/see nurses notes. There are no notes in the chart telling me why the [Alprazolam] wasn't given. During an interview on 6/16/25 at 11:30 AM, Staff A, LPN stated, I called [the pharmacy] on the 13th to get her [Resident #7] medication. I did not document in the progress notes that I couldn't administer the medication. I really should have done that. Review of the policy and procedure titled Medication Administration General Guidelines last approval date of 01/2025 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedure: D. Documentation (including electronic) .6) If a dose of regularly scheduled medication is withheld, refused, not available or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of an antibiotic is needed), the space provided in [name of clinical software] is coded with appropriate code. An explanatory note is entered in nurses notes/progress note. If a dose of vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.

Based on observations, interviews, and record reviews, the facility failed to follow infection control standards of practice during 1 of 5 medication administration observations and 2 (Resident #4 and #20) of 10 residents reviewed for oxygen therapy. Findings include: 1). During a medication administration observation on 1/15/25 at 8:40 AM for Resident #39, Staff B, Registered Nurse (RN) removed the cap to a vial of Ceftriaxone sodium injection solution 1 gram and removed the cap to a vial of sterile water. Staff B, RN opened a sterile needle with syringe and inserted the needle into the vial of sterile water without wiping the rubber of the vial with an alcohol wipe. Staff B, RN withdrew 2.1 ml [milliliters] of sterile water and inserted the needle of the syringe with sterile water into the vial of Ceftriaxone sodium injection solution 1 gram without wiping the rubber top of the Ceftriaxone vial with an alcohol wipe. Staff B, RN left the needle in the vial of Ceftriaxone and shook the vial. Staff B, RN then attempted to withdraw the solution using the syringe still attached, but had difficulty removing the solution. Staff B, RN pushed the solution in the syringe back into the vial and removed the needle. Staff B, RN opened a new sterile needle with syringe and inserted it into the vial of Ceftriaxone without wiping the rubber stopper of the vial with an alcohol wipe. During an interview on 1/15/25 at 8:48 AM, Staff B, RN stated, I am old school and the vial top [rubber stopper] is clean when I remove the caps to the vials. During an interview on 1/15/25 at 10:53 AM, the Director of Nursing (DON) stated, When a vial cap is removed, the top of the cap should be wiped with an alcohol wipe before inserting a needle. Review of the National Library of Medicine website (https://www.mcbi.nlm.nih.gov) related to general safety practices for injections read, Procedure for septum vials. Wipe the access diaphragm (septum) with 70% alcohol (isopropyl alcohol or ethanol) on a swab or cotton-wool ball before piercing the vial, and allow to air dry before inserting a device into the bottle. 2) During an observation on 1/13/25 at 10:03 PM, Resident #4 room was observed to have a nebulizer mask on the bedside table and not bagged. During an observation on 01/13/25 10:08 AM, Resident #20 asleep in bed; nebulizer mask was on the bedside table and was not bagged. Photographic evidence obtained. During an interview on 1/13/25 at 12:30 PM, the DON stated, nebulizer mask should be placed in a bag and not on the bedside table. Review of the policy titled, Respiratory Therapy Equipment, last reviewed on 12/19/24, read Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to resident and staff. Procedure. Oxygen Administration. 5. Keep oxygen cannula and tubing used PRN in a plastic bag when not in use.

Based on record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 1 (Resident #39) of 6 residents reviewed for medication administration. Findings include: Review of Resident #39's physicians order dated 9/10/24 read, Insulin NPH (Neutral Protamine [NAME]) Isophane & Regular Subcutaneous Suspension (70-30) [70% Isophane and 30% regular or short acting insulin] 100 unit /ml (Insulin NPH Isophane & Reg (Human)) Inject 10 unit subcutaneously in the evening for DM [Diabetes Mellitus] Hold for BG <150 [Blood Glucose less than 150]. Review of Resident #39's Medication Administration Record (MAR) for the month of January 2025 documented Insulin NPH Isophane & Regular Subcutaneous Suspension Insulin was administer on 1/10/2025 at 2100 [9:00PM] when blood glucose level was 126 and on 1/14/2025 at 2100 for a blood glucose level of 123. Review of Resident #39's MAR for the month of December 2024 documented Insulin NPH Isophane & Regular Subcutaneous Suspension was administered on 12/15/2024 at 2100 for blood glucose of 145, on 12/17/2024 at 2100 for blood glucose of 143, on 12/18/2024 at 2100 for blood glucose of 133, 12/23/2024 at 2100 for blood glucose of 145, 12/24/2024 at 2100 for blood glucose of 144, 12/26/2024 at 2100 for blood glucose of 143, and on 12/30/2024 at 2100 for blood glucose of 145. Review of Resident #39's physicians order dated 12/9/2024 read, Midodrine HCI Oral Tablet 10 mg (milligrams) give 10 mg by mouth three times a day for hypotension hold if SBP >135 [systolic blood pressure is greater than 135]. Review of Resident #39's MAR for the month of January 2025 documented Midodrine was administered on 1/12/2025 at 0600 [6:00 AM] for a systolic blood pressure of 162. Review of Resident #39's MAR for the month of December 2024 documented Midodrine was administered on 12/14/2024 at 2200 for systolic blood pressure of 148, on 12/15/2024 at 0600 for systolic blood pressure of 148, on 12/18/2024 at 2200 for systolic blood pressure of 140 and on 12/19/2024 at 0600 for systolic blood pressure of 140. During an interview on 1/15/2025 at 12:31PM the attending provider stated, It is more of an issue with the nurses not documenting our conversations because the staff will contact me and act accordingly. They follow what I tell them but do not document our conversation. During an interview on 1/15/2025 at 2:00 PM, the Director of Nursing stated, Any conversation with a provider should be documented in the system. Review of the policy and procedure titled Documentation with a last review date of 12/19/2024 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical area and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members.

Based on observations, interviews, and record reviews, the facility failed to ensure a comprehensive care plan was developed for 4 (Resident #4, 49, 77, and 79) of 10 residents reviewed for oxygen therapy. Findings include: 1) Review of Resident #79's admission record documented an admitted [DATE] with diagnosis that included heart failure, hypertensive heart disease, and COPD (chronic obstructive pulmonary disease). Review of Resident #79's physician order dated 9/1/2024 read, Oxygen @ 2 L/Min (at 2 liters per minute) via nasal cannula inhalation as needed as needed {sic} for COPD. Review of Resident #79's comprehensive care plan did not document focus for respiratory services. 2) Review of Resident #77's admission record documented an admitted [DATE] with diagnosis that included acute and chronic respiratory failure with hypercapnia and pneumonia. Review of Resident #77's physician order dated 1/14/2025 read, Oxygen tubing, cannula/mask change weekly and PRN (as needed) every night shift every Sat [Saturday] AND as needed. Review of Resident #77's physician order dated 1/14/2025 read, Oxygen @ 2L/Min via NC (at 2 liters per minute via nasal cannula) inhalation as needed as needed [sic]. Review of Resident #77's physician's order dated 12/5/2024 read, Oxygen tubing, cannula/mask change weekly and PRN Discontinued on 01/5/2025. Review of Resident #77's physician's order dated 12/5/2024 read, Oxygen @ 4L/Min via nasal cannula inhalation as needed as needed Discontinued on 1/5/2025. Review of Resident #77's comprehensive care plan did not reveal a focus for respiratory services. During an interview on 1/15/2025 at 12:07 PM, Staff E, MDS Coordinator, stated, [Resident #77's name] and [Resident #79's name] do have orders for oxygen. I do not see a focus of respiratory services [on the comprehensive care plan]. During an interview on 1/15/2025 at 2:03 PM, the Director of Nursing (DON) stated, Residents should have a focus [on the comprehensive care plan] of services they need. If they have oxygen orders they should have a respiratory focus. Review of the policy and procedure title Resident Assessment Instrument Comprehensive Care Plan Policy with a last review date of 12/19/2024 read, Policy Statement: Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI) and to comply with state and federal regulations. Policy statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes. 49777 3) During an observation on 1/13/2025 at 10:10 AM, Resident #4's oxygen concentrator was set at 3.5 L/Min (liters per minute). Photographic evidence obtained. During an observation on 1/14/2025 at 2:50 PM, Resident #4's oxygen concentrator was set at 1.5 L/Min per nasal cannula. Photographic evidence obtained. During an observation on 1/16/2025 at 9:42 AM, Resident #4's oxygen concentrator was set at 1.5 L/Min and the resident was asleep in the bed. Review of Resident #4's physicians order for oxygen read, Oxygen @ 2_L/Min (2 liters per minute) via nasal cannula inhalation as needed every shift for SOB (shortness of breath). During an interview on 1/16/2025 at 9:45 AM, Staff A, Registered Nurse (RN), Supervisor, stated, It looks like the 02 [oxygen] is set at 1.75 L/Min. Sometimes the residents change their setting. When Staff A, RN was asked if it [resident self-adjusting oxygen setting] was addressed in the care plan, Staff A, RN did not respond. Review of Resident #4's comprehensive care plan did not document a focus for respiratory care services or the resident self-adjusting of the oxygen concentrator settings. 4) During an observation on 1/13/25 at 10:00 AM, Resident #49's oxygen concentrator was set at 3 L /min (liters per minute) per nasal cannula. Photographic evidence obtained. Review of Resident #49's physicians order dated 7/31/2024 read, Oxygen @ 2L/min per continuous inhalation via NC (nasal cannula) every shift. Review of Resident #49's comprehensive care plan did not include self-adjusting of the oxygen concentrator settings. During an interview on 1/16/2025 at 10:10 AM, Staff C, RN, [the nurse caring for Resident #4 and #49] stated that two of her residents [Resident #4 and #49] complains of breathing problems. I have identified that the settings are changed frequently, and I change the setting back to 2L/Min. They are [Resident #4 and #49] not care-planned to address changing the O2 settings. During an interview on 1/16/2025 at 10:43 AM the Director of Nursing (DON), stated, If a resident is manipulating their O2 (oxygen) setting, we would revise the behavioral and O2 care plan to include resident manipulation of setting for O2. I was not aware of [Resident #4's Name] or [Resident #49's Name] manipulating their O2 settings. During an interview on 1/16/2025 at 10:50 AM, Staff D, Minimum Data Set (MDS) Coordinator, License Practical Nurse (LPN) stated the MDS coordinator checks orders daily to revise care plans for O2 order revisions from the day before and on Monday, to check for order revisions from the weekend. I am not aware of [Resident #4's Name and Resident #49' Name] changing the O2 settings.

Based on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for one resident (Resident #109) of four reviewed for discharge. Findings include: Review of Resident #109's admission record documented the resident was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included pneumonia, sepsis, acute respiratory failure, chronic obstructive pulmonary disease, hypertension and atrial fibrillation. Review of the Minimum Data Set (MDS), Assessment Return Not Anticipated, Section A ,dated 10/21/24 documented Resident #109 was discharged to a hospital. Review of Resident #109's progress notes dated 10/21/24 read, Pt (patient) and family decided that they wanted pt transferred to [Name of Nursing Home] said that was the facility originally chosen for pt however they didn't have any available beds at time of discharge from hospital so, pt decided until a bed became available that she would come to this facility. Bed became available pt was transferred to [Name of Nursing Home] sent all documentation needed. [Name of Nursing Home] arranged transport. no DME (Durable Medical Equipment) or HH (home health) established due to transfer of facility. During an interview on 1/14/25 at 2:05 PM. the MDS Director confirmed the 10/15/24 assessment was inaccurate due to Resident #109 being transferred to a skilled nursing facility and not sent to the hospital.

Based on record review and interview, the facility failed to administer medications in accordance with professional standards of practice for 3 of 3 residents reviewed for medication administration, Residents #6, #7 and #8. Findings include: 1. Review of Resident #6's admission record revealed the resident was admitted with the diagnoses including nontraumatic acute subdural hemorrhage (bleeding in the brain), nontraumatic chronic subdural hemorrhage, pneumonia, seizures, dementia, essential primary hypertension, anxiety disorder, and major depression. Review of Resident #6's physician order dated 11/10/2023 reads, Amlodipine Besylate oral tablet 10 milligrams give one tablet by mouth one time a day related to essential primary hypertension hold for systolic BP [blood pressure] less than 110 and or heart rate less than 60. Review of Resident #6's physician order dated 11/10/2023 reads, Lisinopril oral tablet 10 milligrams give one tablet by mouth one time a day related to essential primary hypertension hold for systolic BP less than 110 and heart rate less than 60. Review of Resident #6's physician order dated 11/10/2023 reads, Levetiracetam oral tablet (Keppra) 500 mg [milligrams] give 1 tablet by mouth two times a day. Review of Resident #6's physician order dated 11/10/2023 reads, Doxycycline Hyclate 100 mg, give 100 mg by mouth every 12 hours for pneumonia for 6 days until finished. Review of Resident #6's Medication Administration Record for November 2023 for administration of Levetiracetam oral tablet (Keppra) 500 mg showed the medication was administered on 11/12/2023 at 12:37 AM (scheduled for 11/11/2023 at 9:00 PM), on 11/13/2023 at 12:49 PM (scheduled for 9:00 AM); on 11/14/2023 at 10:54 PM (scheduled for 9:00 PM); on 11/16/2023 at 3:31 PM (scheduled for 9:00 AM); on 11/17/2023 at 7:27 PM (scheduled for 9:00 AM); on 11/18/2023 at 12:31 AM (scheduled for 11/17/2023 at 9:00 PM); on 11/18/2023 at 11:22 AM (scheduled for 9:00 AM); on 11/19/2023 at 12:25 PM (scheduled for 9:00 AM); on 11/20/2023 at 10:46 PM (scheduled for 9:00 PM); on 11/22/2023 at 11:23 AM (scheduled for 9:00 AM); on 11/23/2023 at 1:18 PM (scheduled for 9:00 AM); on 11/24/2023 at 6:33 PM (scheduled for 9:00 AM) and at 11:21 PM (scheduled for 9:00 PM); on 11/27/2023 at 10:36 AM (scheduled for 9:00 AM); on 11/29/2023 at 11:22 AM (scheduled for 9:00 AM); and on 11/30/2023 at 10:18 PM (scheduled for 9:00 AM). Review of Resident #6's Medication Administration Record for November 2023 for administration of Amlodipine Besylate oral tablet 10 mg showed the medication was administered on 11/18/2023 at 11:22 AM (scheduled for 9:00 AM); on 11/19/2023 at 12:25 PM (scheduled for 9:00 AM); on 11/22/2023 at 11:23 AM (scheduled for 9:00 AM); on 11/23/2023 at 1:18 PM (scheduled for 9:00 AM); on 11/24/2023 at 6:33 PM (scheduled for 9:00 AM); on 11/26/2023 at 10:57 AM (scheduled for 9:00 AM); on 11/27/2023 at 10:36 AM (scheduled for 9:00 AM); on 11/29/2023 at 11:22 AM (scheduled for 9:00 AM); and on 11/30/2023 at 10:18 PM (scheduled for 9:00 AM). Review of Resident #6's Medication Administration Record for November 2023 for administration of Lisinopril oral tablet 10 mg showed the medication was administered on 11/18/2023 at 11:22 AM (scheduled for 9:00 AM); on 11/19/2023 at 12:25 PM (scheduled for 9:00 AM); on 11/22/2023 at 11:23 AM (scheduled for 9:00 AM); on 11/23/2023 at 1:18 PM (scheduled for 9:00 AM); on 11/24/2023 at 6:33 PM (scheduled for 9:00 AM); on 11/26/2023 at 10:57 AM (scheduled for 9:00 AM); on 11/27/2023 at 10:36 AM (scheduled for 9:00 AM); on 11/29/2023 at 11:22 AM (scheduled for 9:00 AM); and on 11/30/2023 at 10:18 PM (scheduled for 9:00 AM). Review of Resident #6's Medication Administration Record for November 2023 for administration of Doxycycline Hyclate 100 mg showed the medication was administered on 11/16/2023 at 3:31 PM (scheduled for 9:00 AM). 2. Review of Resident #7's admission record revealed the resident was admitted with the diagnoses including Parkinson's disease, Alzheimer's disease with late onset, unspecified systolic congestive heart failure, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, cardiomegaly, hyperlipidemia, presence of cardiac and vascular implant and graft, bilateral cataracts, peripheral vascular disease, personal history of COVID-19, right knee contracture, left knee contracture, major depressive disorder, essential primary hypertension, chronic atrial fibrillation, anxiety disorder, age-related osteoporosis, and unspecified osteoarthritis. Review of Resident #7's physician order dated 10/9/2023 reads, Sotalol HCL [hydrochloride] tablet 160 milligrams give one tablet by mouth one time a day for hypertension hold for systolic BP less than 110 and or heart rate less than 60. Review of Resident #7's physician order dated 11/6/2023 reads, Eliquis 2.5 milligrams give one tablet by mouth two times a day for DVT [deep vein thrombosis] prophylaxis related to chronic atrial fibrillation. Review of Resident #7's physician order dated 11/6/2023 reads, Nuplazid oral capsule 34 milligrams give one capsule by mouth one time a day for psychosis. Review of Resident #7's physician order dated 11/6/2023 reads, Potassium chloride oral solution 20 [NAME] [milliequivalents]/15 ml [milliliters] give 7.5 ml by mouth one time a day for supplement. Review of Resident #7's physician order dated 11/17/2023 reads, Carbidopa Levodopa oral tablet 25-100 mg [milligram] give one tablet sublingually two times a day for Parkinson. Review of Resident #7's Medication Administration Record for November 2023 for administration of Eliquis tablet 2.5 mg showed the medication was administered on 11/8/2023 at 2:26 PM (scheduled for 9:00 AM); on 11/8/2023 at 6:56 PM (scheduled for 5:00 PM); on 11/9/2023 at 3:06 PM (scheduled for 9:00 AM); and on 11/9/2023 at 6:20 PM (scheduled for 5:00 PM). Review of Resident #7's Medication Administration Record for November 2023 for administration of Carbidopa Levodopa oral tablet 25-100 mg showed the medication was administered on 11/8/2023 at 2:26 PM (scheduled for 11:30 AM); on 11/8/2023 at 6:56 PM (scheduled for 4:00 PM); and on 11/9/2023 at 3:06 PM (scheduled for 11:30 AM). Review of Resident #7's Medication Administration Record for November 2023 for administration of Potassium chloride oral solution showed the medication was administered on 11/9/2023 at 3:06 PM (scheduled for 9:00 AM). Review of Resident #7's Medication Administration Record for November 2023 for administration of Sotalol HCL tablet 160 mg showed the medication was administered on 11/9/2023 at 3:06 PM (scheduled for 9:00 AM). Review of Resident #7's Medication Administration Record for November 2023 for administration of Nuplazid oral capsule 34 mg showed the medication was administered on 11/9/2023 at 3:06 PM (scheduled for 9:00 AM). 3. Review of Resident #8's admission record revealed the resident was admitted with the diagnoses including type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, hyperlipidemia, hypothyroidism, anxiety disorder, rheumatoid arthritis, mild protein calorie malnutrition, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified psychosis, adult failure to thrive, psoriasis, old myocardial infarction, and essential primary hypertension. Review of Resident #8's physician order dated 10/20/23 reads, Amlodipine Besylate oral tablet 10 milligrams give one tablet by mouth one time a day for hypertension. Review of Resident #8's physician order dated 10/20/2023, Biotin oral tablet 10 milligrams give one tablet by mouth one time a day for supplement. Review of Resident #8's physician order dated 10/20/2023 reads, Buspirone HCL oral tablet 10 milligrams give two tablet by mouth two times a day for anxiety. Review of Resident #8's physician order dated 10/20/2023 reads, Lamictal oral tablet 200 milligrams give one tablet by mouth one time a day for anticonvulsant. Review of Resident #8's physician order dated 10/20/2023 reads, Maxzide 25 milligrams 37.5 25 milligrams give one tablet by mouth one time a day for hypertension. Review of Resident #8's physician order dated 10/20/2023 reads, Pilocarpine HCL oral tablet 5 milligrams give one tablet by mouth four times a day for glaucoma. Review of Resident #8's physician order dated 10/20/2023 reads, Zoloft oral tablet 50 milligrams give four tablet by mouth one time a day for depression. Review of Resident #8's physician order dated 11/8/2023 reads, Fibercon oral tablet give one tablet by mouth two times a day for Constipation. Review of Resident #8's physician order dated 11/13/2023, reads, B12 fast dissolve oral tablet disintegrating 5000 MCG [micrograms] give one tablet by mouth one time a day for supplement. Review of Resident #8's physician order dated 11/13/2023 reads, Vitamin D3 oral tablets 125 MCG give one tablet by mouth in the morning for supplement. Review of Resident #8's physician order dated 11/21/2023 reads, Claritin oral tablet 10 milligrams give one tablet by mouth one time a day for allergies. Review of Resident #8's Medication Administration Record for November 2023 showed on 11/24/2023, Lamictal oral tablet, Claritin oral tablet, Vitamin D3 oral tablet, B12 fast dissolve oral tablet, Biotin oral tablet, Maxzide 25 oral tablet, and Buspirone HCL oral tablet were administered at 3:24 PM (all scheduled for 9:00 AM); on 11/24/2023, Gabapentin capsule was administered at 3:25 PM (scheduled for 2:00 PM); on 11/29/2023, B12 fast dissolve oral tablet, Buspirone HCL oral tablet, Fibercon oral tablet, Vitamin D3 oral tablet, Lamictal oral tablet, Maxzide 25 oral tablet, Zoloft tablet, Pilocarpine HCL tablet were administered at 11:24 AM (scheduled for 9:00 AM); on 11/30/2023, Buspirone HCL, Vitamin D3 oral tablet, Maxzide 25 oral tablet, Lamictal oral tablet, Zoloft oral tablet, Pilocarpine HCL oral tablet, Claritin oral tablet, Amlodipine Besylate oral tablet, Biotin oral tablet were administered 10:19 PM (scheduled for 9:00 AM); on 11/30/2023, Pilocarpine HCL oral tablet was administered at 10:19 PM (scheduled for 1:00 PM); and on 11/30/2023, Gabapentin oral capsule was administered at 10:20 PM (scheduled for 2:00 PM). During an interview on 12/1/2023 at 11:30 AM, the Director of Nursing (DON) stated, The standard is that medications are administered within 2 hours. I was not aware that medications were not administered or documented as administered per our policies and I do expect nurses to administer medications and document as soon as they are given. This is a standard. There are medications which must be given on time and they should be administered on time. During an interview on 12/1/2023 at 5:30 PM, Staff A, Licensed Practical Nurse (LPN), stated, I should document that I have given my medications as soon as I do it. I sometimes forget and don't until the end of my shift. I have given medications late sometimes. I can't tell you exactly when I did that. I should not document them at the end of my shift. All medications should be administered within 2 hours of when they are due. I think that I am able to get my work done most of the time. I just help the residents and sometimes my computer logs out. I think that's how that happened. I should administer the medications with an hour of them due. Review of the facility policy and procedure titled Medications, oral reads, Reporting and Documentation: The following should be reported to the staff/charge nurse and should be documented in the resident's medical record: 1. The drug name, dose, time, date and route of administration. (Note: Such information should be documented on the resident's medication administration record immediately after the drug is given).

Based on interview and record review, the facility failed to ensure the resident's representative was notified of a change in condition for 1 of 3 residents, Resident #1. Findings include: Review of the Admission Record for Resident #1 documented the resident was admitted on [DATE] with diagnoses to include hypertension, muscle weakness, mild protein calorie malnutrition, diabetes mellitus, dementia and sepsis. Review of laboratory results dated [DATE] documented results that were not within the resident's normal limits and were high for the blood urea nitrogen (BUN), chloride, and the BUN creatinine ratio. Review of the nursing progress note for Resident #1 dated 10/11/2023 at 04:02 AM read. Nurse was called to resident room it was noted that a very small open area to sacrum skin was peeling off. Area cleaned and barrier cream applied will inform MD and family later. Review of nursing progress notes for the period of 10/03/2023 to 11/14/2023 did not contain documentation the resident's representative was notified of the elevated laboratory results or the skin breakdown for Resident #1. During an interview on 11/14/2023 at 11:07 AM Resident #1's representative stated that she was not informed of the skin breakdown identified on 10/11/2023, or the abnormal laboratory results on 10/3/2023. During an interview on 11/14/2023 at 12:20 PM Staff A, License Practical Nurse (LPN) stated, I did not inform the family of the laboratory results. During an interview on 11/14/2023 at 12:45 PM the Director of Nursing (DON) stated, The responsible party/family are to be notified of any change in skin integrity for the resident or abnormal lab results. The DON confirmed the family was not informed of the skin breakdown on 10/11/2023 or results of the elevated labs on 10/3/2023. Review of policy and procedure titled, Change in a Resident's Condition or Status read, The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on interview and record review the facility failed to ensure a PASRR (Pre-Admission Screening and Resident Review) Level I was completed to determine if a newly admitted resident had or may have a mental disorder or related conditions prior to admission for 1 of 3 residents, Resident #49. Findings include: Review of Resident #49's admission record documented Resident #49 was admitted on [DATE]. On 6/24/2022 the resident was diagnosed with adjustment disorder, psychotic disorder with hallucinations, and post-traumatic stress disorder. Review of Resident #49's medical record did not contain a Level 1 PASRR. Review of Resident #49's care plan, initiated on 9/11/2022, read, [Resident #49's name] has a behavior problem consist of paranoia, and is non-compliant with instructions for safety. [Resident #49's name] has a mood problem r/t [related to] Admission, PTSD [Post Traumatic Stress Disorder], Adjustment D/O [disorder], Anxiety, Depression, Psychotic-Hallucinations. During an interview on 10/4/2023 at 12:02 PM, the Administrator stated I do not have one [PASRR], we had a waiver. The DON [Director of Nursing] would need to know about the PTSD. During an interview on 10/4/2023 at 12:40 PM, the Director of Nursing stated, I was not working here during that time. [Resident #49's name] should have had a PASRR upon admission and once diagnosed with PTSD she should have had a reassessment. Review of the policy and procedures titled Admission/Social Services-Pre-Admission Screening and Resident Review (PASRR), last reviewed 12/30/2022 the policy read, The purpose of PASRR is to ensure individuals who are being considered for placement in a Nursing Facility are evaluated for serious mental illness and/or intellectual disability and are offered the most integrated setting appropriate for their long term care needs (including determining whether a Nursing Facility is appropriate). All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for possible metal illness or the presence of an intellectual disability (ID) or both (Level I). If a mental illness (MI) or intellectual disability (ID) appears to exist, the person must be referred for further evaluation (Level I) before Nursing Facility admission. The Level I PASRR screen must be done prior to admission for all persons seeking admission to the facility.