Every finding on record at Heartland Living & Rehab at the Moses H Cone Memor

Based on observation, record review, and Responsible Party and staff interviews, the facility failed to dispose of a urinary catheter drainage bag left on the resident's sink for 1 of 3 residents (Resident #94) on 1 of 3 halls reviewed for clean, comfortable, and homelike environment. The findings included:Review of Residents #94's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was coded for use of an indwelling urinary catheter.Interview and observation with Residents #94's Responsible Party (RP) on 04/27/26 at 11:40 AM revealed concerns of cleanliness of Resident #94's bathroom. An observation conducted at the same time revealed a leg bag (a small, wearable urine collection bag used to collect urine from an indwelling catheter) laying on the resident's bathroom counter next to the sink. There was observation of approximately 50 milliliters (ml) in the catheter leg bag, but no signs of urine on the sink. The RP indicated the leg bag had laid there for multiple days and was not sure if it was Resident #94's catheter leg bag. The RP indicated she visited Resident #94 almost daily and observed it in the resident's bathroom at least a few days. The RP stated she had not vocalized concerns to staff, because she was not sure if it was placed there for a purpose and the resident did not use the restroom at all.Interview with Nurse #3 on 04/30/26 at 5:15 PM revealed last Wednesday (04/22/26) she was assigned to Resident #94 and Resident #94 had come back from a urologist appointment and his catheter leg bag was switched to an overnight drainage bag. Nurse #3 stated she had removed the bag and thought she had emptied it, but another resident required immediate attention down the hall, and she had left it sitting on the bathroom counter next to the sink. Nurse #3 revealed all catheter bags were to be discarded per facility policy, and she had made a mistake by leaving it on the sink.Interview with Housekeeper #1 on 04/27/26 at 1:35 PM revealed she had been assigned to Resident #94's room consistently for the past month. Housekeeper #1 further revealed last Thursday (04/23/26) she had cleaned Resident #94's bedroom and bathroom and observed the catheter leg bag on the bathroom counter next to the sink. The Housekeeper stated she cleaned around the catheter bag but did touch it. Housekeeper #1 indicated she did not report it to staff because she thought nursing staff had left it there for a reason and she had not been educated to report if a catheter bag had not been discarded.Interview with Nurse Aide (NA) #6 on 04/30/26 revealed she was assigned to Resident #94 on 04/25/26 and 04/26/26. NA #6 further revealed Resident #94 was incontinent and did not use the bathroom, but she had used the bathroom to retrieve water for personal hygiene needs. NA #6 stated she does not recall seeing a catheter leg bag on the counter of the sink. The NA indicated she would have immediately discarded the bag and notified the assigned Nurse.Phone interviews were attempted with Housekeeper #2, who was assigned to Resident #94's room on 04/26/26, on 04/29/26 at 3:30 PM and 04/30/26 at 9:20 AM but were not successful. Interview and observation with the Director of Nursing (DON) on 04/27/26 at 11:55 AM revealed the catheter leg bag on the sink in Resident #94's bathroom and the DON stated per facility policy catheter bags were to be discarded after use. The DON revealed Resident #94 was incontinent and nursing staff completed personal hygiene in the resident's room. The DON was observed discarding the catheter leg bag and cleaning the sink. An interview with the Administrator on 04/20/26 at 4:10 PM revealed she expected nursing staff to discard catheter bags per facility policy.

Based on observations, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to administer oxygen as specified in the physician order for 2 of 2 residents reviewed for oxygen therapy (Resident #53 and Resident #35).Findings included: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (low levels of oxygen in body tissue which are common with chronic heart and lung conditions and causes symptoms like confusion, restlessness, difficulty breathing rapid heart rate and bluish skin), chronic obstructive pulmonary disease, and hypertension. Review of Resident #53's care plan dated 03/12/26 revealed the resident required oxygen at times or continuously. The resident was at risk for signs and symptoms of respiratory distress, dry or bloody nose, irritated skin around the ears from tubing or if mask is work, possible irritation round the mouth, increased fatigue, headaches. The goal was for Resident #53 to benefit mentally and physically with use of oxygen therapy. Interventions included to ensure oxygen was titrated to appropriate setting as ordered by the Medical Director, the oxygen concentrator was functioning properly, and oxygen saturations as ordered and PRN (as needed). Resident #53's quarterly Minimum Data Set (MDS) 04/15/26 revealed the resident was moderately cognitively impaired and required oxygen. The MDS further revealed Resident #53 required substantial to maximum assist with lying to sitting on side of the bed and sit to stand. Physician order dated 04/13/26 revealed Resident #53 was ordered oxygen at 3 liters per minute via nasal cannula every day and night shift for respiratory failure with hypoxia. An observation and interview with Resident #53 on 04/28/26 at 11:40 AM revealed Resident #53 in bed with a nasal cannula on and the oxygen tubing connected to the oxygen concentrator. The oxygen concentrator was adjacent to the upper half of the bed and at least two feet away from the bed. The oxygen flow meter was set at 4 liters per minute when the flow meter was viewed at eye level. Resident #53 shook her head that she had not changed the oxygen flow rate when asked. A phone interview with Nurse Aide (NA) #3 on 04/30/26 at11:40 AM revealed she was often assigned to Resident #53. NA #3 indicated Resident #53's health had declined the last few weeks and she had become weaker. NA #3 further revealed Resident #53 was unable to reach over and down towards the oxygen tank without falling out of bed and was unable to sit up without staff assistance. NA #3 revealed she never changed Resident #53's oxygen flow rate and it was the assigned nurse's responsibility to check the resident's oxygen and tubing. NA #3 stated she did not recall Resident #53 ever changing her oxygen flow rate. An interview with Nurse #3 on 04/28/26 at 12:15 PM revealed she had checked Resident #53's oxygen when she arrived on shift at 7:00 AM and indicated she recalled it set at 3 liters per minute. Nurse #3 further revealed Resident #53 was able to sit up on the side of the bed but could not stand without assistance. Nurse #3 indicated Resident #53 might have been able to change the oxygen but confirmed where the oxygen concentrator was placed Resident #53 would not be able to reach it and stated she did not know how Resident #53's oxygen was set at 4 liters per minute. An observation and interview with the Director of Nursing (DON) on 04/28/26 at 12:05 PM revealed the DON reviewed Resident #53's records and stated the resident's oxygen concentrator should be set at 3 liters per minute. The DON was then accompanied to Resident #53's room and confirmed Resident #53's oxygen flow rate was at 4 liters per minute. The DON changed the oxygen flow rate from 4 liters per minute to 3 liters per minute. The DON stated she expected staff to check physician orders for oxygen settings and follow them. Interview with the Nurse Practitioner (NP) on 04/29/26, at 10:15 AM revealed she expected Resident #53's oxygen order to be followed. The NP further revealed Resident #53's oxygen level set at 4 liters per minute could cause an overload of oxygen to the resident. The NP indicated if Resident #53 required a different level of oxygen, then she would expect staff to notify her and there to be an order to change it. An interview with the Administrator on 04/30/26 at 4:00 PM revealed she expected Resident #53's oxygen order to be followed. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (low levels of oxygen in body tissue). The physician order dated 04/09/26 revealed Resident #35 was ordered to receive oxygen at 3 liters per minute via nasal cannula every day and night shift for respiratory failure with hypoxia. Review of Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required oxygen. The MDS further revealed Resident #35 was dependent for moving from lying to sitting on side of the bed and from sit to stand. Review of Resident #35's care plan dated 04/15/26 revealed the resident required continuous oxygen. The goal for Resident #35 was to benefit mentally and physically with use of oxygen therapy. Interventions included to ensure oxygen was titrated to appropriate setting as ordered by the Medical Director, the oxygen concentrator was functioning properly, and oxygen saturations as ordered and PRN (as needed). An observation and interview with Resident #35 on 04/27/26 at 11:18 AM revealed the resident lying in bed on her back with a nasal cannula in her nostrils and the oxygen tubing connected to the oxygen concentrator. The oxygen concentrator was located on the floor on the left side of the bed adjacent to the headboard approximately two feet away from the bed. The oxygen flow meter was set at 2 liters per minute when the flow meter was viewed at eye level. When asked, Resident #35 stated she had been on her back all morning and was unable to reach the oxygen concentrator and she had not changed the oxygen flow rate. Resident #35 denied any shortness of breath. An observation and interview with Resident #35 on 04/27/26 at 2:22 PM revealed Resident #35 lying in bed on her back with a nasal cannula in her nostrils and the oxygen tubing connected to the oxygen concentrator. The oxygen flow meter was set at 2 liters per minute when the flow meter was viewed at eye level. Resident #35 denied any shortness of breath. Review of Resident #35's Medication Administration Record revealed Nurse #4 documented on 4/27/26 the resident's oxygen flow rate was set at 3 liters per minute for the 7:00 AM to 7:00 PM shift. An interview on 04/27/26 at 2:23 PM with Medication Aide (MA) # 1 revealed she thought the oxygen flow rate for Resident #35 was 2 liters per minute but needed to check. She stated the nurse was responsible for setting and monitoring the rate of oxygen and she (MA #1) checked the pulse oxygen saturation rate that morning and documented it at 98%. MA #1 further stated she was not sure what the oxygen flow rate was for Resident #35 and she would check with the nurse. On 4/27/26 at 2:27 PM the physician orders for oxygen administration for Resident #35 were reviewed with MA #1 and Nurse #4 present. Nurse #4 indicated she was Resident #35's assigned nurse that day and confirmed Resident #35's oxygen flow rate was 3 liters per minute. Nurse #4 and MA #1 were accompanied to Resident's #35's room. Nurse #4 and MA #1 observed the oxygen concentrator for Resident #35 and stated the oxygen flow rate was on 2 liters per minute. Nurse #4 changed the flow rate to 3 liters per minute. Nurse #4 stated she did not know why the rate was on 2 liters and did not recall when she last checked it that shift. An interview with Nurse Aide (NA) #6 on 04/30/26 at 9:25 AM revealed she was often assigned to Resident #35. NA #6 stated the resident was unable to reach over and down towards the oxygen concentrator without falling out of bed and was unable to sit up without staff assistance. She did not believe that Resident #35 was physically able to change the oxygen flow meter. NA #6 revealed she never changed Resident #35's oxygen flow rate. An interview was conducted with Nurse #7 on 04/30/26 at 10:00 AM who was the assigned nurse that day and stated she was familiar with Resident #35 as she was regularly assigned to care for her. Nurse #7 stated it was the nurse's responsibility to monitor the oxygen flow rate and monitor the respiratory status of all residents receiving oxygen. She stated the nurse should observe at the beginning of the shift to confirm the oxygen flow rate matched the physician order and the resident receiving it was not in respiratory distress. She further stated the oxygen flow rate would be changed only by the nurse. An interview was conducted with the Nurse Practitioner (NP) on 04/29/26 at 10:00 AM during which she stated the oxygen order for Resident #35 should be followed. The NP stated Resident #35's oxygen level set at 2 liters per minute could cause respiratory distress for the resident. The NP indicated if Resident #35 required a different level of oxygen, then she would expect staff to notify her and there to be an order to change it. An interview with the Director of Nursing on 04/30/26 at 11:45 AM revealed the nurse was responsible for setting and monitoring the oxygen flow rate and it should match the physician order. She reviewed Resident #35's record and stated the resident's oxygen concentrator should be set at 3 liters per minute. An interview with the Administrator on 04/30/26 at 4:30 PM revealed she expected Resident #35's oxygen order to be followed.

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 91 days reviewed for sufficient nurse staffing (September 2024, October 2024, November 2024). Findings included: Review of the facility's Posted Nurse Staffing for September of 2024 revealed there was not a Registered Nurse scheduled for at least 8 hours a day on September 6, 2024, September 7, 2024, September 21, 2024, and September 22, 2024. The Posted Nurse Staffing for October 2024 was reviewed and there was not a Registered Nurse scheduled for at least 8 hours a day on October 6, 2024 and October 20, 2024. The November Posted Nurse Staffing was also reviewed and there was not a Registered Nurse scheduled for at least 8 hours daily for November 3, 2024, November 16, 2024, and November 17, 2024. During an interview with the Director of Nursing on 2/25/2025 at 1:19 pm she stated she was responsible for the nurse staffing schedule in September 2024, October 2024, and November 2024. The Director of Nursing stated there was a staffing issue during those months and she was aware there was not a Registered Nurse in the facility for 8 hours on the dates in September 2024, October 2024, and November 2024. The Director of Nursing stated they had initiated a plan of correction for the scheduling of a Registered Nurse for 8 hours daily. The Administrator was interviewed on 2/26/2025 at 3:19 pm and she stated she expected nursing to have a Registered Nurse in the building 8 hours a day every day. The Administrator stated she was not the Administrator during September 2024, October 2024, and November 2024 but had reviewed the Plan of Correction initiated during that time.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure walls in a resident's room did not have stains (room [ROOM NUMBER]A) and failed to ensure a call light panel was securely attached to the wall behind a resident's bed (room [ROOM NUMBER]B) for 2 of 4 rooms on 1 of 3 halls (100 hall) reviewed for a safe, clean and homelike environment. Findings included: 1. On 2/23/2025 at 10:39 am the wall beside the bed in room [ROOM NUMBER]A had two 4-centimeters by 3-centimeters dried, dark brown stains. During observations on 2/24/2025 at 9:59 am and on 2/25/25 at 8:57 am the two 4-centimeters by 3-centimeters dried, dark brown stains remained on the wall beside the bed in room [ROOM NUMBER]A. On 2/25/2025 at 9:18 am Nurse Aide #2 was interviewed, and she stated she was assigned to room [ROOM NUMBER]A and housekeeping was responsible for cleaning the walls. Nurse #1 was interviewed on 2/25/2025 at 9:00 am and she stated room [ROOM NUMBER]A was on her assignment but had not noticed the two dried, dark brown stains to his wall. Nurse #1 stated housekeeping was responsible for cleaning the walls in the room. During an interview with Housekeeper #1 on 2/25/2025 at 9:12 am she stated the two 4- centimeters by 3-centimeters dried, dark brown stains on the wall beside the bed in room [ROOM NUMBER]A was dried stool. Housekeeper #1 stated she had the same assignment on 2/24/2025 and did not notice the stains on the wall beside the bed but housekeeping cleaned the walls twice a week in the residents' rooms. The Administrator was interviewed on 2/26/2025 at 9:15 am and she stated she was not aware of the two dried, dark brown stains on the wall beside his bed in room [ROOM NUMBER]A. She stated the walls should be washed daily when housekeeping completed the daily room cleaning and as needed. 2. On 2/23/2025 at 10:44 am an observation of room [ROOM NUMBER]B revealed the call light panel, which was above the head of the resident's bed, was detached from the wall and protruded 1 inch. The panel had a thick amount of caulk around the outer edges of the panel that was broken and the wiring to the panel was visible. On 2/25/2025 at 9:23 am an observation was made of room [ROOM NUMBER]B and the call light panel at the head of the bed continued to protrude from the wall 1-inch and the thick caulk around the edges of the call light panel and the caulk had broken away in areas. The wiring to the panel was visible. The resident in room [ROOM NUMBER]B stated she was afraid the panel would eventually fall out of the wall. During an interview with the Maintenance Director on 2/26/2025 at 8:59 am he stated he came to work at the facility about one month ago. He stated he had not been aware the call light panel in room [ROOM NUMBER]B was protruding from the wall, and it looked like someone had tried to repair around the panel by filling the area between the wall and the panel with caulk instead of fixing the panel flush with the wall. The Maintenance Director stated the protruded call light panel was not a danger to the resident. The Administrator was present during the observation and interview with the Maintenance Director on 2/26/2025 at 8:59 am and was then interviewed on 2/26/2025 at 9:02 am and stated they had fixed a lot of maintenance issues since she came to the facility a month ago and she was not aware the call light panel in room [ROOM NUMBER]B was protruding from the wall. The Administrator stated she was in room [ROOM NUMBER]B on 2/22/2025 and the call light panel was not protruding from the wall that day. The Administrator stated the call light panel should be attached to the wall and they would get it fixed immediately.

Based on observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #55) reviewed with a urinary catheter. The findings included: Resident #55 was admitted to the facility on [DATE]. Her cumulative diagnoses included obstructive uropathy (a condition where the flow of urine is blocked, leading to a buildup of urine in the urinary tract). Resident #55's care plan included an area of focus related to the resident having an indwelling urinary catheter in place (Initiated on 2/6/25). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderately impaired cognition. No behaviors nor rejection of care were reported. The assessment indicated Resident #55 required supervision or touching assistance for eating and personal hygiene; partial to moderate assistance for sit to stand and chair/bed to chair transfers; and substantial to maximum assistance for toileting, bathing, dressing and bed mobility. The MDS reported Resident #55 had an indwelling urinary catheter. An observation was conducted on 2/24/25 at 10:20 AM as Resident #55 was sitting in her wheelchair with a urinary catheter collection bag hanging from her wheelchair. At the time of this observation, 1 inch of the bottom of Resident #55's urinary catheter bag and approximately 2 inches of the catheter tubing were lying on the floor. The resident appeared confused at the time of the observation and could not provide any information regarding her urinary catheter. Another observation was conducted of Resident #55 on 2/26/25 at 8:20 AM as she laid in her bed with the head of the bed raised and her breakfast meal placed on the bedside tray table in front of her. One-half (1/2) of the resident's urinary catheter bag and approximately four (4) inches of the catheter tubing was observed to be lying on the floor. On 2/26/25 at 8:25 AM, Nurse Aide (NA) #1 was identified as the NA who was assigned to care for Resident #55. Accompanied by the NA to Resident #55's room, another observation was made of the resident's catheter bag and tubing lying on the floor. When NA #1 was asked what her thoughts were with regards to the position of the catheter bag and tubing, the NA stated, It shouldn't be on the floor. The NA was observed to wash her hands and don gloves as she prepared to address the positioning of the catheter bag and tubing. Upon her request, an interview was conducted on 2/26/25 at 8:53 AM with the facility's Director of Nursing (DON). The DON stated she was made aware of the concerns related to Resident #55's urinary catheter bag and tubing having been on the floor. She reported that the entire catheter bag and tubing system was replaced this morning since they had been observed to be lying on the floor. An interview was conducted on 2/26/25 at 2:45 PM with the facility's Infection Preventionist. During the interview, the Infection Preventionist reported NA #1 told her about Resident #55's catheter bag and tubing found lying on the floor earlier that morning. The Infection Preventionist stated that because of this observation, she went ahead and changed the whole system. She stated that changing the system, brought it [the catheter bag] up and off the floor. When asked if the catheter bag and tubing should be on the floor, she reported they should not.

Based on observations, interviews with the staff and consultant pharmacist, and record reviews, the facility failed to acquire a medication (a combination calcium and vitamin D supplement) ordered for administration resulting in multiple doses of the prescribed medication being missed for 1 of 5 residents (Resident #61) observed for medication administration. The findings included: Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and heart failure. On 9/27/23 at 8:15 AM, Medication (Med) Aide #2 was observed as she prepared and administered 11 oral medications to Resident #61. At that time, the med aide reported this resident's calcium and vitamin D combination tablet was not available on the med cart for administration because it had not been delivered by the pharmacy. A follow-up interview was conducted on 9/27/23 at 11:28 AM with Med Aide #2. During the interview, the med aide confirmed Resident #61's calcium / vitamin D tablets had been previously supplied by the pharmacy. When the process of acquiring medications from the pharmacy was discussed, Med Aide #2 reported the calcium / vitamin D had been ordered from the pharmacy but had not come in. Med Aide #2 reported she did not know why it hadn't been delivered by the pharmacy. A review of Resident #61's electronic medical record (EMR) included her current physician's orders and revealed an active medication order (dated 4/12/23) was written for 315 milligrams (mg) calcium with 250 International Units (IU) vitamin D3 to be given as one tablet by mouth every day. This medication was not administered to Resident #61 as ordered on 9/27/23. A review of the documentation on Resident #61's September 2023 Medication Administration Record (MAR) revealed the resident did not receive the calcium / vitamin D tablet as ordered on 17 of 26 days during the month. The MAR indicated a dose of the calcium / vitamin D supplement was previously missed on each of the following dates: 9/1/23, 9/7/23, 9/8/23, 9/9/23, 9/11/23 - 9/18/23, 9/20/23 - 9/22/23, 9/25/23 and 9/26/23. Seventeen (17) notations were made within the electronic MAR notes which indicated the medication was unavailable and had not been delivered by the pharmacy. An interview was conducted on 9/27/23 at 3:27 PM with Nurse #1. Nurse #1 was identified as the hall nurse assigned to care for Resident #61. During the interview, the nurse reported she was unaware Resident #61's calcium and vitamin D supplement was not available because she typically did not work on that medication cart (the 200 Hall Med Aide's Med Cart). When asked what the process was for ordering refills of medications from the pharmacy, Nurse #1 reported she could call the pharmacy to check on an order to see if it was already ordered and scheduled for delivery. An interview was conducted on 9/27/23 at 4:07 PM with the facility's consultant pharmacist. During the interview, the pharmacist was asked what the process was for ordering refill medications from the dispensing pharmacy. The pharmacist reported that staff should typically be requesting medication refills electronically. If that didn't work for some reason, staff could manually fax a refill request to the pharmacy. A follow-up interview was conducted on 9/28/23 at 9:25 AM with the consultant pharmacist. The pharmacist reported that Resident #61's calcium and vitamin D supplement had been previously dispensed by the pharmacy on 4/22/23, 5/19/23, 6/29/23 and 7/28/23. She stated the dispensing pharmacy reported they had notified the facility this supplement was available as an over-the-counter (OTC) house stock. The pharmacist indicated the failure to have Resident #61's calcium / vitamin D available for administration appeared to be a miscommunication between the facility and dispensing pharmacy as to which OTC products would be supplied by the pharmacy and which ones would be obtained by the facility as house stock. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the medication administration observations were discussed. The DON reported she was made aware that Resident #61's calcium and vitamin D supplement had not been available for administration. She stated that since the med administration observation, the medication was delivered by the pharmacy and the resident received a dose as ordered on 9/28/23.

Based on observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to: 1) Label medications with the minimum information required, including the first and last name of the resident on 3 of 3 medication (med) carts observed (the 300 Hall Nurse's Med Cart, the 100 Hall Nurse's Med Cart, and the 300 Hall Med Aide's Med Cart); 2) Store medications in accordance with the manufacturer's storage instructions on 2 of 3 med carts (300 Hall Nurse's Med Cart and the 300 Hall Med Aide Med Cart); and 3) Discard an expired medication on 1 of 3 med carts observed (the 300 Hall Med Aide's Med Cart). The findings included: 1-a. An observation was conducted on [DATE] at 3:58 PM of the 300 Hall Nurse's medication (med) cart in the presence of Nurse #3. The observation revealed the following medications stored on the med cart failed to be labeled with the minimum information required: --An opened, manufacturer's bottle of 0.4 milligrams (mg) nitroglycerin tablets (a medication used to treat angina or chest pain) was stored on the med cart. A hand-written notation on the top of the cap only read, 305B ,d+[DATE]. The bottle of tablets did not include the minimum required information, including the resident's first and last name. --One Lantus Solostar insulin pen with a handwritten notation on the pen read, ,d+[DATE] and [a last name only]. The medication label did not include the minimum information required, including both the first and last name of the resident. 1-b. An observation was conducted on [DATE] at 3:58 PM of the 300 Hall Nurse's med cart in the presence of Nurse #3. The observation revealed two vials of 0.5 mg/3 mg per 3 milliliters (ml) of ipratropium/albuterol inhalation solution (an inhaled medication delivered via a nebulizer to treat asthma or chronic obstructive lung disease) dispensed for Resident #74 were stored outside of the manufacturer's foil pouch. There was no notation of when the vials had been removed from the foil pouch. Storage Conditions printed on the foil pouches read: Protect from light. Unit dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. An interview was conducted with Nurse #3 on [DATE] at 4:15 PM. During the interview, the findings of the med cart observation were discussed. The nurse confirmed the vials of inhalation solution should have been dated as to when they were removed from the pouch. Upon review of the insulin pen, the nurse stated the pen may have been obtained from the facility's emergency medication stock. 2-a. An observation was conducted on [DATE] at 4:22 PM of the 100 Hall Nurse's medication cart in the presence of Nurse #4. The observation revealed the following medications stored on the med cart failed to be labeled with the minimum information required: --One Lantus Solostar insulin pen with a handwritten notation on the pen read, [an initial for the first name and a last name]. A pharmacy auxiliary sticker placed on the pen indicated the Date opened was [DATE]. The medication label did not include the minimum information required, including both the first and last name of the resident. --One Humalog insulin Kwikpen with a handwritten notation on the pen read, [last name only]. A pharmacy auxiliary sticker placed on the pen indicated the Date opened was [DATE]. The medication label did not include the minimum information required, including both the first and last name of the resident. --One Basaglar insulin pen with a handwritten notation on the pen read, [DATE] and [a last name only]. The medication label did not include the minimum information required, including both the first and last name of the resident. An interview was conducted with Nurse #4 on [DATE] at 4:30 PM. Upon review of the insulin pens identified without the minimum required labeling information, the nurse reported she thought sometimes the pharmacy delivered multiple insulin pens at a time with only one label provided. 3-a. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed one packet of 0.8 grams (g) sevelamer carbonate for oral suspension (a phosphate binder) was not labeled with the minimum required information, including the resident's name. 3-b. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened bottle of neomycin / polymyxin B / dexamethasone 0.1% ophthalmic suspension (a combination antibiotic and corticosteroid eye drop) dispensed for Resident #47 was stored lying on its side in the med cart. Storage instructions on the manufacturer's labeling of the bottle read in part, Store upright. 3-c. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened bottle of 1% prednisolone ophthalmic suspension (a steroid eye drop medication) dispensed for Resident #74 was stored lying on its side in the medication cart. The manufacturer's storage instructions printed on the label of the eye drops provided instructions to store the bottle in an upright position. 3-d. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened manufacturer's box of Dulcolax suppositories (a stimulant laxative) containing 6 suppositories and labeled for Resident #74 was stored on the med cart. The suppositories had a manufacturer's expiration date of [DATE] printed on its label. An interview was conducted with Med Aide #1 on [DATE] at 4:33 PM as the concerns regarding the med cart observations were identified. At that time, Med Aide #1 confirmed the manufacturer's labeling on the eye drop bottles indicated they should be stored in the upright position. She also confirmed the suppositories were past their expiration date. An interview was conducted on [DATE] at 4:07 PM with the facility's consultant pharmacist. During the interview, an inquiry was made as to what information she would expect to be included on the label of a medication dispensed from the pharmacy. The pharmacist reported that she would certainly expect the full name of the resident that the medication belonged to be on the medication. During a follow-up interview conducted with the pharmacist on [DATE] at 9:25 AM, the pharmacist reported only one insulin pen had been pulled from the emergency drug kit for resident use within the last 3 months. She stated that upon review of the extra insulin pens stored in the med room refrigerator, all pens were being sent out from the pharmacy with a mini-sticker which included all of the minimum required information. It was not known why the mini-sticker labels were missing from several insulin pens stored on the med carts. An interview was conducted on [DATE] at 4:53 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect medications to be stored in accordance with the manufacturer's instructions.

Based on record review, resident interviews, staff interviews and observations, the facility failed to provide a room free of a strong smell of urine. This was evident in 1 of 5 rooms reviewed for clean, homelike environment (room [ROOM NUMBER]). Findings included: Resident #10 was admitted in the facility on 12/13/13 with the most recent readmission on 10/11/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 was independent with toilet use and required oversight, encouragement or cueing with personal hygiene with one-person physical assist. Resident #10 required one-person physical assist with bathing with physical help limited to transfer only. A review of Resident #10's care plan dated 4/20/23 revealed Resident #10 Resident sometimes resisted/refused care which may compromise health/ safety/ well-being. Often refused baths and personal hygiene care. Also sometimes refused to allow laundry to wash dirty clothes or allow staff to move dirty clothes piled on the floor. Refused to be evaluated by psych services and medical MD's multiple times. Interventions included to approach resident warmly and positively to convey acceptance, warmth, and welcome and speak in a calm, gentle manner, to provide positive feedback for demonstrating desired behaviors/cooperation with staff and assess for uncommunicated/unmet needs when behaviors occur such as hunger, thirst, pain, and toileting needs and provide appropriate interventions. Interventions also included to be aware resident sometimes refused room rounds to ensure cleanliness of room, identify unsafe situations of presence of inappropriate items. Explain this is for their well-being/comfort and safety and encourage compliance. In addition. resident was very reclusive and didn't want anyone to handle her things. The care plan addressed Resident #10 had occasional bladder incontinence due to her impaired mobility, dependence on staff, increased weakness, and decreased endurance presented a barrier to independent toileting activities. An intervention for bladder incontinence included to utilize disposable briefs to prevent soiling of clothing/ bed linens and reduce risk for skin issues. An observation on 9/25/23 at 2:20 PM of room [ROOM NUMBER] was conducted in conjunction with an interview with Resident #10 who resided in the room. The observation revealed the room smelled strongly of urine from the doorway into the hallway. The bathroom door was open, and the bathroom was observed to be neat and clean. The resident in the bed closest to the window (Resident #10) stated she was continent of bladder but wore a pull up for incontinent episodes. The odor of urine was pungent on Resident #10's side of the room. She said she tried to make it to the bathroom when she needed to urinate but had been incontinent at times. An observation on 9/26/23 at 11:44 AM of room [ROOM NUMBER] was conducted in conjunction with an interview with Resident #10 who resided in the room. The observation revealed the room smelled strongly of urine from the doorway into the hallway. Resident #10 stated housekeeping cleaned the room once a day and the facility did her laundry. She stated she wore pull ups for incontinence episodes. On 9/26/23 at 12:00 PM an interview with the Laundry and Housekeeping Manager revealed housekeeping deep cleaned room [ROOM NUMBER] bimonthly. Resident rooms were swept and mopped daily, and hard surfaces were disinfected daily. She stated, to her knowledge, Resident #10 had not refused to have her room cleaned. On 9/26/23 at 12:03 PM an interview with Housekeepers #1 and #2 revealed Resident #10 did not refuse to allow room to be cleaned. They stated that they cleaned and mopped the room daily, but it still smelled of urine due to Resident #10's incontinence episodes. On 9/26/23 at 12:08 PM an interview with Nurse Aide #3 (NA) revealed she had worked at the facility for [AGE] years and was usually assigned to Resident #10. She stated Resident #10 would not allow staff to assist her with care because she wanted to be independent. She further stated Resident #10 refused showers because she was very private and preferred to bathe herself in the bathroom sink. She added Resident #10 would not give staff the soiled pad from her bed unless staff had a clean one to provide her. NA #1 added when Resident #10 refused to shower this morning she got NA #4 to try but Resident #10 still refused. An interview with NA #4 on 9/26/23 at 12:12 PM revealed she had worked at the facility for two years and was familiar with Resident #10. She stated that NA #3 had asked her to try to convince Resident #10 to shower but she had refused. Resident #10 was offered a bed bath and she refused. On 9/28/23 at 10:45 AM an observation of room [ROOM NUMBER] was conducted in conjunction with an interview with the Staff Development Coordinator (SDC). Upon entering the room there was no odor of urine noted. The SDC and housekeeping staff were observed in the process of cleaning Resident #10's room. Staff moved furniture and boxes and swept and mopped under them. The waste basket next to Resident #10's bed was clean with a fresh liner. The SDC stated Resident #10 often refused to leave her room so that staff could clean but had agreed to attend activities and allow staff to clean the room this day. She explained Resident #10 was very independent and preferred to bathe herself in the sink rather than shower. On 9/28/23 at 10:46 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #10 was adamant she could care for herself and had a right to refuse up to a point. She explained Resident #10 had agreed to palliative care because of her refusal of care and refusal to allow staff to clean her room and linens. She stated she expected Resident #10's room to be clean and free of odors. She explained she expected staff to reapproach Resident #10 often to see if she would allow more assistance with her care and cleanliness.

Based on observations, staff interviews, and record review, the facility staff failed to clean and disinfect a blood glucose meter (glucometer) dedicated for individual-resident use in a manner that would protect against the cross-contamination from contact with other meters or equipment. This was observed for 2 out of 8 sample residents (Residents #64 and #17) who were observed to have a blood glucose (sugar) check. The findings included: A review of the facility policy entitled Glucometer Disinfection (Date Implemented: January 2018; Date Reviewed / Revised: December 2019) included the following Policy Explanation and Compliance Guidelines related to the disinfection of glucometers, in part: Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned, disinfected, and air-dried after each use and according to manufacturer's instructions for multi-resident use 2. The glucometers should be disinfected with a wipe pre-saturated with an EPA [Environmental Protection Agency] registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 3. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 4. Procedure [designated with the letters a. through n.] . i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions The manufacturer's Guidelines for Cleaning and Disinfecting the [Brand Name of Meter] used at the facility were also reviewed. The Cleaning and Disinfecting Procedures read, in part: Step 6 (of 7) Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. Do not wrap the meter in a wipe. A review of the manufacturer instructions for the disinfectant wipes used to disinfect individual-resident glucometers at the facility included read in part, Allow treated surface to remain wet for two (2) minutes. Let air dry. The manufacturer of the disinfectant wipes provided additional clarification regarding the product's wet contact time under the topic of Most Frequently Asked Questions. The response read, The contact time listed on the product label is the total amount of time that it takes to inactivate all of the microorganisms listed on the product label. This time is typically referred to in minutes, and should be communicated to staff members that are utilizing the disinfectant. In certain geographies and also in settings where temperature, relative humidity, and air changes may vary, it is possible that the surface may not remain visibly wet for the designated contact time. Current EPA [Environmental Protection Agency] guidance requires that the treated environmental surface or equipment remains wet for the contact time stated on product label. Additional wipes may be needed in order to comply with the EPA guidance, however the overall contact time does not change . An observation was conducted of Nurse #2 on 9/27/23 at 11:41 AM as she prepared to do a blood glucose check for Resident #64. The nurse pulled Resident #64's glucometer stored in the manufacturer's box from the medication (med) cart. Both the meter and the box were labeled with Resident #64's name. The nurse removed the glucometer from the box and collected the supplies needed for a blood glucose check (test strips, two alcohol prep pads, a lancet, and gloves). She wiped the glucometer with an alcohol wipe for 3 seconds, placed the meter directly on top of the med cart, then inserted a test strip. The nurse picked up the glucometer with supplies and entered the resident's room on 9/27/23 at 11:45 AM. After the blood glucose check, the nurse exited the room at 11:47 AM and returned to the med cart. Nurse #2 was observed as she wiped the glucometer with a disinfectant wipe for two (2) seconds, then immediately returned the meter to the box before storing it in the med cart. The meter did not appear to be visibly wet when placed in the box for storage. On 9/27/23 at 11:53 AM, Nurse #2 was observed as she removed a new glucometer from its box and prepared to do a blood glucose check for Resident #17. The nurse placed the meter on top of her closed laptop computer, donned gloves, and used an alcohol wipe to wipe the glucometer for 2-3 seconds prior to using it. The nurse discarded her gloves and performed hand hygiene. Nurse #2 then gowned and gloved at the entrance of Resident #17's room (the resident was on Enhanced Contact Precautions). On 9/27/23 at 11:57 AM, the nurse placed the glucometer on the resident's bedside tray table. She used the meter to test Resident #17's blood glucose before placing the meter back on the bedside tray table. Nurse #2 was observed as she slid the glucometer across the table's surface, then picked it up and returned to the med cart. On 9/27/23 at 12:00 PM, the nurse used an alcohol wipe to wipe the glucometer for 2-3 seconds before returning it to the box for storage in the med cart. When finished, the nurse was observed to pull a disinfectant wipe from the container placed on top of the med cart to wipe off the top of the med cart. An interview was conducted on 9/28/23 at 9:03 AM with Nurse #2. During the interview, the concerns regarding the glucometer disinfection observed were discussed. The nurse reported either an alcohol wipe or disinfectant wipe could be used to disinfect a glucometer. Nurse #2 stated she typically used a disinfectant wipe to disinfect the residents' glucometers at the beginning and end of each day. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, the DON reported the facility's nurses were educated to disinfect the individual-resident use meters after each use in accordance with the manufacturer's directions. She stated the disinfectant used at the facility required a 2-minute wet contact time. On 9/28/23 at 11:35 AM, a follow-up interview was conducted with the Directors and the DON. At that time, the Directors confirmed that wiping the glucometer with a disinfectant wipe only kept the meter wet for 50 seconds and would require a meter to be re-wiped after a minute or so to keep the surface wet for recommended contact time indicated by the manufacturer of the disinfectant wipes. Upon request, an interview was conducted on 9/28/23 at 11:20 AM with the facility's corporate Director of Operations and Director of Clinical Operations. During the interview, the Directors expressed concern regarding possible discrepancies between the glucometer instructions for disinfection (indicating the glucometer should not be wrapped in a wipe) and the disinfectant wipe instructions for disinfecting the machine. At that time, the Directors were informed the observations conducted of glucometer disinfection included use of an alcohol pad or a 2-3 second wipe of glucometers with a disinfectant wipe.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 7/14/22. This was for 1 deficiency that was cited in the area of Free of Medication Error Rate of 5 Percent or More (F759). The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QA). The findings included: This citation is cross referred to: F759: During the facility's recertification survey on 9/28/23, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. During the facility's recertification survey of 7/14/22, the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 33 opportunities. There were medication errors for 1 of 4 residents during medication pass observations. The medication error rate was 6.06%. The Administrator was interviewed on 9/28/23 at 2:40 pm. He stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Practitioner and the Medical Director were always invited to attend. He also stated that the QA committee usually meets quarterly but they have met monthly this year due to new staff. He also added that the facility has to utilize a lot of agency staff since Covid began and they have recently been able to decrease the amount of agency staff needed. He stated the facility nursing staff meet to discuss this issue and investigate new ways to achieve compliance.

Based on observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. The findings included: 1. Resident #72 was admitted to the facility on [DATE]. His cumulative diagnoses included diabetes. On 9/27/23 at 11:30 AM, Nurse #1 was observed as she checked Resident #72's blood glucose (sugar) with the result noted to be 337 milligram (mg) / deciliter (dl). The nurse was then observed as she returned to the medication cart and prepared to administer Novolog insulin in accordance with his sliding scale insulin orders (where the dose of insulin administered would be dependent on the resident's current blood glucose level). Based on Resident #72's blood glucose result, Nurse #1 reported she needed to administer 9 units of Novolog insulin to the resident. The nurse was observed as she primed the insulin pen. Priming an insulin pen before each injection is recommended by the manufacturer to remove air from the insulin cartridge and needle; priming the pen ensures a full dose is administered. After the insulin pen was primed, Nurse #1 dialed the pen to indicate a dose of 9 units of Novolog insulin would be administered to the resident. Nurse #1 was observed as she injected the 9 units of insulin subcutaneously (under the skin) to Resident #72 on 9/27/23 at 11:37 AM. A review of the resident's electronic medical record (EMR) included physician orders dated 8/16/23 for insulin coverage scheduled at 11:30 AM daily. The order indicated Novolog insulin was to be injected subcutaneously according to the following sliding scale: If the resident's blood glucose (BG) = 70 - 120, cover with 0 units of insulin; If BG = 121 - 150, administer 1 unit of insulin; If BG = 151 - 200, administer 2 units of insulin; If BG = 201 - 250, administer 3 units of insulin; If BG = 251 - 300, administer 5 units of insulin; If BG = 301 - 350, administer 7 units of insulin; If BG = 351 - 400, administer 9 units of insulin; If BG is greater than 400, call Medical Doctor (MD). Based on Resident #72's current sliding scale insulin orders, 7 units of Novolog insulin should be administered for a BG of 337 mg/dl. An interview was conducted with Nurse #1 on 9/27/23 at 1:07 PM. During the interview, the nurse was asked about the discrepancy of the insulin dose administered to Resident #72 (9 units) versus 7 units of sliding scale insulin ordered for a blood glucose of 337. The nurse reported she was taught to always double prime an insulin pen. When asked for further clarification, the nurse stated she always primed an insulin pen with 2 units of insulin. After the initial priming, she would then dial the insulin pen to add 2 more units of insulin to the actual dosage ordered for administration. She reported this would double prime the pen. Upon inquiry, Nurse #1 acknowledged she always added 2 units to the prescribed insulin dose administered to a resident. An interview was conducted on 9/27/23 at 4:07 PM with the facility's consultant pharmacist. During the interview, the pharmacist was asked what her thoughts were with regards to the double priming of an insulin pen. The pharmacist responded by stating the initial priming of the pen was done to ensure accuracy of the insulin dose administered to the resident. Additional insulin should not be added to the insulin dose administered to a resident. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, the DON reported education had already been provided to Nurse #1 on correct insulin dosing and administration with a return demonstration. 2. Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and heart failure. On 9/27/23 at 8:15 AM, Medication (Med) Aide #2 was observed as she prepared and administered 11 oral medications to Resident #61. At that time, the med aide reported this resident's calcium and vitamin D combination tablet was not available on the med cart for administration because it had not been delivered by the pharmacy. A review of Resident #61's EMR included her current physician's orders and revealed an active medication order (dated 4/12/23) was written for 315 milligrams (mg) calcium with 250 International Units (IU) vitamin D3 (the natural form of vitamin D produced by the body from sunlight) to be given as one tablet by mouth every day. This medication was not administered to Resident #61 as ordered on 9/27/23. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, results of the medication administration observations were discussed. The DON reported she had been made aware that Resident #61's calcium and vitamin D supplement was not available for administration. She stated this medication has since come in from the pharmacy and the resident received a dose of it on 9/28/23.

Based on observations, staff interviews, and record review, the facility failed to implement a comprehensive fall prevention care plan for a resident (Resident #67) with a history of falling. This occurred for 1 of 2 residents reviewed for falls. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, cerebral infarction, and convulsions. A review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 6/27/2023, revealed Resident #67 had severe cognitive impairment, required extensive assistance of one staff member for bed mobility, and total assistance of two staff members for transferring. She had no documented falls since the prior assessment. A review of the comprehensive care plan, dated 6/27/2023, identified a focus area that read; Resident #67 was at risk for falls related to multiple factors including her cerebral vascular accident, hemiplegia, increased weakness, decreased endurance, decreased safety awareness, lack of coordination, and cognitive deficits. The interventions included: 1. A fall mat beside the bedside that was started on 6/2/2021. 2. Do not leave the Resident in the room unattended when up in the wheelchair and was started on 1/9/2021. 3. Provide a scoop mattress for the bed and was started on 1/29/2021. A review of the most recent fall incident report history for Resident #67 revealed she experienced an unwitnessed fall from the bed on 7/18/2023. An observation was conducted of Resident #67 on 9/25/2023 at 3:14 p.m. sitting in her wheelchair and the bed did not have a scoop mattress. She was alone in the room. An observation was conducted of Resident #67 on 9/26/2023 at 10:50 a.m. sitting in her wheelchair and a scoop mattress was not on the bed. She was alone in the room. An observation was conducted of Nursing Assistant (NA) #1 and #2 on 9/27/2023 at 3:06 p.m. as they provided assistance, using a mechanical lift, to transfer Resident #67 from the wheelchair to the bed. The Resident was placed onto a non-scooped mattress with no positioning devices. The two NA's then asked the resident if they could assist her anymore and went to exit the room. An interview was conducted with NA #1 and NA #2 on 9/27/2023 at 3:10 p.m. and they stated they were finished conducting care. They both were asked if the Resident was on a scoop mattress and they replied, No. The two stated they did not place a fall mat at the bedside and did not realize she should have one. NA#2 stated he would review the care plan and get a fall mat as needed. An interview was conducted with Nurse #1 on 9/27/2023 at 3:13 p.m. and she stated she had been employed at the facility for approximately 6 months. She added Resident #67 was on her assignment regularly. She revealed she was not familiar with the Resident's plan of care and did not recall seeing a fall mat placed beside the bed. She stated Resident #67 had not had a scoop mattress during her employment. An interview was conducted with the Director of Nursing on 9/17/2023 at 3:20 p.m. and she observed the room for Resident #67. She revealed the Resident did not have a fall mat and did not have a scoop mattress. She stated the two interventions were on the care plan and should be in use. She felt the issue occurred when a room change had to occur last December of 2022 and then the Resident was moved back to the current location after room renovations were completed, in March 2023. She added, at that time, the intervention items must have been misplaced and this was not picked up on during regular Administrative rounds.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice/End of life care (Resident #74) and discharge location (Resident #85). This occurred for 2 of 23 residents reviewed for accuracy of assessments. The findings included: 1. Resident #74 was admitted to the facility on [DATE] with a cumulative diagnosis which included heart failure and a history of a cerebrovascular accident (stroke). The resident's admission Minimum Data Set (MDS) was dated 5/3/23. A review of the resident's electronic medical record (EMR) revealed her physician orders included a Hospice consult on 5/9/23. A significant change MDS assessment dated [DATE] was completed for resident #74. However, review of this MDS revealed the section on Health Conditions did not indicate the resident had a life expectancy of less than 6 months. Also, the MDS section on Special Treatments, Procedures and Programs did not indicate Resident #74 was receiving Hospice services. An interview was conducted on 9/28/23 at 4:03 PM with the facility's MDS Nurse. When asked what prompted the significant change MDS to be completed for Resident #74 on 5/9/23, the nurse reported it was completed due to the resident's admission to Hospice on 5/9/23. Upon further inquiry, the MDS Nurse reviewed the Section J and Section O of the resident's MDS assessment. At that time, the MDS Nurse reported Section J should have indicated Resident #74's life expectancy was less than 6 months and Section O should have indicated the resident was on Hospice. The MDS Nurse acknowledged these two pieces of information had been miscoded and reported she would submit a correction for them. 42900 2. Resident #85 was admitted to the facility on [DATE]. A review of the electronic record for Resident #85 documented he was discharged on [DATE] to a non-Medicare/Medicaid bed at the facility. A review of the discharge MDS assessment, dated 7/26/2023, documented Resident #85 was discharged to an acute care hospital. An interview was conducted with the MDS Coordinator on 9/28/2023 at 3:06 p.m. and she reviewed the MDS discharge assessment, dated 7/26/2023, for Resident #85. She revealed the Resident had been discharged to a non-Medicare/Medicaid bed at the facility and the discharge to the hospital was not accurate. An interview was conducted with the Administrator on 9/28/2023 at 3:18 p.m. and he revealed it was his expectation that all MDS assessments be completed accurately.

Based on observation, record review and staff interviews, the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 33 opportunities. There were medication errors for 1 of 4 residents (Resident # 42) during medication pass observations. The medication error rate was 6.06%. Review of current physician orders for Resident # 42 indicated the following medications were due to administer during the morning medication pass: [MEDICATION(S)]-[MEDICATION(S)] 25-100 tab let via gastric tube three times a day. [MEDICATION(S)] 10 mg tablet via gastric tube once daily. Review of records revealed there were no physician orders or progress notes to indicate Resident #42 could have medications crushed and administered at the same time via gastric tube. During observations of a medication pass on 7/13/22 at 8:58 am, Nurse #1 indicated Resident # 42 had a gastric tube and her medications were to be administrated via this route. Nurse #1 crushed 2 pills and mixed with 10 milliliters (mL) water in the same medication cup. After checking placement of the gastric tube per facility policy, Nurse # 1 administered the crushed medications via gastric tube. This writer asked Nurse # 1 if there was a physician's order to administer medications at the same time without a specified amount of water flush in between, in which she responded, I don't think so. This writer and Nurse # 1 checked the physician's orders together outside of Resident # 42's room, and no orders were found to indicate the medications could be crushed and administered at the same time. Nurse #1 explained at that time that she was aware she was supposed to administer pill medications separately with a specified water flush in between medications. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) together on 7/13/22 at 2:00 pm. The NHA and the DON both indicated all medications intended for gastric tube administration should be prepared and given separately according to their facility policy and procedures. The NHA further indicated the manner in which Nurse # 1 administered medication on 7/13/22 to Resident # 42 was a medication error due to improper administration via gastric tube.

Based on staff interviews and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #79) reviewed for planned discharge to the community. Findings included: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had severely impaired cognition. The MDS assessment also indicated discharge planning was occurring since Resident #79 expected to be discharged to the community. The baseline care plan indicated Resident #79 was at the facility for a respite stay and would be discharged back to her home in the community upon completion of the respite stay. Resident #79 discharged home on[DATE]. Resident #79's closed paper chart and electronic health record was reviewed for a discharge summary and was not located in either chart. A discharge summary would have ensured the facility communicated necessary information when Resident #79 discharged home. On 3/19/21 at 4:59 PM an interview was completed with the facility Social Worker (SW) and Director of Operations. The SW stated she was responsible for discharge planning when a resident came to the facility for a short stay and planned to return home to the community. The SW explained Resident #79 came to the facility for a respite stay and then returned home. She said a discharge summary was not completed when the resident discharged home. The SW was aware a discharge summary should have been completed prior to discharge and reported it wasn't completed because the discharge process was inconsistent. During the interview the Director of Operations revealed she had recently audited closed charts and identified inconsistencies with discharge documentation. She had completed audits of discharged residents back to April 2020 and was still identifying charts that were out of compliance with discharge documentation, including discharge summaries. She had recently educated staff regarding the requirements for discharge documentation. The Director of Operations stated when Resident #79 discharged home in December 2020 the facility should have provided her with a discharge plan of care, medication list and a discharge summary that included a recapitulation of the resident's stay.

Based on record review and staff interviews the facility failed to transcribe orders for intravenous/PICC line site care for 1 of 1 residents reviewed for PICC line care (Resident #286). Findings include: Resident #286 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was assessed to have a PICC/Intravenous line to the Right upper extremity. A review of the comprehensive minimum data set (MDS) assessment dated [DATE], revealed the named Resident was cognitively intact, required extensive assistance of two people for bed mobility, transfers and toileting. The MDS coded the resident had [CONDITION(S)] and received IV [CONDITION(S)] of antibiotics while a resident. The comprehensive care plan dated 8/30/2020 did not include a focused problem area for intravenous maintenance or infection. An interview was conducted with the Director of Nursing that revealed intravenous line orders would be added to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress notes revealed documentation, dated 9/11/2020, of a dressing change due to dried blood at the site. This was the only dressing change documentation in the progress notes discovered. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment administration record for Resident #286, for the month of September and October 2020 did not include dressing change orders for the intravenous site. An interview was conducted on 3/19/2021 at 9:40 AM, with the Administrator and he stated the closed chart for Resident #286 was reviewed by himself and a corporate consultant and they did not find any evidence that a PICC line dressing change occurred more than one time in the months of September and October 2020. He stated it was his expectation that orders be transcribed to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress note dated 10/5/2020 documented the named Resident was complaining of burning during antibiotic intravenous therapy being delivered through the PICC line. The Antibiotic was stopped, the PICC line was flushed and the pain stopped. On 10/6/2020 at 1:09 PM, a nursing progress note documented the Resident complained of right arm burning. The Nurse Practioner was notified and orders to flush the line were received. The resident requested to be evaluated at the hospital. The Resident was transferred to the hospital and admitted on [DATE].

Based on staff interview and record review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for a resident with an active [DIAGNOSES REDACTED].#51). Findings included: Resident #51 was admitted on [DATE] with pertinent Diagnoses: [REDACTED]. Resident #51 PASRR Level I Determination Notification document dated 10/27/17 revealed nursing facility placement was appropriate and that there was no [DIAGNOSES REDACTED]. This was sent with Resident #51 from another facility where she had previously been living. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was not cognitively impaired. The MDS further revealed that Resident #51 was totally dependent on staff for transfers and required extensive assistance with bed mobility and toileting. Resident #51's medical record showed that a current care plan was in place for her [DIAGNOSES REDACTED]. An interview was conducted with the facility's social worker on 3/19/21 at 8:25 am revealed she was unaware that Resident #51 had a [DIAGNOSES REDACTED]. She handed me a copy of a PASRR Level II that she had completed the previous day after looking into Resident #51's chart and agreed that she should have had one completed upon entry to the facility. An interview was conducted with the facility's Administrator on 3/19/21 at 2:39 PM who was aware of Resident #51's diagnoses of [MEDICAL CONDITION] Disorder but was unaware that she had not had a PASRR Level II completed. The facility's Administrator was made aware that a PASRR Level II has now been submitted for Resident #51.

Based on record review and staff interviews, the facility failed to close and transmit 3 of 3 discharged residents (Resident #1, #2 and #3) MDS (Minimum Data Set-a tool used for resident assessment) within 120 days. Findings included: 1. Resident #1 was discharged [DATE]. The discharge assessment was completed by MDS Nurse #1, but was not signed as completed by a registered nurse (RN) so it remained open and un-transmitted on 4/12/19. 2. Resident #2 was discharged [DATE]. The discharge assessment was completed by MDS Nurse #1, but was not signed as completed by a registered nurse (RN) so it remained open and un-transmitted on 4/12/19. 3. Resident #3 was discharged [DATE]. The discharge assessment was completed by MDS Nurse #1, but was not signed as completed by a registered nurse (RN) so it remained open and un-transmitted on 4/12/19. An interview was conducted on 4/11/19 at 2:55PM with the Administrator, Director of Clinical Operations, and the Clinical Nurse Consultant. The Administrator stated, We're without an MDS RN currently. We had one until (MONTH) 2019, and then another one from (MONTH) 2019 through 3/13/19. Since 3/13/19 other MDS RNs have come in from other facilities to help (MDS Nurse #1). The Director of Clinical Operations stated she could not give a reason why these 3 discharge MDSs were not signed without speaking to her 'expert', or the former MDS nurse. An interview was conducted on 4/11/19 at 4:05PM with the Director of Clinical Reimbursement Services. She stated, I am an RN. I come to the facility at least once weekly. I function as the MDS Coordinator and do all the education on MDS for them. We currently don't have an RN in that job. Those 3 MDSs that weren't signed I cannot say why they weren't signed. After (MDS Nurse #1) completed them she would give a list to (MDS Nurse #3) and she would sign them as complete. But as far as knowing why those three were missed I don't know why. They should have been signed and closed in a timely fashion because we had an RN in the building full time at that time.

Based on observations, record review and staff interviews, the facility failed to maintain a clean splinting device for 1 (Resident #14) of 3 residents reviewed for limited range of motion. Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITION] and [MEDICAL CONDITION]. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 required extensive assistance with 2 people for bed mobility and transfers, extensive assistance with one person for dressing, toileting and bathing. Resident #14 required minimal assistance with meals. He had a functional limitation in range of motion in his upper extremity on one side. A review of the care plan updated on 2/20/19 revealed resident #14 required restorative care; splinting. Intervention was to apply right resting hand splint after morning care for 6-8 hours as tolerated for contractures. An observation on 4/11/19 at 9:31 AM revealed Resident #14 out of bed to his wheelchair in his room. A right hand splint was observed on Resident #14 ' s dresser. The splint was observed to be visibly soiled in the area where the thumb rests and the straps that secure the splint to the resident ' s hand. A follow up observation was made on 4/11/19 at 1:56 PM. Resident #14 was out of bed in his wheelchair watching television in his room. Resident #14 had a splint in place to his right hand. The splint remained visibly soiled under Resident #14 ' s thumb and on the straps that secure the splint to the resident ' s hand. An interview was conducted with Nursing Assistant (NA) #1 on 4/11/19 at 2:42 PM. NA#1 revealed the restorative nursing assistant applies the splints and removes them. An interview was conducted with Restorative Aide (RA) #1 on 4/11/19 at 2:58 PM. RA#1 revealed she applied the splint to Resident #14 ' s right hand today. She stated either restorative staff or the second shift nursing assistants remove the splints and clean them and allow them to air dry. She stated the splint should not be applied if it is soiled. She observed the splint on Resident #14 ' s right hand at this time and stated it didn ' t look like it had been cleaned. RA #1 revealed she should ensure the splint was clean prior to applying. An interview was conducted with the Therapy Manager on 4/11/19 at 3:19 PM. She stated she also manages the Restorative Program. She revealed the restorative aides apply the splints and if they are visibly soiled, they should be cleaned prior to use. An interview was conducted with the Director of Nursing on 4/12/19 at 2:00 PM. She revealed her expectation was for splints to be clean prior to use.

Based on record review and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set-a tool used for resident assessment) for 4 of 25 residents records reviewed (Resident #16, Resident #33, Resident #50, and Resident #83). Findings included: 1. Resident #16 was admitted to the facility 8/28/17 and re-admitted [DATE]. A review of a quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired, required total assistance for all activities of daily living except eating, had both lower limbs impaired, and was frequently incontinent. Active [DIAGNOSES REDACTED]. The special treatments and procedures section of the MDS was coded No for Resident #16 having had received [MEDICAL CONDITION] while a resident. Care plans last updated 3/26/19 for Resident #16 revealed a care plan, which read, in part, Resident is receiving [MEDICAL CONDITION]/[MEDICAL CONDITION] treatment for [REDACTED]. Interventions included evaluate response to the treatment after each session, provide with anti- emetic (a medication used to prevent vomiting) medications as needed, and allow rest periods throughout the day as needed. Physician orders [REDACTED]. Review of the MAR (Medication Administration Record) dated 3/1/19 through 3/31/19 revealed Resident #16 received Revlimid 5mg 3/16/19 through 3/31/19 with no missed doses, and [MEDICATION NAME] 2.5mg every day of (MONTH) 2019. An interview with Nurse #1 on 4/11/19 at 8:30AM revealed Resident #16 had active [DIAGNOSES REDACTED]. She stated Resident #16 was taking a [MEDICAL CONDITION] medication by mouth until 4/10/19. An interview was conducted on 4/11/19 at 8:45AM with MDS Nurse #1. She stated, I'm familiar with (Resident #16). Her active [DIAGNOSES REDACTED]. She receives Revlimid, a medication used to slow [DIAGNOSES REDACTED] symptoms and stops the growth [MEDICAL CONDITION] cells. She was going out to get chemo ([MEDICAL CONDITION]). The last time she went out was 3/21/19. She was getting chemo every 2 weeks. Section O (Special Treatments and Procedures) is where [MEDICAL CONDITION] is coded, but it's not coded for (Resident #16). She also takes [MEDICATION NAME] for [MEDICAL CONDITION]. It's a medication used to treat [MEDICAL CONDITION] in post-menopausal women. If medications are classified as [MEDICAL CONDITION] drugs Section O should be coded as [MEDICAL CONDITION]. But when I looked up Revlimid it didn't say [MEDICAL CONDITION] drug. An interview was conducted with the Director of Nursing on 4/11/19 at 9:20AM. She stated, (Resident #16) is on Revlimid which helps her symptoms and is part of her [MEDICAL CONDITION] plan. She also takes [MEDICATION NAME] as part of her [MEDICAL CONDITION] plan. Her Oncologist prescribed it. She stopped taking it 4/4/19. She started it 3/16/19. My expectation for MDS accuracy is for it to be coded accurately. An interview was conducted with the Consultant Pharmacist on 4/11/19 at 9:40AM. She stated Revlimid is a [MEDICAL CONDITION] agent. She stated, It's an anti-neoplastic agent. She also stated [MEDICATION NAME] is an anti-neoplastic agent ([MEDICAL CONDITION] drug) used to treat [MEDICAL CONDITION] in post-menopausal women. She stated Resident #16 received both medications from 3/19/19 through 3/31/19. 2. Resident #33 was admitted to the facility 12/13/2018 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #33 to be cognitively intact without behaviors or rejection of care. A. The Oral/Dental Status section of the MDS was reviewed and revealed no obvious or likely cavities, no loose natural teeth, no mouth or facial pain and no discomfort or difficulty chewing. Resident #33 was observed on 4/9/2019 at 11:25 AM and he was missing all teeth on his top jaw and had darkened and pitted teeth on the bottom jaw. Resident #33 was interviewed on 4/11/2019 at 4:40 PM and reported mouth pain on the left side of the lower jaw and only had 6 teeth, 3 on each side of the lower jaw. He further reported he was able to chew food by avoiding chewing on the left side. MDS Nurse #1 was interviewed on 4/12/2019 at 11:56 AM and she reported she visited with Resident #33 every day and he had not complained of mouth pain to her and she had not noticed his missing teeth or tooth decay. MDS Nurse #1 further reported she had not completed Resident #33 ' s admission MDS and the nurse who did was no longer working at the facility. The Director of Clinical Operations was interviewed on 4/12/2019 at 1:32 PM and she reported it was her expectation the MDS assessment was coded correctly. B. An occupational therapy note dated 12/14/2018 documented Resident #33 had limited range of motion of his left and right shoulder. A review of the admission MDS assessment dated [DATE] coded Resident #33 to have impairment on both sides upper body range of motion. The Quarterly MDS assessment for Resident #33 dated 1/25/2019 was coded as 0-none for limb impairment of upper body range of motion. Resident #33 was observed on 4/9/2019 at 11:15 AM. He was unable to lift his left or right arm above his head. An interview was conducted with Resident #33 on 4/9/2019 at 11:15 AM. He reported he had limited range of motion of both shoulders. The Rehabilitation Program Director (RPD) was interviewed on 4/11/2019 at 4:46 PM. The RPD reported Resident #33 had been treated by occupational therapy for functional mobility, dressing and toileting and Resident #33 was noted to have limited range of motion of both shoulders, as well as impaired strength. The MDS Nurse #1 was interviewed on 4/12/2019 at 11:56 AM and she reported she visited with Resident #33 every day and had not noticed he had limited range of motion of his shoulders. The Director of Clinical Operations was interviewed on 4/12/2019 at 1:32 PM and she reported it was her expectation the MDS assessment was coded correctly. C. The Quarterly MDS assessment for Resident #33 dated 1/25/2019 revealed bed rails were not used and other types of restraints were used daily. Resident #33 was observed on 4/9/2019 at 11:15 AM in bed. He had ¼ upper side rails on his bed and both sides were up. An interview was conducted with Resident #33 on 4/9/2019 at 11:15 AM. He reported he used the side rails to assist him to transfer in and out of bed and the rails did not prevent him from exiting the bed. Nursing assistant (NA) #2 was interviewed on 4/10/2019 at 4:18 PM and she reported Resident #33 used the side rails on his bed to assist with stability to transfer from his wheelchair into his bed. An interview was conducted with NA #3 on 4/11/2019 at 3:23 PM and she reported the side rails on Resident #33 ' s bed assisted him to transfer. MDS Nurse #1 was interviewed on 4/12/2019 at 1:30 PM and she reported she thought bed rails were coded as restraints for all residents. The Director of Clinical Operations was interviewed on 4/12/2019 at 1:32 PM and she reported it was her expectation the MDS assessment was coded correctly. 3. Resident #50 was admitted to the facility 4/15/2014 and readmitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment for Resident #50 revealed bed rails were not used and other types of restraints were used daily. The annual MDS assessment dated [DATE] assessed Resident #50 to be cognitively intact without behaviors and she required extensive 2-person assistance with bed mobility. Resident #50 was observed on 4/8/2019 at 6:04 PM in bed. She had ¼ side rails on her bed and both sides were up. An interview was conducted on 4/8/2019 at 6:04 PM with Resident #50. She reported the side rails were to assist her with bed positioning and provided her with a place to grip when she was turning in bed. Nursing assistant (NA) #2 was interviewed on 4/10/2019 at 4:18 PM. NA #2 reported Resident #50 required 2-person assistance to turn and reposition in bed, but she had side rails to assist her with turning. NA #5 was interviewed on 4/11/2019 at 3:59 PM and he reported Resident #50 required 2-person assistance with bed mobility and the side rails assisted her to turn in bed. An interview was conducted with NA #6 on 4/11/2019 at 4:00 PM and she reported Resident #50 had side rails on her bed to assist with bed positioning. MDS Nurse #1 was interviewed on 4/12/2019 at 1:30 PM and she reported she thought bed rails were coded as restraints for all residents. The Director of Clinical Operations was interviewed on 4/12/2019 at 1:32 PM and she reported it was her expectation the MDS assessment was coded correctly. 4. Resident # 83 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #83's Quarterly Minimum Data Set (MDS) assessment dated [DATE] did not reflect Resident #83 was receiving [MEDICAL TREATMENT]. A review of the physician's orders [REDACTED].>An interview was conducted with Nurse #4 on 4/11/19 at 2:40 PM. She revealed Resident #83 had been on [MEDICAL TREATMENT] for a long time and went to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. An interview was conducted with the Corporate Director of Operations, on 4/11/19 at 9:20AM. She stated, We assess residents through observations, electronic medical record review, hospital and physician notes and staff interviews. Once you assess and gather information you complete the MDS accurately and timely. Resident care plans are developed from there. We also do baseline care plans within 48 hours. We've been bringing in RN's (Registered Nurses) to help with MDS. Our SDC nurse (Staff Development Coordinator) is transitioning to MDS next week. An interview was conducted with MDS Nurse #1 on 4/11/19 at 3:35 PM. She revealed she is currently completing MDS's for the whole building. She stated [MEDICAL TREATMENT] should have been coded on Resident #83's quarterly MDS, but she missed it.

Based on observations, facility staff interviews, and record reviews, the facility failed to ensure the required safety precautions were taken for 2 of 3 sampled residents reviewed for accidents (Resident #6 and Resident #8). Resident #6 experienced a fall from his bed while he was being given a bed bath by a nursing assistant on 1/13/19, resulting in a laceration of the forehead and a closed displaced [MEDICAL CONDITION] phalanx (the bone closest to the palm of the hand) of the right little finger. After the 1/13/19 fall, the facility determined the resident required two person assistance while in bed when receiving ADL care. On 2/7/19, the resident was being provided incontinence care by one nursing assistant when the resident experienced another fall from the bed and sustained a laceration above his left eyebrow and a skin tear on his right middle finger. The facility failed to follow the manufacturer's instruction to safely transfer Resident #8 out of bed with a mechanical lift. Immediate Jeopardy began on 2/7/19 when Resident #6 experienced his second fall from the bed as he was being provided incontinence care with staff assist of one. This fall occurred after the facility had determined the resident required the assistance of two staff members to provide ADL care. Immediate Jeopardy was removed as of 2/14/19 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance with this tag at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for example number 2 where a plan of correction is required. The findings included: 1) Resident #6 was admitted to the facility on [DATE] with a cumulative [DIAGNOSES REDACTED]. A review of Resident #6 ' s baseline care plan dated 1/11/19 indicated the resident required staff assist of one for bathing/hygiene, dressing/grooming, eating, and toileting. The baseline care plan noted this resident required the assistance of two staff members for ambulation and transfers. A review of the resident ' s most recent individualized care plan included the following areas of focus, in part: --1/12/19 (Resident) is at risk for bleeding related to aspirin use. --1/12/19 (Resident) requires assistance with activities of daily living (ADLs). The care plan interventions included: Provide assistance with adequate staff support for all safety compromising activities .transfers, toileting, etc. --(Not dated) (Resident) is at risk for falls related to multiple factors. The care plan interventions included, in part: Provide assistance with adequate staff support for all safety compromising activities .check for needs often .encourage resident to summon assistance for all safety compromising activities; and, Ensure adequate staff support for safety compromising activities and ensure safe positioning, safe parameters and proper body alignment to maximize safety. Review of an Incident Report dated 1/13/19 at 11:20 AM revealed Resident #6 experienced a fall in his room while bathing. A Nurse ' s Note written on this report (authored by Nurse #1) described the incident and indicated the nursing assistant (NA) called the nurse into Resident #6 ' s room after the resident experienced a fall. A laceration was noted above the resident ' s right eyebrow and a pressure dressing was applied for the bleeding to stop. A Witness Statement of what happened (authored by NA #1) read, in part: As I was finishing my bed bath with (the resident) he was on his side turned and steady. I turned to get a towel and the (resident) leaned/turned further in the bed and falling hitting his right side and head on the A/C unit (heating/air conditioning unit). Further falling off the unit hitting his face and left side on the floor . The resident was transported to the Emergency Department (ED) for evaluation and treatment. A telephone interview was conducted with NA #1 on 2/13/19 at 9:10 AM. During the interview, the NA was asked to describe the incident that occurred with Resident #6 on 1/13/19. The NA reported he went into the resident ' s room to help him get washed up and dressed; the resident was lying in bed at the time. When the NA had finished giving the resident the 1st part of his full bath, he was going to work on his lower body and provide perineal care on the resident ' s backside. The NA used a draw sheet to turn the resident away from him so that he was lying on his left side. The NA reported he himself was standing on the right side of the bed (towards the door). At that time, the resident was lying on his side and reportedly, not wobbly at all. The NA reported the resident was not on the edge of the bed and I was right by him and within reach. The NA stated he took his hand to grab a washcloth which had been placed within reach. As he turned to the right to grab the cloth, the resident rolled out of bed. When he rolled, his upper body hit the heating/air conditioning unit, then he hit the bed, then hit the floor face down after that. NA #1 added, It literally happened when I turned my body to grab the rag. I wasn ' t away from him .I had all my water, soaps, and towels all within reach . When I turned back towards him I saw him hit the floor. The NA reported the resident ' s bed was in a high position at the time of the fall because he was providing a bath. When asked if the NA touched the resident as he rolled off the bed, the NA stated he dropped the towel and reached for him, but at that point he was already falling and out of reach. The NA reported after the fall, he literally pulled the call light cord out of the wall to request help. Upon inquiry, NA #1 reported he was alone in the room when the fall occurred. When the nurse came, he assisted her by getting the resident ' s vital signs. Then when the Emergency Medical Technicians (EMTs) arrived, he helped them transfer the resident onto the stretcher. During the interview with NA #1, the NA was asked how he knew what needed to be done to keep a resident safe while providing ADL care. The NA reported he sometimes asked questions of the resident and/or the nurse if he was not familiar with the resident. He also reported electronic information from the Kardex typically included some notes listed in regards to providing ADL care. At the time of Resident #6 ' s fall from the bed on 1/13/19, however, the facility had not been determined the resident required 2-person assistance with his ADL care. An interview was conducted on 2/14/19 at 3:27 PM with Nurse #1. Nurse #1 was the 1st shift nurse who was assigned to Resident #6 ' s hall on 1/13/19 when the resident fell . The nurse reported upon entering the room, the resident was bleeding above his right eye brow with blood all over his face. When asked if she identified any other injuries at that time, she stated she did not. Nurse #1 reported she assessed the resident, had vital signs taken, and tried to stop the bleeding. Upon inquiry, the nurse reported there would have been additional staff to assist with the resident ' s ADL care, if needed. After the fall on 1/13/19, the nurse reported seeing NAs get a second person to help provide care to the resident. However, she was uncertain if 2-person assistance was always used to provide ADL care to Resident #6 after this incident. Hospital Emergency Department (ED) records dated 1/13/19 indicated the resident had a laceration of the forehead with repair using Dermabond (a skin adhesive that holds wound edges together) and a closed displaced [MEDICAL CONDITION] phalanx of the right little finger. The resident's right 5th finger fracture was reduced (setting of the bone to ensure it healed properly) using gentle traction and a finger splint was applied. The resident was discharged from the ED to the facility on [DATE]. A review of the facility ' s follow-up report from the 1/13/19 incident read, Resident recently admitted to facility. Resident was receiving ADL care while position on his side. Resident rolled off bed. Resident sent to ER (emergency room ) for evaluation related to laceration above right eye and already right femur fracture. Resident will be two person assist when in bed during ADL care. A review of Resident #6 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. He had no behaviors nor rejection of care. Section G of the MDS assessment indicated the resident required extensive assistance with 2+ person physical assist for bed mobility, transfers, toileting and personal hygiene. He also required extensive assist from staff for locomotion on the unit, dressing, and eating. The resident was incontinent of bowel and bladder. Section K of the MDS revealed Resident #6 was 72 inches tall and weighed 237 pounds. A review of the facility ' s Communication Log book kept on Resident #6 ' s hall revealed the log documented changes made to a resident ' s Kardex. A Kardex (also known as a Care Guide) is a summary of individual patient needs, which included information for nursing assistants regarding the assistance required to meet the ADL care needs for a resident. A review of the Communication Log book included a sheet for Resident #6 and revealed a change was made on 1/13/19 to indicate the resident required 2-person assist with ADL care. A printed copy of Resident #6 ' s most recent (undated) Kardex was provided by the facility for the surveyor to review at 4:45 PM on 2/12/19. Each resident ' s Kardex was made available to the nursing assistants electronically via a Kiosk on the hall. Resident #6 ' s Kardex read in part, Resident will be a two person assist with care. Review of an Incident Report dated 2/7/19 at 12:01 PM revealed Resident #6 experienced a fall in his room. The Nurse ' s Note on this report described the incident and revealed NA #2 notified the hall nurse (Nurse #2) after Resident #6, fell on the floor while he was log rolling him to change him. The note indicated Resident #6 hit his head against the heating/air conditioning unit. Nurse #2 assessed the resident while he was lying on his left side. The nurse reported the resident had a laceration with bleeding above his left eyebrow and a skin tear on his right middle finger. A Witness Statement of what happened revealed NA #2 stated the resident fell while he was trying to log roll him. The resident was reported to have moved suddenly and rolled off the bed, hitting his head against the heating/air conditioning unit. The resident was transported to ED for evaluation and treatment. Hospital Emergency Department (ED) records dated 2/7/19 indicated the resident had a facial wound repaired with Dermabond. X-ray films were taken and showed no evidence of a fracture. Resident #6 was discharged back to the facility for continued rehabilitation. A review of the facility ' s follow-up report from the 2/7/19 incident read, Resident noted with a recent fall in facility and a history of recurrent falls prior to admission. (NA) notified nurse resident fell on the floor while he was log rolling him to change him. (NA) reported he hit his head against heating unit (heating/air conditioning unit). Nurse assessed resident, while resident was lying on his left side. Neuro checks initiated. Sent to ER (emergency room ) for evaluation related to fall and laceration on left forehead and right middle finger. Resident return with negative CT (Computerized Tomography) Scan results and 1 cm (centimeter) laceration to the left forehead that was repaired with Dermabond. Resident will be a two person assist with ADL care. A telephone interview was conducted on 2/13/19 at 11:22 AM with NA #2. NA #2 was identified as the NA who was caring for Resident #6 at the time of his fall on 2/7/19. NA #2 described the incident that occurred on 2/7/19. The NA reported he came in to check on the resident for rounds and then went on to provide incontinence care for him. NA #2 stated he log rolled the resident so he was on his left side. When asked to describe the log roll, the NA reported he used a draw sheet, had the resident cross his right leg over the left and used a slight tug towards him to roll the resident on his left side. The NA reported he was on the right side of the bed (closer to the door) and the resident ' s bottom was facing the NA. As the NA reached back to the bedside table to get the wipes and briefs, the resident lifted his left shoulder over to the right (like he was trying to get over more or re-position). At that moment, the resident, plunged over and off of the bed. He lifted up and dipped more to his left . and whoop he went over to his side. The NA reported the resident basically rolled forward and hit the heating/air conditioning unit with part of his body, then went down on the floor. He stated, It went so quick. When asked if the NA was able to touch the resident as he fell off the bed, he responded by saying, It happened too fast. Upon further inquiry, the NA stated he was alone in the room at the time of the incident. During the telephone interview conducted with NA #2 on 2/13/19 at 11:22 AM, the NA reported he ran to get the nurse immediately after the fall occurred. He reported the resident was bleeding from the left side of his head above the eye and it appeared he had hit his hand on either the heating/air conditioning unit or the window sill. The nurse came back to the room with him, she assessed the resident, and they put a draw sheet under the resident and used it to slide him back to the bed. The NA reported 911 was called and we stayed with him in the room until EMS arrived. Resident #6 was then transported to the hospital. When NA #2 was asked if he was aware (before the fall) that the resident required 2-person assistance for ADL care in the bed, he stated he was not. NA #2 reported he had not checked the Kardex before the fall and did not think he needed 2 people to provide the care. After the fall, however, the NA stated he looked at the Kardex and saw it indicated the resident required 2-person assist for ADL care. An interview was conducted on 2/12/19 at 2:56 PM with Nurse #2. Nurse #2 was the nurse who was assigned to care for Resident #6 on 2/7/19 (the date of the resident ' s second fall). During the interview, the nurse recalled when she went to assist the NA #2 after Resident #6 fell off of the bed the NA reported to her that he had a log-rolled the resident to do incontinence care in the bed. The nurse stated she had understood the resident continued to roll, and rolled over and off of the bed. When the nurse got to the room, the resident was lying on his left side and next to the heating unit (heating/air conditioning unit). He had a laceration over his left eye brow (bleeding) and a skin tear on his middle finger of the right hand. His little finger appeared swollen. The nurse reported she was talking with the resident and he was talking with her. When asked if anything was hurting on him, he said it was not. Once he said that, the nurse figured it was safe for her and the NA to put him back on the bed. Once safely on the bed, another nurse came and assessed him. The nurses decided to send the resident out for safety sake. The on-call provider was contacted and an order received to send him to the ED. During the interview conducted on 2/12/19 at 2:56 PM with Nurse #2, she was asked how many staff members were required to assist the resident with his ADLs such as incontinence care. The nurse reported that female aides always had two in the room together to do his incontinence care and bed mobility. When asked if there should have been two NAs providing the incontinence care on 2/7/19, she stated, Yes, there should have been. The nurse added that there should be a care guide in the Kiosk to tell NAs how many people were needed for ADL care. Interviews were conducted on 2/13/19 at 2:28 PM with the facility ' s Physical Therapist (PT) and Therapy Manager (a Speech Therapist). During the interview, the PT and Occupational Therapist (OT) notes for Resident #6 were reviewed. The therapy staff reported a PT and OT therapy evaluation was completed on day 1 or day 2 after a resident ' s admission. Since Resident #6 was admitted to the facility on a weekend, a PRN therapist (one who works as needed) did the assessment. Upon further inquiry, however, the therapists reported a resident ' s needs for bed mobility and ADL care within the bed were not addressed by therapy, except when moving from a lying down to sitting up position. An interview was conducted on 2/13/19 at 4:40 PM with the facility ' s Director of Nursing Services (DNS). During the interview, the Communication Log book from Resident #6 ' s hall was reviewed. The DNS explained a Communication Log book was kept on each hall and was intended to communicate any changes that were made to a resident ' s care plan and electronic Kardex to the nursing staff. The DNS reported that nursing assistants were supposed to review the Communication Log book to see if any changes had been made for their residents. After reviewing a change noted in the log book, staff was supposed to sign the form in the log book to indicate he/she was aware of the change made to the resident ' s care. Review of a form for Resident #6 in the Communication Log book revealed a change was made on 1/13/19 which indicated the resident required 2-person assist with ADL care. However, the DNS noted that only two NAs had signed this form as having reviewed the information. The DNS stated the Communication Log Book was the facility ' s communication piece; and, she felt this was where the facility ' s system failed. A follow-up interview was conducted on 2/15/19 at 4:20 PM with the DNS. During the interview, the DNS was asked how many staff members she would have expected to provide incontinence care to Resident #6 on 2/7/19. She responded by stating, It should have been two like in the Kardex. The DNS added that NA #2 acknowledged this information was available in the Kardex at the time the resident ' s fell on [DATE]. On 2/14/19 at 10:30 AM, the facility ' s Executive Director, DNS, and Director of Operations and Compliance Officer were informed of the immediate jeopardy. The facility provided the following acceptable credible allegation of Immediate Jeopardy removal on 2/16/19 at 9:03 AM: 1) Resident #6 experienced a fall from bed on 1/13/19 during the 7-3am shift while Activities of Daily Living (ADL) care was being provided by CNA. The resident ' s initial plan of care related to ADL bed mobility stipulated assistance needed with bed mobility. The plan of care was not clear if the assistance needed required one-person or two-person assistance. Resident Representative (RR) and attending physician notified and resident transported to Emergency Department (ED) for evaluation on 1/13/19 and returned same day with a report sustaining a closed displaced [MEDICAL CONDITION] phalanx of right little finger. Report was given to the RR following resident ' s return from ED. Upon return to the facility, Resident #6 was re-assessed for care needs that were addressed through care planning and KARDEX. Interventions initiated were as follows: Resident to be a 2 person assist with ADLs added to resident plan of care and KARDEX Intervention was communicated to line-staff by the Staff Development Coordinator (SDC) through the facility ' s Communication Log on 1/13/19 Resident #6 experienced a subsequent fall from bed on 2/7/19 during the 11pm-7am (12:58AM) shift while CNA was providing peri-care. Nurse was notified by CNA prior to moving resident for proper assessment and determined to have sustained a skin tear to left eyebrow and right middle finger. Physician notified and resident sent to ED for evaluation. RR notified of fall with transport on 2/7/19 to the ED for further evaluation Resident returned from ED to the facility on [DATE] 6:55AM with a report of laceration to left eye. The facility administrator interviewed the CNA involved in the incident of 2/7/19 regarding care delivery. When asked if the CNA had reviewed the resident ' s KARDEX prior to delivering care, the CNA responded that he did not review it prior to care, but did review it after the incident. When further questioned as to knowledge that reviewing the resident KARDEX prior to delivery of care is protocol, he responded he did, but did not review the KARDEX. The CNA received one-on-one counseling from the facility administrator regarding reviewing the KARDEX and remains suspended at this time. 2) Corrected Action for Residents with the potential to be affected: All residents have the potential to experience an accident/incident due to impaired cognitive function, physical limitations, comorbidities, and/or effects of some medications. This plan of correction will address this potential for accident. After review of the Resident #6 initial plan of care it was identified the plan was not clear on the amount of assistance needed by the resident. Based upon this, the facility ' s interdisciplinary team re-assessed 100% of all residents with regards to bed mobility and positioning on 2/13/19 to ensure the individual needs of residents are met without compromising safety. Identified needs, including the required assistance (one-person/two-person) were documented and updated on the resident ' s Kardex and Care Plan on 2/14/19. Any resident identified through the re-assessment by the IDT team as needing assistance with bed mobility and positioning will be referred to therapy for screen/evaluation to assure the amount of assistance is accurate. a. All CNAs (direct care) will be audited for referring to resident KARDEX before conducting bed mobility/positioning as identified in the resident ' s KARDEX. This audit will be conducted by the Director of Nursing Service (DNS), and designees on 2/13/19-2/14/19. Any staff not observed on/before 2/14/19 will be observed/audited by nursing administrative staff prior to the start of the employees ' next scheduled shift 3) Measures/systems implemented to ensure the deficit practice does not occur again: ·Staff education will be given to all CNAs by the DNS/designee on/before 2/14/19 regarding the following: Staff (CNA) to review each resident ' s KARDEX prior to care. ·Any staff not inserviced will be inserviced prior to start of the employee ' s next scheduled shift. ·All Licensed Staff will be inserviced by the DNS/designee on/before 2/14/19 regarding: ·The importance and necessity to monitor staff under their supervision for following protocol in referencing the resident KARDEX for guidelines of care. Any staff not inserviced will be inserviced prior to start of the employee ' s next ·Any change in a resident ' s plan of care/KARDEX affecting delivery of care will be communicated directly to the charge nurse by a member of the IDT team using the Interdisciplinary form. The charge nurse will advised that it will be their responsibility to inform the direct care staff of the change and updated KARDEX as evidenced by applicable staff signatures on the Communication Form. ·The importance of referring to resident ' s KARDEX prior to resident care to be given added emphasis in New Employee Orientation for CNAs ·The importance for licensed nurses to oversee and monitor the staff under their supervision to assure the care protocols are followed will be given added emphasis in the New Employee Orientation for Licensed Nurses. 4. Compliance with the action plan established by the facility with regards to this area of concern will be monitored on a scheduled and routine basis. ·The Bed Mobility Audit which includes the following: o Name of staff person visually observing the CNA conduct bed mobility o Observe if position of resident was appropriate for care delivery o Type of assistance needed (one person/two person) o Mobility completed per plan of care (KARDEX) o Height of bed appropriate o Any issues with performance and if so, how was the issue addressed This Bed Mobility Audit will be completed at a minimum of 10 times weekly for four weeks,and as needed by the DNS/designee. Outcomes of the scheduled audits will be discussed during the facility morning administrative (which members of the facility Quality Assurance (QA) Committee are present). Any non-compliance will be addressed as observed. Outcomes of compliance with established plan will also be brought to the facility monthly QA by the DNS/designee for committee review, discussion and changes needed in plan should they occur. All discussion will be included in the QA meeting minutes. Following the 4 weeks of Bed Mobility audits, Bed Mobility audits will continue with a minimum of 10 audits per month x 7 months, and as needed. The outcomes of audits will be brought to the facility monthly QA meetings by the DNS to be reviewed by the QA Committee members for compliance. Any discussion and/or revisions to the plan will be contained in the meeting minutes. Any revisions to the plan will require re-inservicing to applicable staff by the DNS/designee and require monitoring to begin again at the 10 times per week times 4 weeks. Licensed nursing staff will be monitored using the Nurse Monitor Sheet and will be conducted by the DNS/designee 10 times per week times 4 weeks, and as needed. This monitoring tool will assess the nurses ' compliance with 1) Intervention ordered 2) Intervention carried out as ordered 3) Follow any action taken 4) DNS notified of non-compliance. Outcomes of the scheduled audits will be discussed during the facility morning administrative (which members of the facility Quality Assurance (QA) Committee are present). Any non-compliance will be addressed as observed. Following the initial 4 weeks, the Nurse Monitor Sheet will continue to be used at a minimum of 10 times per month X 7 months, or as needed. This monitoring will be conducted by the DNS/designee. The outcomes of audits will be brought to the facility monthly QA meetings by the DNS/designee to be reviewed by the QA Committee members for compliance. Any discussion and/or revisions to the plan will be contained in the meeting minutes. Any revisions to the plan will require re-inservicing to applicable staff by the DNS/designee and require monitoring to begin again at the 10 times per week times 4 weeks. The facility administrator will be responsible for implementing this plan and assuring monitoring is done as outlined. In the event of the administrator ' s absence, the DNS is responsible for assuring compliance with plan. In keeping with the timeline of actions outlined, immediate jeopardy removal will be obtained by 2/14/19. The facility ' s credible allegation of Immediate Jeopardy removal was validated on 2/16/19 at 1:20 PM. The validation was evidenced by interviews with both licensed nursing staff and non-licensed nursing staff on where to locate information regarding safety measures necessary for a resident ' s care, including the number of persons required to provide ADL care. Review of on-going in-service records revealed licensed and unlicensed staff were in-serviced prior to working on the floor. A review of the Bed Mobility Audit Tool and the assessments of residents (with regards to bed mobility and positioning) was also conducted as part of the validation process. 2) Review of the manufacturer's instruction for the facility's mechanical lift used for resident transfers specified all three straps on both sides of the lifting pad must be used and attached to the lift's bar to safely lift a resident. Resident #8 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as alert and oriented who required limited assistance of 1 (one)staff for bed mobility and the transfer into and out of bed. His lower extremities were weak, and his balance was unsteady. Section K indicated Resident #8's height was recorded as 69 inches and a weight recorded as 392 pounds. Record review revealed on 12/25/18 staff were trying to transfer Resident #8 from the bed to chair and was unable. Staff lowered the resident to the floor and no injuries were sustained. A mechanical lifting device was then used to transfer the resident off the floor. Staff were educated to use this mechanical lift for all resident transfers. Review of the care plan dated 12/25/18 revealed an approach to use a mechanical lift for transfers. Observation on 2/14/19 at 10:25 AM was conducted during the transfer of Resident #8 from his bed to the wheelchair using the mechanical lift, performed by Nursing Assistant (NA) #6 and NA #7. The lifting pad used with the mechanical lift was placed underneath the resident. This lifting pad had 3 looped style straps on each side. The straps at the ends were attached to the lifting bar. The middle strap on each side was not attached to the lifting bar. NA #7 began to lift the resident with the mechanical lifting device until an inquiry was made about the lack of attachment of the middle strap to the bar. NA #7 lowered the lift and NA #6 then secured the middle straps to the bar. Resident #8 was then transferred into his wheelchair. Interview on 2/14/19 at 10:40 AM with NA #6 who stated he does not use the middle strap on the pad to secure the resident for lifting and no reason was provided. Interview on 2/16/19 at 10:52 AM with the Administrator and Director of Nurses (DON) was conducted. The DON expected the staff to attach each strap on the pad to the bar of the mechanical lift and follow the manufacturer's instruction.

Based on resident ' s family, staff and physician interviews, and oncologist and facility record reviews, the facility failed to prevent a significant medication error by failing to initiate administration of and to correctly administer an antineoplastic medication used to [MEDICAL CONDITION] (lenalidomide) for 1 of 3 residents whose medications were reviewed (Resident #4). The resident ' s Oncologist noted on 10/12/18 that her lab results reflected a progression of her [DIAGNOSES REDACTED]. The medication was ordered by the oncologist on 10/30/18 from a specialty pharmacy, and brought to the facility by Resident #4 ' s family on 11/5/18. The medication was stored on the hall medication cart (unopened) and not administered until 1/10/19. A count of the lenalidomide capsules conducted on 2/14/19 revealed only 6 capsules had been administered to Resident #4 to date. Failure to receive the medication prescribed due to the progression of myeloma may have delayed the resident ' s response to the treatment. The findings included: Resident #4 was admitted to the facility on [DATE] with re-entry to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of the facility ' s (MONTH) (YEAR) Physician order [REDACTED].#4 revealed her medications included 2.5 milligrams (mg) letrozole to be given as one tablet by mouth daily for [MEDICAL CONDITION] (initiated on 2/21/18). A review of the resident ' s medical record included an Oncology Consult Progress Note dated 10/12/18. The note indicated Resident #4 was seen at the oncology office by the Nurse Practitioner (NP) on 10/12/18. The following issues were addressed: [DIAGNOSES REDACTED] in relapse and malignant neoplasm of breast, Stage 4. The notes read, in part: (Resident #4) is here today with her (family member) to discuss her myeloma progression and starting her on lenalidomide (brand name of Revlimid). She is receiving bortezomib (an antineoplastic agent used to treat [DIAGNOSES REDACTED] that is administered either subcutaneously or intravenously) every 2 weeks and is tolerating that well. Lenalidomide is an antineoplastic medication used to treat [DIAGNOSES REDACTED] in patients by multiple mechanisms, including inhibiting the growth of myeloma cells. The plan of treatment noted in the Oncology Consult Note for Resident #4 read, (Resident #4) will start on lenalidomide 5 mg daily. (Name of oncologist) has prescribed this She will receive bortezomib today. She is tolerating that well. I reviewed with (name of family member) the labs that we drew that indicated a slow progression of her myeloma. I also gave him detailed info about the lenalidomide in (resident ' s) after visit summary. An addendum was made to the 10/12/18 Oncology Consult Progress Note by the oncologist which indicated he met with Resident #4 and a family member. At that time, her lab work indicating the progression of the [DIAGNOSES REDACTED] was discussed, along with the need to intensify her treatment. The oncologist noted, There are many ways of doing this, but I think the simplest one would be to add lenalidomide . The oncologist also indicated he had discussed the medication with their oral [MEDICAL CONDITION] pharmacy specialist to help obtain the medication for Resident #4. A review of Resident #4 ' s electronic medical record (EMR) revealed the oncology consult report dated 10/12/18 was scanned into the resident ' s EMR at the facility on 10/16/18. Review of Resident #4s (MONTH) (YEAR) Physician order [REDACTED]. A review of the resident ' s (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of the resident ' s medical record included another Oncology Consult Progress Note dated 10/30/18. The note indicated Resident #4 was seen at the oncology office on 10/30/18 with the following issues addressed: [DIAGNOSES REDACTED] not having achieved remission; lytic bone [MEDICAL CONDITION] on x-ray (areas of bone damage that result [MEDICAL CONDITION] plasma cells building up in the bone marrow); and malignant neoplasm of breast, Stage 4. The resident ' s medication list from the oncology notes included 5 mg lenalidomide to be given as one capsule by mouth once daily. A review of Resident #4 ' s electronic medical record (EMR) revealed the oncology consult report dated 10/30/18 was scanned into the resident ' s EMR at the facility on 11/2/18. Review of the resident ' s medical record included a Progress Note authored by the facility ' s NP and dated 11/2/18. A review of the resident ' s medications indicated 5 mg lenalidomide was being initiated. Review of Resident #4s (MONTH) (YEAR) Physician order [REDACTED]. A review of the resident ' s (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the resident ' s medical record included a Physician ' s Progress Note dated 12/20/18. The note indicated Resident #4 was seen for a nursing facility follow up of chronic medical diagnoses. Her history of present illness (HPI) included the following notation, in part: She was receiving infusion therapy for IgG kappa (a classification) [DIAGNOSES REDACTED] which is progressing slowly. She was last seen by oncology 10/12/18; that assessment was reviewed .At the last visit lenalidomide was initiated . Review of Resident #4s (MONTH) (YEAR) Physician order [REDACTED]. A review of the resident ' s (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Resident #4 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed by staff to have severely impaired cognitive skills for daily decision making. She required extensive assistance by staff for all of her Activities of Daily Living (ADLs). Further review of Resident #4 ' s medical record included an Oncology Consult Progress Note dated 1/10/19. This note read, in part: (Resident #4) returns today for follow-up and treatment of [REDACTED]. As far as the [MEDICAL CONDITION] is concerned, she continues on letrozole, with good tolerance. She receives bortezomib every 2 weeks. She takes this with good tolerance. Also on 10/30/18 we prescribed lenalidomide at 5 mg daily. Receipt of this by the patient was confirmed 11/5/18 by our oral [MEDICAL CONDITION] pharmacists. The oncologist noted, however, that lenalidomide was not included on the patient's list of medications from the facility. The plan of treatment noted in the Oncology Consult Note for Resident #4 read, (Resident #4) looks clinically very stable and has no complaints. However her numbers (referring to lab work showing progression of the [DIAGNOSES REDACTED]) have been going up. She was supposed to have started lenalidomide certainly by the first week in November, but I do not find it in her MAR. I have written a request to Heartland Living to let us know whether the patient has been receiving the medication, how much medication she has been receiving, whether she has missed any doses, and whether they have noticed any side effects. The oncologist also noted he provided the direct line to his nurse to document the facility ' s response and asked her family members to inquire at the facility as to what happened to the medication they delivered in early November. The oncologist noted, If she has been receiving lenalidomide and the labs today show further progression, we will need to intensify the bortezomib and move to weekly, or we can consider switching to carfilzomib (another antineoplastic medication indicated to treat [DIAGNOSES REDACTED]). Of course that she has not been receiving lenalidomide and that is what we need to do and then follow-up. On 1/10/19 at 3:27 PM, a physician's order [REDACTED]. The medication order instructed 5 mg lenalidomide to be administered to Resident #4 as one capsule once daily for 21 days, stop for 7 days; then restart the same cycle. A Med Error Report dated 1/31/19 revealed one extra daily dose (22 days versus 21 days) of lenalidomide was administered to Resident #4 due to a transcription error. The resident ' s physician was notified; no clinical harm was noted. On 2/13/19 at 1:00 PM, a telephone interview was conducted with the oncologist ' s nurse. The nurse reported after Resident #4 ' s (MONTH) appointment, additional lab results were received by the oncologist which indicated progression of her [DIAGNOSES REDACTED]. When the resident came in for her 10/12/18 appointment, it was decided lenalidomide would be initiated. The nurse reported while her condition was not curable, it was treatable and controllable. She stated lenalidomide was a medication that was dispensed from a specialty pharmacy and the process of acquiring it took some time. Upon review of Resident #4 ' s records, she stated the oncology office was still trying to obtain insurance authorization for the medication as of 10/17/18. Upon further review, the nurse reported their records indicated the medication was sent to the resident ' s family member on 11/3/18. The nurse recalled speaking with someone at the facility on 1/10/19 about Resident #4 ' s lenalidomide and the delay in getting her started on the medication. She reported there was a huge communication problem. A telephone interview was conducted with Resident #4 ' s oncologist on 2/13/19 at 1:21 PM. During the interview, the oncologist was asked how the delay in receiving lenalidomide would potentially affect Resident #4. He stated the lenalidomide was prescribed due to the resident ' s progression of the myeloma. Although the resident was reported to have a chronic condition that was not curable, the oncologist stated, I would have preferred she had been started (on the medication) 2-3 months earlier. He stated, It ' s been very difficult for us to understand what the problem was. A telephone interview was conducted on 2/14/19 at 10:20 AM with a representative from the specialty pharmacy which dispensed Resident #4 ' s lenalidomide. During the interview, the representative reported 1 bottle of lenalidomide was shipped to the resident ' s family member on 11/3/19; and, a second bottle was shipped to the family member on 2/5/19. Each bottle of lenalidomide contained 28 capsules. A telephone interview was conducted on 2/14/18 at 8:20 PM with Resident #4 ' s family member. During the interview, the family member reported he attended the oncology consultation with Resident #4 on 10/12/18. He recalled being told by the oncologist ' s office that the resident ' s new medication (lenalidomide) could not be obtained through the facility. The family member reported the oncologist ' s office set up everything with the specialty pharmacy; he did not receive a printed prescription for the medication. Upon further inquiry, the family member stated he received the medication at his home and brought it to the facility within a day or so after it was delivered to him in early November. He stated he gave the medication bottle to the nurse and she put it in the medication cart. The family member was asked if he could recall who he gave the medication to. He stated, Yes, but he declined to identify the staff member. When asked what he told the staff member when he handed her the medication bottle, he reported he explained what the medication was and that it was coming from the doctor. The family member reported that when he later went back to see the oncologist with Resident #4, He (the doctor) was fussing at me thinking he had not brought the medication in to the facility. The family member reported he went to the facility right after that appointment (1/10/19) and talked with the DNS. He stated the facility said they did not have an order for [REDACTED]. When asked how he needed to obtain refills for the medication, he reported the specialty pharmacy called him about a week before they sent the second bottle of medication (lenalidomide) out to him. He reported he received the second bottle of medication a few days ago, but had not yet brought it into the facility. During an interview conducted on 2/16/19 at 10:15 AM with the DNS, it was reported Med Aide #2 had indicated she was the staff member who received the first bottle of lenalidomide from Resident #4 ' s family member. The DNS reported that based on the family member ' s recollection, it had been determined the first bottle of the lenalidomide was brought in to the facility on [DATE]. An interview was conducted on 2/15/19 at 11:05 AM with the NP who helped care for Resident #4. Upon request, the NP reviewed the notation she wrote on 11/2/18. The NP reported the lenalidomide was listed on the resident ' s medication list with an authorization number. When asked, the NP stated the authorization number showed, They are asking for (insurance) authorization. She further explained that once a medication was put on the list (even by another provider such as oncology), it would automatically go over to the med list for her note. The NP reported the next time she saw the resident was on 1/14/19. Lenalidomide was included as one of the current meds on the resident ' s medication list at that time. An interview was conducted on 2/12/18 at 11:30 AM with the facility's Medical Director (who was also the resident ' s physician). During the interview, the Medical Director reported his records showed a NP facility note on 11/2/18 which included lenalidomide on Resident #4 ' s medication list. The physician also reported he could see a progress note he himself authored on 12/20/18 which included lenalidomide on the resident ' s medication list (he was unsure why this was because the resident was not receiving it and did not have it ordered for administration at the facility). The physician reported the facility could not enter a new order unless he or the NP signed the order; he did not recall doing so until after the delay in the med administration for lenalidomide was identified on 1/10/19. The physician questioned whether the delay in receiving this medication would have made a difference for Resident #4. An interview was conducted on 2/12/19 at 9:15 AM with the facility ' s Director of Nursing Services (DNS) in the presence of the Executive Director. During the interview, the nurse was asked to describe the facility ' s process of communication with outside consultants. The DNS reported a face sheet and current medication list (either the physician's order [REDACTED]. Upon return from the consult appointment, a packet of information would come back with the resident. The DNS reported there may be a note written at the bottom of the consult form brought back to the facility. Whether or not there was a new order for the resident, the consultation information was supposed to be put in the provider box for the facility ' s NP or physician to review. She reported that if there was a new medication order, the nurse would fax the order to the facility ' s contracted pharmacy. When asked who would initiate a new medication order recommended by an outside consultation, the DNS stated the nurse receiving the consult back would usually do so. A follow-up interview was conducted on 2/12/19 at 5:21 PM with the facility ' s DNS. The DNS reported she was first informed of a problem with the delay in Resident #4 receiving lenalidomide on 1/10/19. The resident ' s family member came directly from the oncologist ' s office visit on that date over to the facility. He was concerned because the oncologist ' s office made him aware the resident was supposed to be taking some medication that they noticed was not included on the med list sent to them by the facility. The DNS stated she understood the family member had obtained a prescription for the lenalidomide from the oncologist because the medication would only be covered by insurance through another pharmacy. Around the first part of November, (YEAR), the prescription for lenalidomide was filled and the family member brought the medication in to the facility. She reported the family member could not recall who he gave the medication to. The DNS stated after she checked the resident ' s physician's order [REDACTED]. When she went to the med cart, she discovered an unopened bottle of lenalidomide labeled for Resident #4 was stored on the cart. When asked if anyone had questioned why the medication was on the med cart, she stated, No. The DNS reported she called the oncologist ' s office and talked with his nurse on 1/10/19. The DNS received a verbal order for the administration of the lenalidomide and a fax with the order. The DNS was uncertain at that time why the facility had not been aware of the need to initiate lenalidomide for Resident #4. A second follow-up interview was conducted on 2/15/19 at 4:20 PM with the DNS. The DNS reported upon investigation, they discovered the resident ' s oncology consults did come to the facility. She reported consultation reports were sent from the oncologist to the attending physician, in addition to paperwork being sent to the facility via the transport driver. She stated the facility has identified a problem with the consult reports getting scanned into the electronic medical records before they were reviewed by a nurse, the NP, or the physician. A telephone interview was conducted on 2/16/19 at 12:54 PM with the facility ' s transportation staff member. During the interview, the staff member reported when she previously transported Resident #4 back from an outside consult, she would typically put the consult packet (containing information from the outside consult) on the desk at the nursing station. She reported this process has recently been changed and she has been instructed to now place this packet of information directly in the hands of the nurse on duty to ensure the consult was reviewed. The resident ' s (MONTH) 2019 MAR indicated [REDACTED]. According to the MARs, a total of 29 lenalidomide capsules were documented as administered to the resident by the following staff members: Med Aide #1 administered 2 capsules; Med Aide #2 administered 20 capsules; Med Aide #3 administered 2 capsules; and Med Aide #4 administered 4 capsules; and Med Aide #5 administered 1 capsule. An observation and interview was conducted on 2/14/19 at 10:10 AM with Med Aide #1. Med Aide #1 was assigned to Resident #4 ' s hall medication cart. At that time, one bottle of lenalidomide labeled for Resident #4 was observed to be stored on the med cart. Labeling on the medication bottle also included an original prescription date of 10/30/18 and the date dispensed by the pharmacy (11/2/18). Upon request, Med Aide #1 counted the lenalidomide capsules remaining in the medication bottle. The Med Aide was observed as she poured the capsules out of the original container one at a time (while counting) into two medication cups. One medication cup was counted and contained 9 capsules. The second medication cup was counted and contained 11 capsules. After the capsules had been poured into the two medication cups for counting, two additional capsules were observed to be left at the bottom of the original container and were added to the total count. The Med Aide confirmed the counts. It was determined a total of 22 capsules remained in the medication bottle originally containing 28 capsules. After counting the capsules, Med Aide #1 was observed as she returned all capsules back to the original medication bottle, secured the cap on the bottle, and returned the lenalidomide medication bottle to a drawer on the medication cart. An observation and interview was again conducted on 2/15/19 at 8:35 AM with Med Aide #1. Med Aide #1 was assigned to Resident #4 ' s hall medication cart. At that time, the resident ' s bottle of lenalidomide stored on the med cart was observed. Upon opening the bottle of lenalidomide, only 7 capsules were seen lying on the bottom of the bottle. The 7 capsules were clearly visible and easily counted without removing them from the container. The labeling on the medication bottle was confirmed to be the same as that observed on 2/14/19, and included the resident ' s name, an original prescription date of 10/30/18, and the date dispensed by the pharmacy (11/2/18). When asked, the Med Aide reported she did not recall the exact number of capsules that were counted from Resident #4 ' s lenalidomide bottle the previous morning (2/14/19). Upon further inquiry, however, Med Aide #1 stated, It was more. A thorough inspection of all drawers and compartments in the medication cart conducted by Med Aide #1 revealed there were no other bottles of lenalidomide stored on the med cart. An interview on 2/15/19 at 9:10 AM with the DNS and facility ' s Executive Director (ED). During the interview, the count discrepancy of Resident #4 ' s lenalidomide medication from 2/14/19 (22 capsules) to 2/15/19 (7 capsules) was discussed. At the time 22 capsules of lenalidomide were counted (10:10 AM on 2/14/19), Resident #4 ' s MAR indicated [REDACTED]. However, the lenalidomide bottle originally contained 28 capsules, which indicated the resident could have only received a total of 6 lenalidomide capsules. The DNS and ED stated they had not been informed of the 2/14/19 count of lenalidomide. However, the DNS reported a medication audit was conducted the evening of 2/14/19. The DNS reported she observed 7 capsules of lenalidomide were remaining in the bottle at approximately 9:30 PM on 2/14/19. Based on the MAR indicated [REDACTED]. The DNS reported the MAR indicated [REDACTED]. During the interview, the DNS confirmed only one bottle of lenalidomide was on the medication cart. She reported Resident #4 ' s family member brought in the second bottle of lenalidomide earlier that morning (on 2/15/19), which the DNS still had in her possession. The second bottle of lenalidomide was observed to be sealed (unopened). This medication was labeled with Resident #4 ' s name and a pharmacy dispensed date of 2/4/19. A telephone interview was conducted on 2/16/19 at 10:30 AM with Med Aide #1 in presence of the DNS and ED. During the interview, the med aide was asked to describe the process used to count Resident #4 ' s lenalidomide on 2/14/19. Med Aide #1 reported the lenalidomide capsules were poured into two different medication cups on top of the med cart as the capsules were counted. When asked if she recalled how many capsules were in the bottle of lenalidomide when they were counted on the morning of 2/14/19, the med aide reported she could not remember. However she added, But I know it was more than 7. Med Aide #1 was also asked to describe the process she used to administer medications to a resident. The med aide reported she would first pull up the resident ' s profile on the computer, make sure she had the right resident, the right med, right dose, and right route of administration. She would then pull the med from the cart and hold it up against the electronic MAR indicated [REDACTED]. After she administered the medication to the resident, the med aide reported she would sign off that the resident received the med on the electronic MAR. A telephone interview was conducted on 2/16/19 at 10:41 AM with Med Aide #2. During the interview, the med aide was asked if Resident #4 ' s family member had given her a bottle of medication (lenalidomide) for the resident in (MONTH) (YEAR). She stated, No he didn ' t hand me a bottle the (family member) had just mentioned about (Resident #4) not receiving it. Although she was not sure of the date, she thought this probably occurred in December. The med aide stated since the resident was receiving another [MEDICAL CONDITION] medication, she assumed that was the medication he was talking about. Med Aide #2 stated the family member told her he had a bottle of medication at home and she told him he could bring it in. The med aide stated she thought it might have been the next weekend when she saw the medication bottle (lenalidomide) on the med cart. Med Aide #2 reported sometime later (maybe in January), she looked at the medication bottle and saw this med was different from the one the resident had been receiving. The med aide reported she looked for this medication order in the computer and didn ' t see one, but didn ' t think anything about it and did not follow-up on this. During the interview, Med Aide #2 was asked to describe the process she used to administer medications to a resident. The med aide reported she would log into the computer, look at the medication and the person receiving it. After she double checked that it was the right medication, she would pop the med and put check on the prepped button in the electronic MAR. After she administered the med to the resident, she would record the med was administered on the electronic MAR. If the resident refused the medication, she would record the med as refused on the MAR. When asked, Med Aide #2 reported if her initials were on the MAR indicated [REDACTED]. A telephone interview was conducted on 2/16/19 at 10:58 AM with Med Aide #3. During the interview, Med Aide #3 was asked to describe the process he used to administer medications to a resident. The med aide reported he would pull up the electronic MAR for the resident; pull the medication from the med cart; double check the name of the resident, the name of the medication and the dose; and then administer the medication to the resident. Once he administered the medication, he would then come back to the cart and record the medication administration on the electronic MAR. An attempt to conduct a telephone interview with Med Aide #4 was unsuccessful. An interview was conducted on 2/15/19 at 4:20 PM with the DNS. During the interview, the DNS was asked what her expectation was in regards to Resident #4 ' s lenalidomide. She responded by stating the facility determined the oncology consult reports were scanned into the electronic medical record before being reviewed by nursing staff, the NP, or the physician. The DNS indicated she would have expected the facility to have reviewed this information and known lenalidomide was initiated for the resident. If she would have been aware of the need for the medication, she could have followed up on it. When asked, the DNS also reported that once Resident #4 ' s lenalidomide was initiated, she would have expected the documentation on the MARs to be accurate and for the medication to have been administered to the resident as ordered.