Every finding on record at Heritage Hall King George

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide a safe transfer with a mechanical lift for one (1) resident (Resident #13) in a survey sample of forty-three (43) residents, which resulted in the resident falling from the mechanical lift sustaining a laceration to right posterior scalp requiring four (4) staples. This constituted the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity and substandard quality of care. Upon verification of the removal of the IJ, the scope and severity was lowered to Level Three, Isolated. The findings included: Resident #13 was admitted to the facility 6/3/2026 with diagnoses to include but not limited to dementia with psychotic disturbance, hypertension, complete atrioventricular block, chronic kidney disease, type 2 diabetes mellitus, chronic glaucoma with poor visual acuity, bilateral hearing loss with poor communication, pacemaker, transient cerebral ischemic attack, restlessness and agitation, delusional disorders, pressure ulcer sacrum, osteomyelitis of the vertebra, mood disturbance and anxiety, and repeated falls. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/16/26 coded Resident #13 in Section C. 0100 Cognitive as rarely/never understood with Brief Interview for Mental Status (BIMS) coded as unable to complete. Section E. 0200 Behavior: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing). Section GG0170. Mobility coded Resident #13 as dependent in areas of sit to lying, lying to sitting and chair/bed to chair.On 3/25/26, during a clinical record review for Resident #13, a nurse progress note dated 3/22/26 at 3:09 PM, read in part: RESIDENT COMBATIVE AND CLIMBING OUT OF BED. Staff provided care and placed resident in Hoyer lift to transfer resident into Geri-chair. Resident combative and flailing during transfer and fell out of Hoyer lift. 2 staff members present during transfer, however unable to catch resident. Resident hit the back of her head during fall and bleeding. NP (Nurse Practitioner) made aware and gave order to send resident to ER 911 (Emergency Room). RP (Responsible Party) daughter notified. Resident being combative following fall, and would not allow staff to obtain vital signs or complete thorough assessment. EMS (Emergency Medical Services) arrived at 10:35 AM with 3 EMS providers present. Resident yelling out in pain and screaming my neck, my neck. EMTs (Emergency Medical Technicians) lifted resident manually from floor to stretcher then applied C-collar (collar to support cervical neck) and positioned resident on stretcher for transport. Nurse Progress note dated 3/22/26 at 6:08 PM read in part: Resident back from ER. She received four staples due to laceration on the right side of her head. A review of Nurse Progress note Post Fall Evaluation dated 3/22/2026 at 9:33 PM. Date / Time of Fall: 03/22/2026 10:15 AM Fall was witnessed. Who witnessed fall: 2 aides. Fall occurred in the Resident's room. Activity at the time of fall: Transferring the resident from bed to Geri-chair. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: Right side of the head Did fall result in an ER visit/hospitalization: Yes. ER Visit/Hospitalization Details: Resident was brought back to the facility via ambulance transport company with four staples due to laceration to the right side of head.A review of incident report dated 3/22/26 fall from Hoyer lift verified the Nurse Practitioner and Resident #13's Responsible Party, her daughter was notified of the incident and transferred to the emergency for evaluation and treatment.A review of the e-Interact Change in Condition Evaluation note dated 3/22/26 at 2:35 PM read in part: The Change In Condition/s reported on this CIC Evaluation: Bleeding (other than GI) Falls Trauma (fall related or other). Send to ER.A review of Nurse Practitioner progress note date 3/23/2026 at 3:15 PM read in part: Exam Reason (CC): Follow up fall, head laceration and ER (emergency room) visit. Patient seen today for follow-up fall, head laceration and ER visit. Patient sent to ER due to fall while being transferred from a Hoyer lift and laceration to back of head. Patient sent to ER for evaluation and treatment and returned. Mental status at baseline on exam. Head laceration treated with four staples. Patient's neuro status at baseline on exam. Alert.On 3/25/26 an interview was conducted with the Administrator and Director of Nursing (DON) regarding Resident #13's fall from the Hoyer lift on 3/22/26. According to the DON, they were aware of the incident and had begun a plan of correction on 3/23/26 with education to nursing staff on safe transfers with the Hoyer lift but had not had time to complete it. The DON provided statements written by the staff caring for the resident at the time of the incident, Licensed Practical Nurse #5 (LPN#5) and certified nursing assistant #2 (C.N.A#2). LPN#5's statement reads in part: Resident was trying to get out of the bed and staff decided to dress her, put her in Geri-chair around 10:00 AM and take her to the nurse's station to prevent fall. While I (LPN#5) was helping my co-worker transferring the patient from bed to her Geri-chair, [Resident #13's name redacted], pulled her leg out the sling when the Hoyer lift was already up, and fell, hit her head on the floor. The nurse on the floor heard the noise and rushed to the room and found out the patient was bleeding from the right side of her head. She used pressure on the open area to stop the bleeding while another nurse called 911 and printed paperwork.C.N.A #2's statement read in part: To whom it may concern. I [CNA #2's name redacted], was walking past [Resident #13's) name redacted] room and seen her trying to get out of bed, swinging her legs over the side of the bed. I went in and got her dressed to get up. After getting her dressed, [LPN#5's name redacted] came in and helped put the Hoyer pad under her. She was moving a lot and very combative. She moved around so much she pulled her leg out of the lift when the lift was in the air that she fell out of the lift and hit her head. The time that this happened was about 10:15 AM.A phone interview was conducted with C.N.A #2 regarding Resident #13's fall from Hoyer lift. According to C.N.A #2, she was headed down the hall to assist one of her assigned residents when she saw Resident #13 coming out of her bed and she went in and got her cleaned up, dressed and then [LPN# 5's name redacted] came in to help me put [Resident #13's name redacted] on Hoyer pad and get her up in the chair. She was moving around a lot and very agitated. When we turned the lift around to place her in her chair she pulled her leg out of the sling, it happened so quick, and she fell hitting the back of her head. She was bleeding, so [LPN# 5's name redacted] stayed with her and I went and got the other nurse. Then we sent her out to get her head checked out. She was always moving so much and combative. When asked what color sling she placed under Resident #13 for the Hoyer lift transfer, C.N.A#2 replied, It was a green sling. When just asked how she knew what color sling to use, she replied, We've always used a green sling on her.The survey team conducted interviews on Units A and B regarding how staff knew which size sling to use on a resident for a mechanical lift transfer. According to LPN#2, LPN#6 and C.N.A #1, they were not able to verify which size sling a resident was assigned. They said the Director of Nursing would have that information. An assignment book located in each nursing unit had a list titled Hoyer Lift for Residents. The survey team reviewed the list on Unit A revealing Resident #13 was listed for sling size Small (yellow). On 3/25/26 at 12:25 PM, the Director of Nursing provided a copy of page 4/16 from the manufacturer's [name redacted] manual, titled Regular passive clip slings - Sizing chart. Based on the Sling Color & Size Guide, Resident #13 whose weight was 107.2 pounds and height 61 inches tall (5'1) would generally wear a size small (red) sling. A review of the facility's Mechanical Lift policy with an effective date, revised July 2017, read in part: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions . General Guidelines: .4. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility .Steps in the procedure: Before using a lifting device, assess the resident's current condition, including:Physical:Can the resident assist with transfer?Is the resident's weight and medical condition appropriate for the use of a lift?Cognitive/Emotional:Can the resident understand and follow instructions?Does the resident express fear or appear anxious about the use of a lift?Is the resident agitated, resistant, or combative?Measure the resident for proper sling size and purpose, according to the manufacturer's instructions.Select a sling that is appropriate for the resident's size and task .On 3/25/26 at 1:05 PM, a meeting was conducted with the Administrator and the Director of Nursing to inform them of the survey team's identification of Immediate Jeopardy due to the unsafe transfer of Resident #13 on 3/22/26 resulting in a fall where she sustained a head injury. The risk of this re-occurring was present and posed an imminent risk of safety for other residents due to the staff's lack of knowledge of where to locate the size of mechanical lift sling, failure to use correct size sling and proceeding in transferring resident in the mechanical lift when she was exhibiting agitation, resistance and combativeness.On 3/25/26 at 3:42 PM, the Administrator submitted an Immediate Jeopardy (IJ) Removal Plan. The IJ Removal Plan was reviewed by the survey team, sent to the State Agency for review and the IJ Removal Plan was accepted. The facility's removal plan read: Immediacy Removal Plan - F689 Free from Accidents The staff members that assisted Resident (#13) in the Hoyer lift transfer received one-to-one education on 3/24/26 regarding demonstration of appropriate lift pad and Hoyer lift usage.MD (Physician) notified of failure to provide safe transfer of Resident(#13).RP (Responsible Party) notified of failure to provide safe transfer of Resident (#13).Therapy to screen Resident (#13) for appropriate Hoyer lift pad usage.All other residents that are Hoyer lift transfers may be affected.The DON (Director of Nursing) or designee to complete 100% audit on all current residents using Hoyer to transfer to assure proper Hoyer lift pad is available.DON or designee to educate all nursing and all therapy staff of proper sizing of Hoyer lift pad and return demonstration of the Hoyer lift usage. Each nursing/therapy staff member will be educated prior to the beginning of next scheduled shift.DON will assess and measure each resident that requires Hoyer lift pad according to Arjo sling sizing and measurement guide.Compliance date: 3/25/26 at 3:00 PMOn 3/25/26 beginning at 4:28 PM, the survey team verified all components of the IJ immediacy Removal Plan by: Verifying the one on one education on appropriate Hoyer lift sling size and lift usage to the C.N.A and LPN had been completed.Verified evidence the physician and the responsible party were notified of failure to provide safe transfer of resident.Verified completion of therapy screen for Resident #13 for appropriate lift pad usage.Verified the DON had completed assessments and measurements for current residents and updated the Hoyer lift lists in assignment books at each nursing unit for appropriate size sling (color coded).Interviews were conducted with a random number of certified nursing assistants, licensed nursing staff and members of the therapy team to verify they had received education on proper sizing of Hoyer lift pads and where to locate the size of the pad for the residents and return demonstration of Hoyer lift usage had been completed.The survey concluded verification at 4:42 PM on 3/25/26, at which time the scope and severity was lowered to a level three, isolated. On 3/26/26 at 4:35 PM, during the exit meeting with the Administrator, Director of Nursing, Assistant Director of Nursing, Administrator-in-Training and Regional Nurse Consultants, they were offered an opportunity to present additional information. They had no further information or comments.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain personal hygiene for one of forty-three residents in the survey sample (Resident #76). The findings include:For Resident #76 (R76) the facility staff failed to maintain the resident's fingernails, they were unkept.R76 diagnoses included bipolar, adult failure to thrive, and dementia. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE] and indicated R76 was moderately cognitively impaired. On 3/24/2026 at 1:16 p.m. an attempt was made to interview R76. R76 was a poor historian and gave one-word answers. Observation was conducted and revealed R76 fingernails were long (extending at least a quarter of an inch past each finger) discolored, jagged, with dark colored debris under the fingernails. Review of R76's most recent MDS section GG indicated R76 needed substantial maximum assistance for hygiene. Review of R76's care plan did indicate that R76 is resistant to ADL (activities of daily living) care and had an intervention instructing if R76 resists care to discontinue care and return five to ten minutes later. On 3/26/2026 at 11:34 a.m. certified nursing assistant (CNA #6, aide assigned to R76) was interviewed. CNA #6 observed R76 fingernails and agreed that R76 fingernails were long and was unaware of who is responsible to care for fingernails and verbalized the possibility of an outside agency doing care of fingernails. CNA #6 verbalized R76 eats a lot with his fingers and after a meal R76 hands are cleaned. Review of behavior monitoring and personal hygiene records did not indicate R76 was refusing care for hygiene. On 03/26/2026 at 4:16 p.m. the director of nursing and administrator were made aware of the above concern. No other information was presented prior to the exit conference on 3/26/26.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (Minimum Data Set) assessment for one of forty-three residents in the survey sample (Resident #2). The findings include:For Resident #2 (R2), the facility staff coded in section P of the MDS inaccurately regarding R2 using a trunk restraint. R2's diagnoses included, chronic obstructive pulmonary disease, obesity, depression, and diabetes. bipolar, adult failure to thrive, and dementia. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE] and indicated R2 was cognitively intact. Review of R2's most recent MDS indicated R2 used a trunk restraint less than daily. R2's care plan was reviewed and did not evidence the use of a restraint. On 3/25/2026 at 9:00 a.m. during an interview, R2 was asked about having to wear any type of apparatus that would restrain him from moving about. R2 verbalized not wearing anything that is restraining. On 3/26/2026 at 1:22 p.m. the MDS coordinator was interviewed. The MDS coordinator reviewed section P of the MDS and verbalized the restraint was coded in error and the facility doesn't use restraints. On 03/26/2026 at 4:16 p.m. the director of nursing and administrator were made aware of the above concern. No other information was presented prior to the exit conference on 3/26/26.

Based on interview clinical record review and facility documentation the facility staff failed to ensure that Residents receive adequate supervision and assistance to prevent accidents for 1 Resident (#1) in a survey sample of 5 Residents. Immediate Jeopardy (IJ) was identified on 5/22/24 at 12:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the implementation of the facility's immediacy removal plan, it was determined the IJ was removed on 5/23/24 at 11:15 AM. The scope and severity were lowered to level 3, isolated. The findings included: For Resident #1, the facility staff failed to ensure the Resident was always supervised in the whirlpool tub. Resident #1 was left in the whirlpool bath for approximately 4 hours unattended, resulting in being found unresponsive and requiring transport to the emergency room via rescue squad. On 5/21/24 at approximately 11:30 AM initial tour was conducted, and it was found that Resident #1 was not in the facility. A clinical record review revealed the following progress note related to the resident being sent to the ER via rescue squad on the evening of 5/19/24: 5/20/24 at 12:58 AM: Note Text: 3-11 PM (on 5/19/24) saw resident walk pass the nursing station heading towards the dining room. 6:30 PM resident had not returned to his room for evening meds. I, nurse, at the nursing station asked the CNAs [Certified Nursing Assistants] if anyone had seen resident. Answer was no. CNAs sent to check rooms on A side, while I, nurse, went to look in the activity room, then B side. ASKED CNA IF She had seen resident. Answered no. I checked dining room, it was empty. Back to A side and a CNA stated that he might be visiting a resident on the B side. CNA's sent to check each room. Came back and stated no. 6:45 PM called his sister to ask if family had come to pick him up. Answered no. Then a CNA checked in the shower room and found resident in tub and hollered for help. Everyone responded. Action taken: VS, emptied tub of water, applied O2 at 4 litters [sic], brought a fan in to cool resident off, 911 called and sister called to inform that we had found him and would be sending him out to the hospital [Hospital Initials redacted]. Resident unresponsive but breathing. Shallow breathing in the beginning.7:02 pm VS 92/43, HR 109, T 101.6, O2 94% RA. 2nd set115/51, HR110, O2 93% 4 litters [sic] applied. 7:06 pm called sister to inform that resident had been found and was leaving for the hospital. She asked why and I, nurse, stated it was because he was unresponsive in the shower. She sounded clam [sic] and stated she would leave home to be there. DON and Administrator informed and arrived. On 5/21/24 at approximately 6:10 PM a phone interview was conducted with CNA B, as he was suspended from the facility and unable to return for a face-to-face interview. When asked to explain the events on Sunday 5/19/24, the CNA stated that he had been working many hours, filling in for people who needed time off. He stated that he was called by a co-worker and asked to come in early for her. CNA B said, I was so tired, and I knew I should not, but I did anyway. I got to work at 1 PM, I just hit the floor running. He stated that he was answering lights and passing ice to Residents when Resident #1 came to him and said, Hey [CNA B name redacted] you forgot about me. Resident #1 asked CNA B to shower him as he did not get one on Saturday per the shower schedule. CNA B stated that he agreed, got his towels and clothes, and took Resident #1 to the shower room. CNA B stated that once they were in the shower room, he (Resident #1) insisted on a whirlpool bath instead of a shower. CNA B stated that he told the Resident he did not have enough time to do a whirlpool bath and that a shower would be quicker, however, the Resident insisted that he get a whirlpool bath and CNA B agreed. CNA B stated that he put the Resident in the tub and started running the water making sure the temperature was comfortable for the Resident, then someone called him, and he told Resident #1 he would be right back. He stated that when he left the shower room another resident was yelling about needing to be put on the toilet then another was ringing the call bell. He stated that he started helping residents and answering call bells. He stated that everyone was ringing one after another and needed something. During the above interview, CNA B stated that after he finished toileting one resident, getting another cleaned up from an incontinent episode, changing the bed linens for another resident and getting them cleaned up, and getting fluids for another resident he began passing trays. CNA B stated, I passed the tray to Resident #1's room, but it didn't dawn on me he was still in the shower. I thought to myself he must be in the bathroom. He stated that he assisted other residents with their meals, and then collected the dinner trays. CNA B stated after the dinner trays were collected, the nurse in the hall asked him if he had seen Resident #1 and he stated that he had not. The nurse told all the CNAs to start looking in every room and all bathrooms. CAN D started yelling that she found Resident #1 in the whirlpool tub. CNA B stated, When they asked me, I denied leaving him in the tub. He was sent to the hospital by 911. I felt so bad. CNA B stated that when the Administrator called him to come in on Monday, he told them the truth, The truth is that I was so tired I forgot him. I have been a CNA for [AGE] years and I have never had anything like this happen I feel so bad. When asked if they were supposed to leave residents unattended and unsupervised in the shower or bath, he stated that they were not allowed to leave anyone unattended in the bath or shower. He added I have never done that. It was just a one-time thing. On 5/22/24 a review of the facility policy entitled, Bath, Shower/Tub excerpt was as follows: General Guidelines 2. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. On the morning of 5/23/24, an interview was conducted with Resident #1. Resident #1 was asked, When did you return to the facility. Resident #1 responded that he returned yesterday evening. When asked what caused the hospitalization , Resident #1 stated, It was because I was left in the tub for a long time. I only remember getting in the tub then the next thing I remember was waking up in the hospital. When asked, Do you enjoy whirlpool baths, Resident #1 stated, It does feel good on my bones. Resident #1 was asked if there was any fear of being left in the tub or hesitation about using the whirlpool and Resident #1 said, No that doesn't scare me now because I have been told it won't happen again. The facility Administrator and Director of Nursing were made aware of the identification of IJ on 5/22/24 at 12:55 PM. The date the IJ started was on 5/19/24. Following verification of the implementation of the facility's immediacy removal plan, the IJ was removed on 5/23/24 at 11:15 AM. On 5/22/24 at 5:23 PM, the facility submitted an accepted IJ removal plan which read as follows: The Staff member that placed the resident in the bathroom received one on one education regarding safety and supervision of residents during bathing in the shower room. The CNA was removed from the schedule upon discovery of the cause of the incident. The resident's attending physician has been notified of the incident. The resident was admitted to the hospital. All other residents at risk, independent and / or supervision in ADL of bathing, transferring, will have their closet care plan reviewed to ensure it is clarified they are not to be left alone in the shower room, per policy resident in the shower room must have supervision at all times. The facility 's bath, shower/ tub policy and procedure has been reviewed no changes were warranted at this time. All facility nursing staff have been in serviced on safe practices during bathing to include residents must be supervised during bathing while in the shower room at all times by a staff member and educated on every 2-hour rounding to ensure ADL needs are addressed and location is verified. Education will be completed for each person prior to next scheduled shift. The Administrator is responsible for maintaining compliance. The DON and or designee will observe resident bathing times twice weekly to monitor for compliance and confirm that residents are always supervised during bathing in the shower room. Any negative findings will be addressed at the time of discovery and appropriate disciplinary action taken. Detailed findings of these results will be reported to the Quality Assurance Committee for review, analysis, and recommendations for changes in facility policy, procedure and/or practice. On 5/23/24 at 11:15 AM, the survey team verified that IJ immediacy removal plan dated 5/22/24 at 5:23 PM was implemented, thus the immediacy removed. The surveyor reviewed the facility policy and procedures regarding bathing and showering of residents, and regarding the rounding every 2 hours of all residents and reviewed the in-service sign-off sheets for education content and staff signatures. The surveyor then conducted interviews with scheduled staff: two (2) RNs, nine (9) LPNs, two (2) LPN Unit Managers, 14 CNAs as well as the Director of Nursing and the Assistant Director of Nursing. All interviewed staff were able to verbalize the facility's policy and expectations regarding not leaving residents unattended or unsupervised in the bathing or shower areas and policy regarding rounding on residents every 2 hours to verify resident condition and location. On 5/23/24 during the end-of-day meeting, the IJ issue was reviewed with the Administrator and no further information was provided before survey exit.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that residents are free from significant medication errors for 1 Resident (#10) in a survey sample of 5 Residents. The findings included: For Resident #1 the facility staff failed to hold the blood pressure medications according to the parameters listed in the order. On 5/22/24 a review of the clinical record revealed that Resident #1 had the following orders: Hydralazine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours related to essential hypertenson. Hold if SBP less than 110 -Start Date- 02/01/2024. Isosorbide Dinitrate Oral Tablet 20 MG (Isosorbide Dinitrate) Give 1 tablet by mouth every 8 hours related to essential hypertension. Hold if SBP [systolic blood pressure] less than 110 -Start Date- 02/01/2024. A review of the MAR (Medication Administration Record) Resident #1 was administered both hydralazine and Isosorbide Dinitrate on the following dates when his blood pressure was below 110: 3/13/24 -108/55 at 6 am 3/17/24 - 108/53 at 6 am 3/18/24 101/54 at 6 am 3/20/24 105/56 at 6 am 3/20/24 - 105/56 at 10 pm 3/21/24 - 104/55 at 6am 3/28/24 - 105/55 at 6 am 3/31/24 - 97/45 at 6am and 97/45 at 2pm (*Note the same blood pressure was entered twice) 4/3/24 - 108/54 6 am 4/12/24 102/58 at 6 am 4/17/24 108/53 at 6 am 4/25/24 104/50 at 10 pm 5/1/24 -106/55 at 6 am 5/5/24 - 108/55 at 6 am 5/11/24 - 101/54 at 6 am, 104/55 at 2 pm, and 106/72 at 10 pm 5/11/24 - 104/55 at 2 pm 5/12/24 - 108/60 at 10 pm On 5/23/24 at 2:00 pm an interview was conducted with LPN D who was asked what the significance of parameters on a blood pressure are and she stated it was to be sure that the Resident only received the medication when his or her blood pressure was high. When asked what the danger is if it is given out of the parameters, LPN D stated the Resident's blood pressure could drop suddenly and he or she could fall or faint or become dizzy. A review of the facility policy for Medication Administration read: Medication Administration Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders including any required timeframes. On 5/23/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #2 the facility staff failed to administer midodrine (a medication that raises blood pressure) according to the parameters in the physician orders. On 5/23/24 a review of the clinical record revealed that Resident #2 had orders that read: Midodrine HCl Oral Tablet 10 MG Give 0.5 tablet by mouth three times a day for Hypotension Systolic BP less than 120. Start Date- 05/14/2024 On 5/22/24 the order was changed to read: Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 0.5 tablet by mouth three times a day for Hypotension Hold for SBP >139. Start Date- 05/22/2024. For the first order to give for systolic bp less than 120, midodrine was signed off in the MAR (Medication Administration Record) as being given as follows: 5/14/24 - 9am 125/68 and 1pm 144/58 5/16/24 - 9 am 134/69 5/19/24 - 1 pm 146/70 5/20/24 - 1pm 146/68 5/22/24 - 9 am 159/77 For the second order to hold midodrine for spb more than 139, midodrine was entered into the MAR as being given as follows: 5/22/24 - 9 pm 143/67 5/23/24 - 9 am 138/80 On 5/23/24 an interview was conducted with LPN D who was asked what the significance of parameters on a blood pressure are and she stated it was to be sure that the Resident only received the medication when his or her blood pressure was high. When asked what the danger is if it is given out of the parameters, LPN D stated the Resident's blood pressure could drop suddenly and he or she could fall or faint or become dizzy. A review of the facility policy for Medication Administration read: Medication Administration Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. On 5/23/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 Resident (#1) in a survey sample of three (3) residents. The findings included: For Resident #1 the care plan does not have specific interventions for ADL (Activities of Daily Living) assistance. On 5/22/24 a review of the clinical record revealed the following excerpt from the care plan: FOCUS: Impaired Coping Date Initiated: 04/29/2024 GOAL: [This section was not filled in] INTERVENTIONS: Provide assistance with ADLs / IADLs as needed Date Initiated: 04/29/2024. Provide care in a calm and reassuring manner Date Initiated: 04/29/2024. On 5/24/24 at approximately 3:30 PM an interview was conducted with RN C who was asked the purpose of a care plan. RN C stated the purpose of a care plan is to direct the care of the Resident. When asked if this should include care that is individualized to each Resident, and she stated that it should. When asked if it should specify the exact ADL assistance that each Resident needs, she stated that All aspects of Resident care bathing, transferring, eating, incontinence care and any conditions like diabetes or seizures, and specific interventions like walker or wheelchair and Hoyer lift transfer, adaptive equipment anything that is used to care for that resident should be in the care plan. The following excerpts are from the facility policy entitled Care Plans, Comprehensive Person-Centered. Policy Statement: Comprehensive person-centered care plan that includes measurable objectives and timelines to meet the physical, psychosocial and functional needs is developed for each resident. 7. The comprehensive person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing. On 5/23/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure that Residents were free from unnecessary medications to include duplicate drug therapy for 1 Resident (#1) in a survey sample of 4 Residents. The findings included: For Resident #1 the facility staff failed to ensure the Resident was free from unnecessary medication to include duplicate medications. On 4/9/24 a review of the clinical record revealed that Resident #1 had following orders. GNP Mucus Relief DM Max Oral Liquid 5-100 MG/5ML (Dextromethorphan / Guaifenesin) Give 10 ml by mouth every 4 hours as needed for cough supervised self-administration -Start Date 02/01/2024 6:00 AM - PRN. Guaifenesin Oral Syrup 100 MG/5ML (Guaifenesin) Give 30 ml by mouth every 6 hours as needed for cough -Start Date 02/01/2024 6:00 AM. A review of the clinical records revealed that both medications have been valid orders available for use since 2/1/24. Since 2/1/24 both orders had been utilized for a total of 6 doses administered. 4/11/24 an interview was held with LPN D who stated she was familiar with Resident #1. When asked about the orders for her cough medicine she stated that she uses it when she needs it. When asked about the difference in the 2 medications she stated that they are both for cough and they both have guaifenesin in them so either one could be given. When asked if they should be given at the same time, she stated they should not. When asked if they can both be given in the same day, she stated that technically they could as long as they were at least 4 hours apart. LPN D then stated, I think it would be better if I get them clarified by the nurse practitioner. Per the manufacturer: Dextromethorphan HBR- cough suppressant, calms the cough reflex. Relieves the following symptoms: Cough. Guaifenesin -An expectorant that clears the airways by thinning and loosening excess mucus in the air passages, making it easier to cough up the mucus. Relieves the following symptoms: Chest Congestion. The prescriber did not make clear when to give the Guaifenesin and when to give the Guaifenesin / Dextromethorphan as both were prescribed for cough. On 4/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review the facility staff failed to provide care and services that meet professional standards of quality for 2 Residents (# 1 and #2) in a survey sample of 4 Residents. The findings included: 1. The facility staff failed to ensure medications were given per physician orders for Resident #1. On 4/9/24 at approximately 3:00 PM an interview was conducted with Resident #1 who stated that she was, Happy at the facility there were some improvements that needed to be made. When asked about her medications and treatments she stated that she was not getting her medications right a while ago, but they are getting better. A review of the clinical record revealed the following: The MAR (Medication Administration Record) was reviewed, and it was found that on 2/9/24 Advair Diskus Inhaler marked as #9, Not given see nurses note. The nurses note read as follows: 2/9/2024 9:57 AM - Orders - Administration Note Text: Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT 1 puff inhale orally two times a day Rinse mouth after use - unavail. -Reordered from pharmacy. (NP's name) notified. 3/29/2024 -3:23 PM - Nurses Note Text: 7-3 F/U pain 4/9. No complaints at this time. New order of Monistat 3 for Vulvovaginitis. Family notified. Nurses note reflect that the order put in for Monistat 3 was then discontinued at 9:52 PM as med was not available from the pharmacy. Order was received to start when available. 3/29/2024 -9:52 PM -Orders - Administration Note: Text: Monistat 3 Combination Pack Vaginal Kit 200 & 2 MG-% (9GM) - Insert 1 applicatorful vaginally at bedtime for Vulvovaginitis for 3 Days Start when available. Med not available. On 4/9/24 at approximately 11:45 AM an interview was conducted with LPN B who stated, If a medication is not available, we check the med bank system (Stat Box) and if it is not there, we then notify the pharmacy, the family member and the MD to see if we can get an order to hold till available. When asked does the physician specify how long you can hold it, she stated that the order will read. May hold till available. On 4/10/24 at 1:22 PM a telephone interview was conducted with the pharmacy representative for the facility. The pharmacy representative was asked if they have a system for back up medications or medications not available immediately from the pharmacy. The pharmacy representative stated that they utilize a backup pharmacy and they can also utilize the STAT order. If a physician orders a medication STAT, then the pharmacy will get it there within 4 hours. When asked about the cut off times for orders she stated, We have cut off times to get medications to the facility by the next run. If they do not meet that cut off time it will be on the one after that if it is available. If it is not available, we have to find a backup and get it to them. If they do not specify STAT order, we get it to them as soon as it is available to send. When asked about over the counter meds that may be unavailable she stated, We use [pharmacy name redacted] and [pharmacy name redacted] locally to fill medications we may not have or that may be OTC [over the counter]. She stated that Those local pharmacies can fill most medications however if it is an IV medication it will have to come from us, as the local pharmacies do not do IV meds. On 4/11/24 a review of the backup medication list revealed the above-mentioned medications were not available from the stat box. On 4/11/24 during the end of day meeting the Administrator was made aware of the findings and no further information was made available. 2. For Resident #2 the facility staff failed to ensure medications were administered per physician orders. On 4/10/24 a review of the clinical record revealed that Resident #2 had discharge orders dated 4/1/24 from the acute care hospital he was in for 6 days due to Osteomeylitits of the right heel. The orders included but were not limited to the following: Piperacillin Sod. Tazobactam Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 4.5 gram intravenously every 8 hours or (13.5 g in a continuous infusion pump). Duration of antibiotics 6 weeks total until 5/6/24. Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy. Upon admission to the facility on [DATE] the orders were put into the system and it was discovered the IV antibiotic that the Resident was to receive was not in stock it would have to be ordered. The facility then entered the time to start on 4/2/24 at 6:00 AM., however the Resident did not receive the first dose of antibiotic until 4/3/24 at 10 PM. The antibiotics were scheduled for 6:00 AM, 2:00 PM, and 10:00 PM. The Resident arrived at the facility at 2:00 PM on 4/1/24 therefore he missed 4 doses of antibiotic therapy. A nursing note was placed in the chart 4/01/2024 10:47 PM - Note Text : Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM Use 4.5 gram intravenously every 8 hours for osteomyelitis 4.5 gm over 4 hrs at 25 ml/hr D/C to start 4/2/24. On 4/9/24 at approximately 11:45 AM an interview was conducted with LPN B who stated, If a medication is not available we check the med bank system (Stat Box) and if it is not there we then notify the pharmacy, the family member and the MD to see if we can get an order to hold till available. When asked does the physician specify how long you can hold it, she stated that the order will read.May hold till available. Gabapentin was ordered at 8:00 AM 1:00 PM and 9:00 PM, Resident #2 did not get his 9 PM dose on 4/1/24 and the following progress note was entered: 04/01/2024 10:47 PM -Note Text : Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth three times a day for neuropathy Awaiting approval from pharm. Resident #2 received Gabapentin starting on 4/2/24 at 8 AM. Symbicort Inhalation -Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow Start Date 04/02/2024 800 AM D/C Date 04/03/2024 2:56 PM The following 2 notes were written about the Symbicort orders: 04/02/2024 4:24 PM - Note Text : Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow On hold til delivered. 04/03/2024 2:53 Type: Orders - Administration Note Note Text : Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow . Medication not available due to insurance coverage, Nurse notified NP (NP's name) on 4/3/2024 @ 2:55 pm. N/O received. Symbicort was not available and had to be ordered . The facility set the start date for 4/2/24 at 8:00 AM., however they actually did not get a replacement medication for the Symbicort until 4/4/24, causing the Resident to miss 5 doses (one dose on 4/1/24, 2 doses each on 4/2/24 and 4/3/24) of this medication that is used to manage his COPD (Chronic Obstructive Pulmonary Disease). Review of the back up med list (stat box) revealed that of the 3 above named medication only gabapentin 100 mg tabs were available however they were in the 100 mg dose form. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On 4/11/24 during the end of day meeting the Administrator was made aware of the findings and no further information was made available.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive services in the facility with reasonable accommodation of resident needs for 1 Resident in a survey sample of 4 Residents. The findings included: For Resident #1 the facility staff failed to ensure the Resident had transportation to appointments outside of the facility. On the afternoon of 4/9/24 an interview was held with the SW who stated, We do arrange transportation for the Resident, however, sometimes the company does not show up, so we then reschedule the appointment for the resident and reschedule transportation as well. The SW stated that on one occasion the ride did not show up to pick up the Resident up after the appointment and the Administrator had to go and pick her up. A review of the transportation logs revealed that Resident #1 missed the following appointments due to transportation issues: On 2/7/24 she missed the cardiology follow up at 9 AM. On 2/14/24 she missed the allergy follow up at 11 AM. On 2/24/24 she missed the cardiology follow up at 7:30 AM On 4/10/24 at approximately 10 AM an interview was conducted with the Administrator who confirmed that there was one occasion where transportation did not show up and she (the Administrator) had to go pick the Resident up at the doctor and transport her back to the facility. On 4/10/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one resident (Resident # 1) of 3 residents in the survey sample was free of significant medication errors. For Resident #1, the facility staff failed to ensure the roommate's medications including psychiatric medications were not left unattended and available for incidental consumption by Resident # 1, resulting in hospitalization for 4 days. This constitutes harm. The findings included: Resident # 1 was admitted to the facility with diagnoses that included but were not limited to: history of stroke with residual left-sided deficit, dysarthria, diabetes mellitus, right below the knee amputation. The most recent MDS (minimum data set) assessment at the time of the incident was a Quarterly assessment with an ARD (Assessment Review Date) of 10/12/2022. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. Resident # 1 required extensive assistance of 1-2 staff persons with activities of daily living. Review of the Physicians Encounter Summary Progress Note dated 11/18/2022 revealed the following documentation: Patient seen today due to AMS (altered mental status) and tachypnea after incidentally taking her roommates medication that include on [sic] tablet or Ativan 0.5 mg, latuda, 80 mg, and levothyroxine 25 mg and clozaril 100 mg. Patient is responding to provider on exam, however altered from baseline and initially not responding. FSBS (Fingerstick blood sugar) 202. Physical exam: Level of Distress: moderate distress and acutely ill. ambulation: Lying in floor. Psychiatric: insight: poor insight. Mental Status: anxious. flat affect. Orientation: not oriented to time, place and person. Memory: recent memory abnormal and remote memory abnormal. Assessment and Plan: 1. Altered Mental status-patient normally A./O (alert and oriented) x 3 at baseline, not responding to provider per baseline. Does mumble when name is called. 2. Tachycardia- HR (Heart rate) in the 110's-120's. will send to the ER (emergency room to evaluate and treat secondary to ingestion of psychiatric medications 3. Medication administered in error Review of the hospital records revealed documentation that Resident #1 was admitted on [DATE] from the Emergency Department at 1734 (5:34 p.m.) and discharged to the facility on [DATE] at 1410 (2:10 p.m.) On the Discharge Summary of the Assessment and Plan Acute toxic encephalopathy secondary to incidental psychiatric drugs ingestion- one Ativan 0.5 mg (milligrams), Latuda 80 mg, Levothyroxine 25 mg, and Clozaril 100 mg. -mental status improving. follow up MRI (Magnetic Resonance imaging) brain -continue supportive treatment, neuro checks -neurology input, fall and aspiration precautions, continue tele monitoring Under hospital course was written: Presented from nursing home for altered mental status after incidentally taking her roommates [sic] medication that include one Ativan 0.5 mg (milligrams), Latuda 80 mg, Levothyroxine 25 mg, and Clozaril 100 mg. Patient was admitted with acute toxic encephalopathy secondary to incidental psychiatric drug ingestion. Patient was seen in consultation with Neurology. Review of the Facility's Medication Administration policy revealed documentation of the following excerpts: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. 6. Medication errors are documented, reported and reviewed by the QAPI (Quality Assurance Performance Improvement) committee to inform process changes and or the need for additional staff training. Also, 26. Medications ordered for a particular resident ay not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing. On 10/31/2023 at 11 a.m., an interview was conducted with the nurse Registered Nurse-B (RN-B) who left the medication at the bedside. RN-B was no longer employed at the facility at the time of the survey. RN-B was very tearful and stated she was still upset that this happened. RN-B stated she should have put the pills in her jacket pocket instead of leaving the medications at the bedside. RN-B stated the fire alarms were ringing loudly and she ran to see what was happening. RN-B stated this had never happened before in her career and she was sorry she did not keep possession of the medications when she went to check out the problem with the alarms. RN-B stated she put the cup of medications for Resident # 2 on the bedside table of Resident # 2. She stated when she returned to the room, she noticed the medication cup was empty but Resident # 2 had not taken the pills. RN-B stated when she asked Resident # 1 if she had taken the pills, Resident # 1 replied yes. RN-B stated immediately she took vital signs, assessed Resident # 1 and notified the provider. RN-B stated she continued to monitor Resident # 1 for adverse reactions to the consumption of unintended medications. On 10/31/2023 at 12:45 a.m., an interview was conducted with the Regional Nurse Consultant who stated she understood that the nurse (RN-B) should not have left the medications at the bedside. She stated that the nurse did not administer the medications to the wrong resident but did not secure the medications when she went to investigate the sounding of fire alarms. The Regional Nurse Consultant stated it was very unfortunate because RN-B was known to be very conscientious and had lots of nursing experience. The Regional Nurse Consultant stated that incident was totally out of the ordinary and the facility staff responded immediately to re-educate the staff to make sure nothing like that ever happened again. Review of the PNC (Past Non Compliance)/action plan documents revealed copies of the training of all nurses regarding medication administration. Action- Corrective Actions- Steps: the resident has been assessed by nursing and the attending physician/NP (nurse practitioner) has been notified of the resident and has examined the resident An incident report has been completed, the resident is own RP (responsible party) The identified staff has been given 1:1 education regarding proper procedure for administered medication as ordered and per nursing standards of practice Date and Signature of Completion:11/18/22- (Assistant Director of Nursing initials) completed 11/18/22 Action: Identification of Deficient Practice(s)- Steps: *All residents receiving medications may have potentially been affected. All licensed nurses have had a medication pass observation to ensure compliance with medication pass policy, specifically to ensure that no medications are left at the bedside. *All nurses demonstrating deficient practices will be in-services [sic] 1:1 and an incident report will be completed for each negative finding and disciplinary action will be taken. Date: Action: Systemic Changes Steps: * The facility policy and procedure for Nursing standards of practice for medication administration has been reviewed and no changes are warranted at this time. * All licensed nurses have been in-serviced on proper procedure for administering medications following nursing standards of practice to include ensuring medications have been taken as ordered and no medications are left at the bedside. Action: Monitoring: Steps: *The Director of Nursing is responsible for maintaining compliance. The DON/designee will conduct twice a week room rounds x 4 weeks to ensure no medications have been left at resident's bedside. Any negative findings will be addressed at the time of discovery and appropriate disciplinary action will be taken. * If deficient practice is identified, monitoring will continue x 4 weeks and re-evaluated.- Date: 1/31/23 initialed by the Director of Nursing Completion date: 12/30/2022 A copy of the Disciplinary Action of a written warning for RN-B was reviewed. The Director of Nursing, Administrator and Regional Nurse Consultant discussed the Past Non Compliance Documents with the surveyor. The Regional Nurse Consultant stated the date of 12/30/2022 was indicative of the date the facility alleged compliance but the monitoring would be on-going. The Director of Nursing stated there had been no incidents of nurses leaving medications at the bedside. The Assistant Director of Nursing stated she provided education in person to the nurses immediately upon knowledge of the incident. The nurses who were not on duty were called on the telephone and given the education. Licensed nurses continued to receive education until 100 percent of the nurses were educated. There was an in-service dated 11/29/2022 entitled Med Pass observation, policy review, Q A (Quality Assurance) return demonstration. There was documentation that all licensed nurses received the in-service education, medication pass observation, and return demonstration. The Director of Nursing stated she still continued to make rounds daily and randomly observed the nurses during med pass. She stated there had been no incidents of nurses leaving medications at the bedside or unattended. The in-services were dated 11/18/2022 Medication cannot be left in residents room unattended at any time under any circumstances. Medication Administration following facility policy and procedure. There was documentation that in-services were provided in person and over the phone During the end of day debriefing on 10/31/2023, the facility Administrator, Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant were informed of the findings. It was discussed that RN-B left the medications of Resident # 2 unattended. RN-B immediately determined that Resident # 1 consumed the medications intended for Resident #2. RN-B was transparent about the error and immediately notified the provider of the error. RN-B assessed and monitored Resident # 1 for adverse reactions and notified the provider of the changes in mental status. The nurse practitioner examined Resident # 1 and ordered to transport to the Emergency Department of evaluation and treatment. Resident # 1 was admitted to the hospital and diagnosed with Acute Toxic Encephalopathy due to incidental ingestion of the roommate's medication. All licensed nurses received in-service education regarding medication administration and never leaving medications unattended at the bedside under any circumstances. Monitoring of the rooms, medication pass and pour observations, and regular rounds were conducted. The Director of Nursing stated random audits, observations and rounds were still being conducted. During the dates of survey, nurses were observed administering medications, audits were validated, and staff interviews were conducted. There was no deficient practice identified at the time of survey or since the allegation of compliance, therefore this deficiency is cited at past non-compliance. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to meet professional standards of quality for one Resident (Resident #2) which resulted in harm for one Resident (Resident #1) in a survey sample of three Residents. Findings included: For Resident #2, on 11/18/22, the facility staff failed to follow professional standards regarding medication administration. Facility staff, Registered Nurse-B (RN-B) left a cup of medications containing 5 pills (including psychiatric drugs) at the bedside unattended. The roommate, Resident # 1, consumed the cup of medications, developed altered mental status and tachycardia (fast heart rate) and subsequently required hospitalization for 4 days, resulting in harm for Resident #1. Resident #2 was admitted to the facility in 2018 with diagnoses that included but were not limited to: Schizophrenia, Dementia, Hypothyroidism, Convulsions, Anxiety, Gastroesophageal Reflux Disease, Schizoaffective Disorder and Hypothyroidism. Resident #2's most recent MDS (minimum data set) assessment at the time of the incident was a Quarterly assessment with an ARD (Assessment Review Date) of 10/26/2022. The MDS coded Resident #2 with a BIMS (Brief Interview for Mental Status) of 14 out of 15 indicating no cognitive impairment. Resident #2 required assistance ranging from supervision to extensive assistance of 1 staff persons with activities of daily living. Resident #2 no longer resided at the facility, therefore a review of the closed clinical record for Resident #2 was conducted on 10/30/2023 and 10/31/2023. Review of the Physicians orders revealed documentation of medication orders of medications that were due to be administered in November 2022 at 6:00 a.m.: Benztropine 0.5 MG (milligrams) po (by mouth) bid (twice a day) for tremors Levothyroxine 25 mcg (micrograms) one tablet po daily every morning for hypothyroidism Ativan 5 milligrams take one tablet p.o. bid (twice a day) Clozapine 100 mg one tablet by mouth every 12 hours for schizophrenia Latuda 89 mg one table p.o. bid with a meal or snack dx (diagnosis) schizophrenia Review of the November 2022 Medication Administration Record revealed N documented for those medications that were due on 11/18/2022 at 6:00 am. Resident # 1 was admitted to the facility with diagnoses that included but were not limited to: history of stroke with residual left-sided deficit, dysarthria, diabetes mellitus, right below the knee amputation. The most recent MDS (minimum data set) assessment at the time of the incident was a Quarterly assessment with an ARD (Assessment Review Date) of 10/12/2022. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. Resident # 1 required extensive assistance of 1-2 staff persons with activities of daily living. Review of the Physicians Encounter Summary Progress Note dated 11/18/2022 revealed the following documentation: Patient seen today due to AMS (altered mental status) and tachypnea after incidentally taking her roommates medication that include on [sic] tablet or Ativan 0.5 mg, latuda, 80 mg, and levothyroxine 25 mg and clozaril 100 mg. Patient is responding to provider on exam, however altered from baseline and initially not responding. FSBS (Fingerstick blood sugar) 202. Physical exam: Level of Distress: moderate distress and acutely ill. ambulation: Lying in floor. Psychiatric: insight: poor insight. Mental Status: anxious. flat affect. Orientation: not oriented to time, place and person. Memory: recent memory abnormal and remote memory abnormal. Lungs: decreased breath sounds and diminished air movement Cardiovascular: and tachycardia Assessment and Plan: 1. Altered Mental status-patient normally A./O (alert and oriented) x 3 at baseline, not responding to provider per baseline. Does mumble when name is called. 2. Tachycardia- HR (Heart rate) in the 110's-120's. will send to the ER (emergency room to evaluate and treat secondary to ingestion of psychiatric medications 3. Medication administered in error Review of the November 2022 Medication Administration Record revealed the scheduled morning medications for Resident # 1 were held on 11/18/2022 after Resident # 1 incidentally consumed Resident # 2's medications that were left unattended. Review of the hospital records revealed documentation that Resident #1 was admitted on [DATE] from the Emergency Department at 1734 (5:34 p.m.) and discharged back to the facility on [DATE] at 1410 (2:10 p.m.) The Discharge Summary included documentation of the Assessment and Plan: Acute toxic encephalopathy secondary to incidental psychiatric drugs ingestion. one Ativan 0.5 mg (milligrams), Latuda 80 mg, Levothyroxine 25 mg, and Clozaril 100 mg. -mental status improving. follow up MRI (Magnetic Resonance imaging) brain -continue supportive treatment, neuro checks -neurology input, fall and aspiration precautions, continue tele monitoring Under hospital course was written: Presented from nursing home for altered mental status after incidentally taking her roommates [sic] medication that include . Patient was admitted with acute toxic encephalopathy secondary to incidental psychiatric drug ingestion. Patient was seen in consultation with Neurology .Patient's mental status has now improved to baseline and antibiotics will be transitioned to p.o. (by mouth) patient is awaiting MRI brain and if it is negative will be discharge back. Review of the Facility's Medication Administration policy revealed documentation of the following excerpts: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. 6. Medication errors are documented, reported and reviewed by the QAPI (Quality Assurance Performance Improvement) committee to inform process changes and or the need for additional staff training. Also, 26. Medications ordered for a particular resident ay not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing. On 10/31/2023 at 11 a.m., an interview was conducted with the nurse Registered Nurse- B who left the medication at the bedside. RN-B was no longer employed at the facility at the time of the survey. RN-B was very tearful and stated she was still upset that this happened. RN-B stated she should have put the pills in her jacket pocket instead of leaving the medications at the bedside. RN-B stated the fire alarms were ringing loudly and she ran to see what was happening. RN-B stated this had never happened before in her career and she was sorry she did not keep possession of the medications when she went to check out the problem with the alarms. RN-B stated she put the cup of medications for Resident #2 on the bedside table of Resident #2. She stated when she returned to the room, she noticed the medication cup was empty but Resident #2 had not taken the pills. RN-B stated when she asked Resident #1 if she had taken the pills, Resident #1 replied yes. RN-B stated immediately she took vital signs, assessed Resident # 1 and notified the provider. RN-B stated she continued to monitor Resident #1 for adverse reactions to the consumption of unintended medications. RN-B stated this incident has continued to bother her because she had never made such a mistake before RN-B stated she was grateful that Resident #1 recovered from accidentally ingesting her roommate's medications. On 10/31/2023 at 12:45 p.m., an interview was conducted with the Regional Nurse Consultant who stated she understood that the nurse (RN-B) should not have left the medications at the bedside of Resident # 2. She stated that the nurse did not actually administer the medications to the wrong resident but did not secure the roommate's medications when she went to investigate the sounding of fire alarms. During RN-B's absence in the room, Resident #1 consumed the medications that had been poured for Resident #2. The Regional Nurse Consultant stated it was very unfortunate because RN-B was known to be very conscientious and had lots of nursing experience. RN-B was a nursing supervisor. The Regional Nurse Consultant stated that incident was totally out of the ordinary and the facility staff responded immediately to re-educate the staff to make sure nothing like that ever happened again. Review of the PNC (Past Non Compliance)/action plan documents revealed immediate action was taken to assess and monitor Resident #1 for adverse reactions, the provider was notified, RN-B was disciplined with a written warning, notification to the state agency of the incident and training of all of the licensed nurses. The Director of Nursing performed the above. The copies of the training of all nurses regarding medication administration were reviewed. The Past Non-Compliance Document stated: Action- Corrective Actions- Steps: the resident has been assessed by nursing and the attending physician/NP (nurse practitioner) has been notified of the resident and has examined the resident An incident report has been completed, the resident is own RP (responsible party) The identified staff has been given 1:1 education regarding proper nursing procedure for administered medication as ordered and per standards of practice Date and Signature of Completion:11/18/22- (Assistant Director of Nursing initials) completed 11/18/22 Action: Identification of Deficient Practice(s)- Steps: *All residents receiving medications may have potentially been affected. All licensed nurses have had a medication pass observation to ensure compliance with medication pass policy, specifically to ensure that no medications are left at the bedside. *All nurses demonstrating deficient practices will be in-services [sic] 1:1 and an incident report will be completed for each negative finding and disciplinary action will be taken. Date: Action: Systemic Changes Steps: * The facility policy and procedure for Nursing standards of practice for medication administration has been reviewed and no changes are warranted at this time. * All licensed nurses have been in-serviced on proper procedure for administering medications following nursing standards of practice to include ensuring medications have been taken as ordered and no medications are left at the bedside. Action: Monitoring: Steps: *The Director of Nursing is responsible for maintaining compliance. The DON/designee will conduct twice a week room rounds x 4 weeks to ensure no medications have been left at resident's bedside. Any negative findings will be addressed at the time of discovery and appropriate disciplinary action will be taken. * If deficient practice is identified, monitoring will continue x 4 weeks and re-evaluated.- Date: 1/31/23 initialed by the Director of Nursing Completion date: 12/30/2022 A copy of the Disciplinary Action of a written warning for RN-B was reviewed. The Director of Nursing and Regional Nurse Consultant stated the expectation was that all nurses would follow the professional standards of Nursing regarding Medication Administration. Both stated the nurses should never leave medications unattended. Nurses should secure medications prior to responding to any emergencies or performing any other tasks. The Regional Nurse Consultant stated the professional guidance used by the facility was [NAME] Fundamentals of Nursing Ninth edition. The facility's Nursing Services Policy and Procedure Manual, Revised August 2006 stated policy Statement: Services provided to our residents are performed in accordance with current acceptable standards of clinical practice. 1. A nursing services policy and procedure manual is available for use by all personnel providing resident care. 2. Our facility's nursing services policy and procedure manuals contain step-by-step guidance for each type of nursing care provided. 3. Our procedure manual is developed using current resource data from approved textbooks on nursing care/treatments, professional journals, and practice guidelines from government agencies. 4. Our procedure manuals are updated on a continuous basis. The Director of Nursing, Administrator and Regional Nurse Consultant discussed the Past Non Compliance Documents with the surveyor. The Regional Nurse Consultant stated the date of 12/30/2022 was indicative of the date the facility alleged compliance but the monitoring would be on-going. The Director of Nursing stated there had been no incidents of nurses leaving medications at the bedside. The Assistant Director of Nursing stated she provided education in person to the nurses immediately upon knowledge of the incident. The nurses who were not on duty were called on the telephone and given the education. Licensed nurses continued to receive education until 100 percent of the nurses were educated. There was an in-service dated 11/29/2022 entitled Med Pass observation, policy review, Q A (Quality Assurance) return demonstration. There was documentation that all licensed nurses received the in-service education, medication pass observation, and return demonstration. The Director of Nursing stated she still continued to make rounds daily and randomly observed the nurses during med pass. She stated there had been no incidents of nurses leaving medications at the bedside or unattended. The in-services were dated 11/18/2022 Medication cannot be left in residents room unattended at any time under any circumstances. Medication Administration following facility policy and procedure. There was documentation that in-services were provided in person and over the phone to all licensed nurses. Review of the Employee file of RN-B revealed the only disciplinary action in the record was the one related to the incident on 11/18/2022. There were no noted negative performance evaluations in RN-B's employee file. The Professional Guidance for Nursing standards per the [NAME] website: Rights of Medication Administration 1. Right patient -Check the name on the order and the patient. Use 2 identifiers. 2. Right medication - Check the medication label. Check the order. 3. Right dose - Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route - Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time - Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation - Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason - Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response - Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize? During the end of day debriefing on 10/31/2023, the facility Administrator, Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant were informed of the findings. It was discussed that RN-B left the medications of Resident # 2 unattended. RN-B immediately determined that Resident # 1 consumed the medications intended for Resident # 2. RN-B was transparent about the error and immediately notified the provider of the error. RN-B assessed and monitored Resident # 1 for adverse reactions and notified the provider of the changes in mental status. The nurse practitioner examined Resident # 1 and ordered to transport to the Emergency Department of evaluation and treatment. Resident # 1 was admitted to the hospital and diagnosed with Acute Toxic Encephalopathy due to incidental ingestion of the roommate's medication. Resident # 1 was also diagnosed with a urinary tract infection for which she was treated while in the hospital. The facility administrative staff responded with timely reporting of the incident to the State Agency, corrective action of a Written Warning for RN-B, All licensed nurses received in-service education regarding medication administration and never leaving medications unattended at the bedside under any circumstances. Monitoring of the rooms, medication pass and pour observations, and regular rounds were conducted. The Director of Nursing stated random audits, observations and rounds were still being conducted. During the dates of survey, nurses were observed administering medications, audits were validated, and staff interviews were conducted. There was no deficient practice identified at the time of survey or since the allegation of compliance, therefore this deficiency is cited at past non-compliance. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to post daily staffing information for Residents, staff, and visitors to see, which has the potential to affect all Residents. The findings included: On 9/1/22 at approximately 11:00 AM, a faciltiy tour was conducted to look for daily staffing posted. Surveyor E was unable to locate it. On 9/1/22 at approximately 12:40 PM, the Director of Nursing (DON) was asked where the daily staffing is posted. The DON and Surveyor E went to the B unit and found the Daily Unit Assignment sheet posted in the hallway. This posting listed the date, staff's first names and their assigned shift. No census data or hours worked was noted. The DON and Surveyor E then went to the A unit. The Daily Unit Assignment was posted in the chart room, which was located behind the nursing station. On 9/1/22, the Director of Nursing (DON) was interviewed. The DON stated the scheduler posts the daily staffing and on the weekends posts for the entire weekend on Friday. When asked what the purpose of posting the daily staffing is, the DON said, For the staff to know where to go since we have two sides. On 9/1/22, the facility Administrator was asked where the staff posting is posted. She said, I will have to check, is it not posted out by the time clock. Surveyor E went and made an observation of the postings around employee time clock and didn't see a posting of daily staffing. On 9/1/22, the facilty staffing coordinator, Employee H was asked where she posts the daily staffing. She stated, On B unit across from the station, on A unit in the chart room. I know families are supposed to have access but A side doesn't really have any where to post it. On 9/1/22 at approximatey 12:55 PM, the faciltiy Administrator approached Surveyor E and asked if the posting in the lobby had been seen. Surveyor E and the Administrator went to the lobby and behind the reception desk in a case/shadow box, there was a posting that was not ligible. It was above eye level and at a distance that the text could not be read. On 9/1/22 at 1:30 PM, upon the survey team's return from lunch, Surveyor E pointed out the daily staff posting behind the receptionist. Surveyor E asked Surveyor D if she could read it and Surveyor D said, No. On 9/1/22 at 1:35 PM, an interview was conducted with Employee J, the business office assistant and receiptionist. The facility lobby had a door that was locked, which seperates the lobby from the Resident care areas and units. Facility staff have to enter a code to unlock the door for access to be gained to the Resident care unit and back to the lobby from the unit. When asked if Residents have access to the lobby, Employee J said they do not, a staff member would have to unlock the door for them to access the lobby. A review of the facility policy titled, Posting Direct Care Daily Staffing Numbers was conducted. This policy read, 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 9/1/22, during an end of day meeting with the facility Administrator, Assistant Administrator, DON, and corporate staff were made aware of the above findings. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to distribute food in accordance with professional standards for food service safety. Specifically, the facility staff failed to ensure a safe holding temperatures for 2 out of 2 milk containers on 08/31/2022 for the lunch tray line. The findings included: On 08/31/2022 at 11:00 A.M., this surveyor observed Employee K, a cook, obtain tray line temperatures. The cold beverages for the tray line were on cart shelves by the tray line. Employee K selected a carton of milk to check the holding temperature. The temperature was 50.8 degrees Fahrenheit. Employee K then selected another milk off the cart and checked the temperature. The temperature was 47.2 degrees Fahrenheit. The cook then stated the milk on the cart would be taken away. The Dietary Manager was informed of findings and stated that the milk should be on ice while serving on the tray line. On 08/31/2022, the facility staff provided a copy of their policy entitled, Food Production. In Section D(b)(1) entitled, Milk Production, an excerpt documented, During service, place on ice to maintain temperature below 41 degrees Fahrenheit. On 08/31/2022 at approximately 6:00 P.M., the administrator and Director of Nursing were notified of findings.

Based on staff interview and facility documentation review, the facility staff failed to test Residents for COVID-19 in on one (A-unit) of two units accordance with The Centers for Disease Control and Prevention guidance. The findings included: Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on 02/02/2022, was reviewed. An excerpt of the document read, Asymptomatic residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after exposure) and, if negative, again 5-7 days after the exposure. On 08/31/2022 at approximately 5:00 P.M., the facility staff provided a copy of their staff line listing. According to the line listing, Staff #17, a nurse, had symptom onset (cough, temperature greater than 100 degrees Fahrenheit, chills/shaking, new malaise, dizziness, sore throat, and body aches) on 08/19/2022 and tested positive for COVID-19 on 08/19/2022. On 09/01/2022, the facility staff provided an as worked schedule for 08/18/2022. According to the schedule, Staff #17 was the only nurse assigned on the A unit to care for Residents from 11:00 P.M. (08/18/2022) to 7:00 A.M. (08/19/2022). On 09/01/2022 at 10:45 A.M., the Infection Preventionist (Employee D) was interviewed. When asked about the timeline for the current outbreak, the Infection Preventionist stated that they were no longer in outbreak. The Infection Preventionist explained that a Resident tested positive on 08/02/2022 and their policy is that outbreak is considered to extend 28 days after a Resident tests positive. The Infection Preventionist stated that Residents would be tested twice a week for the 28 days. This surveyor and the Infection Preventionist reviewed the facility's testing logs. According to the testing logs, Residents were tested on [DATE], 08/09/2022, 08/16/2022, 08/22/2022, 08/23/2022, and 08/26/2022. There was no evidence Residents exposed to Staff #17 on 08/19/2022 were tested until 3 days after exposure. On 09/01/2022, the Administrator was notified of findings. 2. The facility staff failed to conduct routine testing of staff who were not up to date with COVID immunizations for 6 staff (Staff #1, #2, #4, #5, #6, and #10) in a sample of 8 staff reviewed for COVID testing. On 8/31/22, a review was conducted of the staff vaccination matrix and a sample of 11 employees was selected. On 8/31/22 at 2:14 PM, Surveyor E met with the Infection Preventionist (IP) and the QA (Quality Assurance) Nurse to review staff COVID testing. The following testing dates were noted and confirmed by the IP nurse. The hire dates, work status and time card/punches were obtained from Employee F, Human Resources Manager. 2a. Staff #1 had testing occurrences of 8/9/22 and 8/11/22. Staff 1 was hired 3/2/22, and worked on an as needed basis. Staff #1 was noted on the staff vaccination matrix as being partially vaccinated. Review of the vaccination information Human Resources had on file revealed Staff #1 received one dose of a multi-dose, Moderna COVID vaccine on 2/22/22. Staff #1 worked 8/18 and 8/24, without having any testing completed. 2b. Staff #2 had no evidence of any testing conducted in July or August, 2022. Staff #2 was hired 5/20/22, and worked full time. Staff #2 was noted as having been granted a non-medical exemption from vaccination, which was approved on 5/24/22. 2c. Staff #4 was tested [DATE], 7/12/22, 7/15/22, 7/19/22, and 7/22/22. There was no testing occurrences for Staff #4 after 7/22/22. Staff #4 worked 6 additional shifts following 7/22, without any testing. 2d. Staff #5, was noted on the staff vaccination matrix as being partially vaccinated. Staff #5 was tested on ly twice in July, on 7/19 and 7/27. In August she was tested twice weekly from 8/1/22-8/17/22. Following the test on 8/17/22, the other testing occurrences were 8/23/22 and 8/30/22. She had not been tested twice weekly in July or for the last two weeks in August. Review of the time card revealed Staff #5 worked 10 shifts from 8/17-8/31. 2e. Staff #6, was noted on the staff vaccination matrix as having had been granted a non-medical exemption from immunization. Staff #6 was not tested twice weekly. Her testing occurrences for July and August were as follows: 7/19/22, 7/22/22, 7/23/22, 8/2/22, 8/4/22, 8/8/22, 8/11/22, 8/16/22, 8/18/22, 8/22/22, and 8/29/22. When Surveyor E asked if there was any testing between, 7/23/22-8/2/22, the IP said, No. 2f. Staff #10, was noted on the staff vaccination matrix as being partially vaccinated. Review of the testing for Staff #10 revealed that the facility staff had her marked as being boosted, therefore she was not conducting routine testing. She was not tested from July 20, 2022 until Aug. 21. Once they started testing Staff #10, she did not have twice weekly testing. She was tested [DATE], 8/26/22, and 8/31/22. Review of the time card for Staff #10 revealed she worked 17 days in July and 22 days in Aug. During the interview, Staff #10 identified as working at that time, she was called into the office and confirmed that she is not boosted for COVID-19. The Infection Preventionist was made aware that the staff who were not up-to-date were not being tested twice weekly. She confirmed the findings. 3. The facility staff failed to conduct outbreak testing of staff, regardless of their vaccination status. On 8/31/22 and again on 9/1/22, Surveyor E met with the facility Infection Preventionist (IP). The IP confirmed they had been in a COVID outbreak until 8/30/22. When staff testing records for August were reviewed, the IP stated that staff who are up-to-date do not have to be tested unless they are symptomatic. When asked if they are tested during an outbreak, the IP said, No. The testing records revealed no evidence of any staff who are up-to-date with COVID immunizations receiving any COVID testing. On 9/1/22 at approximately 5:45 PM, the Regional Director of Clinical Services (RDCS) stated, Per CMS definition, it says 1 staff or 1 Resident is an outbreak, but VDH (Virginia Department of Health) tells us often no, so we let VDH make the determination if we are in outbreak or not. The RDCS was asked which guidance they follow if there is a discrepancy between the two. The RDCS said, We follow VDH because they are in the area and are experts in their area. Review of the facility policy titled, Coronavirus (COVID-19) with a revision date of 5/10/22, was conducted. This policy read, . Routine testing of staff that are not up to date with all recommended vaccinations will be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site: https://covid.cdc.gov/covid-data-tracker/#county-view (9.14.2021) see Covid 19 Testing Policy . The facility policy titled, COVID-19 Testing was reviewed. This policy read, .Testing Triggered by an Outbreak Investigation/Testing of Staff and Residents During an Outbreak Investigation: A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin. Facilities have the option to perform outbreak testing through two approaches, 1) contact tracing or 2) broad-based (e.g. facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. If testing of close contacts reveals additional HCP or residents with [CONDITION(S)]-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with [CONDITION(S)]-CoV-2 infection. A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. If the outbreak investigation is broadened to either a facility-wide or unit-based approach, follow recommendations below for alternative approaches to individual contact tracing. Alternative, broad-based approach: If close contacts cannot be determined, the facility should investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility) . On 9/1/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No additional information was provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care according to professional standards for one Resident (Resident #38) in a sample size of 38 Residents. For Resident #38, the facility staff failed to re-valuate for leg prosthetics after a fitting for shrinkers socks was completed. The findings included: On 08/30/2022 at 8:45 A.M., Resident #38 was observed dressed, sitting on his bed covers. Resident #38 had bilateral above the knee amputations. When asked if he had any concerns about the care he received at the facility, Resident #38 stated that he wanted his prosthetic legs. When asked if he knew where they were located, Resident #38 stated that he doesn't have prosthetic legs yet, but wants to get them. On 08/31/2022, Resident #38's clinical record was reviewed. Resident #38's Minimum Data Set with an Assessment Reference Date of 07/05/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. On 09/01/2022 at 8:30 A.M., Employee P, an occupational therapist, was interviewed. When asked about Resident #38's most recent dates of service for therapy, Employee P referred to Resident #38's clinical record and stated that Resident #38 was seen by physical therapy from 08/25/202 through 11/24/2020. When asked the reason for the therapy, Employee P stated the reason for the evaluation was for mobility because Resident #38 wanted leg prosthetics. On the Physical Therapy Evaluation dated 08/25/2020 under Patient Goals it was documented, To be able to stand with prosthesis and get out of here. Under the section entitled, Potential for Achieving Rehab Goals it was documented, Patient demonstrates good rehab potential as evidenced by ability to follow 2-step directions, attentive to tasks and active participation in skilled treatment. Employee P stated that Resident #38 currently doesn't have leg prosthetics and gets around in a wheelchair. Employee P stated that Resident #38 transfers himself to the wheelchair independently and has a functional reach of 12 inches, meaning he is not at risk for falls. Employee P then stated that on 11/04/2020, Resident #38 was scheduled for a prosthetic assessment with an outside company for 12/04/2020. Employee P stated that Resident #38 was discharged from physical therapy services on 11/24/2020 because all of his goals were met. Employee P stated that physical therapy services would not be involved in his care again until after the prosthetic fitting occurred. When asked why Resident #38 did not have prosthetic legs currently, Employee P stated that she could not tell from the physical therapy documentation the results of the prosthetic assessment. On 09/01/2022 at 10:35 A.M., the Administrator was notified of findings. The Administrator stated that Resident #38 was seen by outside company twice and was deemed not a good candidate for prosthetics. The Administrator stated she would provide the documents for those visits. At approximately 11:45 A.M., the Administrator provided the following: 1) A handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) A document entitled, Clinical Summary dated 07/30/2021 from a prosthetic company. The document indicated Resident #38 was seen to be evaluated for shrinker socks. 3) A document entitled, Clinical Summary dated 08/06/2021 from the same prosthetic company as dated 07/30/2021. The document indicated Resident #38 was successfully fitted for and provided bilateral shrinker socks. 4) A document from the prosthetic company dated 08/06/2021 entitled, Prescription - Letter/Certificate of Medical Necessity under the header Functional Capacity (from K0-K4) documented, K1-Ability or potential to transfer or ambulate on level surfaces with fixed cadence. Under the header Directions for use it was documented, Use with therapy at this time and re-eval [re-evaluate]. There was no evidence in the documentation that Resident #38 was not a candidate for leg prosthetics. On 09/01/2022 at approximately 7:30 P.M., the Administrator stated there was no further documentation to submit.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to revise the care plan for two Residents (Resident #43, Resident #59) in a sample size of 38 Residents. 1) For Resident #43, the facility staff failed to revise the care plan regarding Resident #43's personal preference to spend time outside. 2) For Resident #59, the facility staff failed to review and revise the care plan based on changing goals, preferences and needs of the resident and in response to current interventions. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The Administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Activity Evaluation. Under the header Policy Statement, it was documented, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. In Section 1 it was documented, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident. In Section 6, it was documented The activity evaluation is used to develop an individual activities care plan separate from or as part of the comprehensive care plan that will allow the resident to participate in activities of his or her choice and interest. The facility staff provided a copy of their policy entitled, Care Plans, Comprehensive Person-Centered. In Section 13, it was documented, Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. 2. For Resident #59, the facility staff failed to review and revise the care plan based on changing goals, preferences and needs of the resident and in response to current interventions. On 8/31/22 at approximately 2:10 PM an interview was conducted with Resident #59 who stated that the facility had removed her call bell from her room and given her a hand held bell that she has to ring. She stated that she felt she had Learned her lesson and would like her call bell back. When asked why the facility took her call bell she stated because I ring it too much. During an interview with the Unit Manager on 8/31/22 at approximately 3:15 PM the unit manager stated that the reason the call bell had been removed from Resident #59 was that she had attempted suicide by placing the call bell around her neck and she was found by the CNA and sent to the ER for evaluation. Upon return to the facility she was given another type of call bell without a cord. The unit manager stated this was for safety and not punitive in any way. A review of the care plan revealed that on 7/10/22 the following was written in Resident #59's care plan 7/10/22 - Q 15 min checks per orders. This was a hand written entry with no definite time frame as to when the 15 minute checks will start or end. On 8/31/22 an interview was conducted with the MDS Coordinator who stated that the care plans are reviewed and revised quarterly in the computer. Between quarterly reviews any changes are handwritten on the copy that is kept in the MDS office. When asked if the care plan book stays in the MDS office she stated that it did. When asked if her office was locked over weekends and evenings she stated that it was. When asked how the staff can access the care plans she stated that they have access to the copy in the computer. When asked is that copy always up to date she stated that it was not, the working copy is the one with the changes and that one is located in the MDS office. When asked about the entry of 7/10/22 she stated that it was hand written in the working copy on that date. When asked how the staff would know when to start and end the 15 minute checks she stated they would have to look at the orders. A review of the Care Plan Policy read: Page 8 The comprehensive person-centered care plan will: a. Include measurable objectives and time frames. On 9/1/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to facilitate Resident self-determination through support of Resident choice for one Resident (Resident #43) in a sample size of 38 Residents. For Resident #43, the facility staff failed to assist Resident #43 spend time outside in August 2022 as was her personal preference. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Resident Rights. In Section 1(e) it documented, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . self-determination.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an ongoing program to support residents in their choice of activities for one Resident (Resident #43) in a sample size of 38 Residents. For Resident #43, the facility staff failed to assist Resident #43 spend time outside in August 2022 as was her personal preference. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Activity Evaluation. Under the header Policy Statement, it was documented, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. In Section 1 it was documented, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident.

Based on staff interview and facility documentation review, the facility staff failed to have an accurate system to track the immunization status of all facility employees affecting one employee (Staff #5) in a sample of 11 employees reviewed, and the facility staff permitted one staff member (Staff #5) who was not fully immunized to continue to work; the facility staff's vaccination rate was 99.5% The findings included: The facility staff failed to have an accurate system to track the COVID immunization status of one employee Staff #5 and permitted her to work after being eligible to receive the second dose, which she didn't receive timely. On 8/30/22, the facility staff provided the survey team with a copy of the staff vaccination matrix and a document titled, COVID-19 Vaccination Record Log for Staff, which included dates of vaccination. These two documents were reviewed and a sample of 11 employees were selected for review. The staff vaccination matrix revealed the following: Staff #5 was listed as being partially vaccinated. The COVID-19 vaccination record log for staff, revealed that Staff #5 was listed as having received one dose on 6/28/22. On 8/31/22 at 2:14 PM, an interview was conducted with the Infection Preventionist (IP) Nurse. She stated that she oversees the COVID testing of Residents and staff but that Human Resources (HR) maintains the staff vaccination cards and staff vaccination matrix. The IP and Employee E, the Quality Assurance (QA) nurse confirmed that second doses of COVID vaccinations are given 30 days from the first dose. On the afternoon of 8/31/22, Surveyor E met with Employee F, the HR Director. The HR director looked through employee files and found the following: Staff #5's information on file indicated she received one dose of a multi-dose vaccine series on 6/28/22. Staff #5 was hired 7/13/22. During this interview, the HR director said, I do recruiting and onboarding. If they don't have the vaccine then they have to file for an exemption prior to hire. They bring their vaccination card when they come in for the drug test or orientation, they can't start without at least one [dose]. We had one or two that only had one dose and I put them on the COVID tracker. I put new hires on there and I send an email to the Administrator every week as to who was hired, terminated, received the booster, etc. I put the information on the tracker but I don't follow-up. On 8/31/22 at 4:24 PM, an interview was conducted with Employee E. Employee E was asked about COVID vaccine requirements for staff. Employee E said, They are required to have their first shot before hired and second when eligible. On 8/31/22 at 4:56 PM, during an end of day meeting, the facility Administrator and Corporate staff were made aware that Staff #5 was noted as being partially vaccinated, is eligible to receive the second dose, and has continued to work. The facility staff indicated they would look into this. On 9/1/22 at 10:53 AM, Surveyor E met with the facility Infection Preventionist and QA nurse. They were both shown Staff #5's information on the COVID-19 Vaccination Record Log for Staff that the facility provided. It indicated Staff #5 received 1 dose of a primary series on 6/28/22, and they were asked when she would be eligible for the second dose. The QA nurse said, 7/26/22. They were then shown Staff #5's time card, which revealed she had worked 7/26/22, 7/30/22, 7/31/22, 8/2/22, 8/3/22, 8/5/22, 8/8/22, 8/9/22, 8/11/22, 8/14/22, daily from 8/17/22-8/23/22, 8/25/22, 8/28/22, and 8/30/22. When asked if this is a problem, they both [the IP and QA nurse] stated, Yes. On the morning of 9/1/22, the facility Administrator provided Surveyor E with a document from CDC that read, Stay Up to Date with COVID-19 Vaccines Including Boosters. This document had a revision date of 8/23/22. The Administrator pointed out that it indicated the 2nd dose of the primary series for the Moderna is due 4-8 weeks after the first dose and stated that Staff #5 was within the 8 weeks of her first dose. Surveyor E then showed the Administrator a document from CDC that read, Stay Up to Date with Your Vaccines dated 1/16/22, that indicated Moderna vaccines are to be given 4 weeks (28 days) apart. On 9/1/22 at 11:02 AM, the Administrator provided Surveyor E with a copy of Staff #5's vaccination card that showed a second dose of the primary vaccination series was completed 8/15/22. The document had a printed date of 9/1/22, 10:50 AM. The Administrator was asked about this and she said, She [Staff #5] just sent it to HR this morning. On 9/1/22, the HR Director, Employee F, confirmed that Staff #5 had emailed her a photo of her COVID immunization card this morning and prior to receiving this at 10:50 AM, she was not aware that Staff #5 had been immunized. The facility staff's vaccination rate was 99.5%. A review was conducted of the facility policy titled, Covid-19 Vaccine Policy & Forms with a revision date of 5/10/22. This policy read, . Guidelines: 1. It is required that all affected individuals working within the center receive a COVID-19 vaccination as a condition of employment or access to the center unless a valid medical or religious exemption is granted. All affected individuals are expected to either receive the 2-shot series or a single dose of a one shot COVID-19 vaccine or obtain an approved exemption from the vaccination requirement. 5. New affected individuals are required to receive COVID-19 vaccination or provide proof of vaccination or provide adequate documentation of exemption at the time of hire or entry to the center. New applicants or affected individuals who have not provided documentation of compliance (or have failed to secure an approved exemption or immunization), will be listed as 'pending' hire and will not participate in the new Team member orientation program. Newly affected individuals who have not provided documentation of compliance (or have failed to secure an approved exemption or immunization) will not be allowed to enter the facility. a. New team member applicants will be given seven (7) business days from the date of the employment health screening to provide adequate documentation of exemption or vaccination before the facility rescinds the offer of employment; during this (7) day period the new applicant will not be allowed to work without proof of vaccination status or documentation of exemption. If documentation is not received, the facility Human Resources will advise the applicant they are not cleared for hire and may result in rescinding the offer of employment. b. Newly affected individuals who receive the initial dose of COVID -19 vaccine on day one of entering the facility and complete the medical exemption form under other stating they have initial dose and will wear Personal Protection Equipment, PPE of a N95 face mask until full vaccination status of 2 weeks after final vaccine will be allowed to enter facility and work. 6.Team members on leave of absence who return are required to be in compliance with this policy upon return and must provide documentation of policy compliance (approved exemption or immunization) prior to the scheduled return to work date. If no documentation is provided to the facility Human Resource office at the time of the return-to-work visit, the team member will be advised that he/she is not cleared to return to work until he/she is in compliance with this policy . CMS (Centers for Medicare and Medicaid Services) issued notice in the QSO Memo titled, Ref: QSO-22-09-ALL, DATE: January 14, 2022. This notice read, .CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute non- compliance under the rule .Within 90 days and thereafter following issuance of this memorandum, facilities failing to maintain compliance with the 100% standard may be subject to enforcement action . On 9/1/22, during the end of day meeting, the facility staff were made aware of the above findings. No additional information was received.

Based on staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to implement their abuse policy for 1 Resident (Resident #2) in a survey sample of 4 Residents. The findings included: For Resident #2, the facility staff failed to implement their abuse policy by not reporting an allegation of abuse and failure to protect the Resident from their alleged abuser during the course of an investigation. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2020 was coded as a quarterly assessment. Resident #2 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated Resident #2 was cognitively intact. Resident #2 was coded as having required supervision for bed mobility, transfers, dressing, eating toileting and personal hygiene. On 9/9/2020 Surveyor A asked the facility to provide all FRI's (facility reported incidents) and grievances for the past year. Review of these documents revealed no information about Resident #2's grievance of being abused by a staff member. On 9/9/2020 during the late morning the facility Administrator provided Surveyor A with a red 3 ring binder and stated, these are for internal use. Review of the documents revealed a Grievance Form dated 12/12/2019 which had not been logged on the grievance logs previously submitted. The form stated, Resident #2 complained that one of the nurses (LPN C) snatched an inhaler from his hand and ended up scratching his palm. Resident #2 also said the nurse hit him but recanted that statement when I asked which part of his body was hit and indicated date complaint/grievance occurred: 12/11/2019. On 9/9/2020 at 5:39 PM when Surveyor A asked the Administrator to explain the red binder, the Administrator stated, this is our grievance book, I keep if I look into it I keep records for our internal records. The Administrator was asked if these allegations were reported to the state, he responded no. I asked if he considered this an allegation of abuse, he said yes. When asked if it should have been reported, the Administrator said yes. Surveyor A asked if it was reported and the Administrator said this wasn't, when I heard of it I had passed the reporting period. I decided to investigate and based on the findings I addressed it. When asked if the alleged perpetrator (LPN C) was suspended or removed from the premises while the investigation was being conducted, the Administrator stated no, we changed her assignment to not take care of Resident #2. The alleged perpetrator remained on the premises and therefore continued to have access to Resident #2 following an allegation of abuse while an investigation was ongoing to determine if abuse had occurred. Review of the clinical record for Resident #2 revealed no documentation of the allegation of abuse or any staff response. On 9/10/2020 at 10:20 AM an interview was conducted with RN A. RN A was asked about the abuse policy/process if a Resident reported they had been mistreated by a staff member, and RN A stated, I would immediately make sure they are ok, I would separate them and whomever if needed, intervene and make sure to report to the chain of command. We have a 2 hour window to report to the state. When asked who makes the report to the state (referring to the OLC), RN A stated, the Director of Nursing, Administrator or Assistant Director of Nursing, I've never been unable to reach them but if I can not reach them then I would file the report. When asked the next steps, RN A stated I've never had it happen but I would send the employee home. On 9/10/2020 at 5:44 PM, an interview was conducted with LPN C, the alleged perpetrator. LPN C was aware of the allegation of abuse Resident #2 made. LPN C stated, she never abused or mistreated Resident #2. LPN C was asked if she was suspended or taken out of work while an investigation was conducted and she said no. LPN C did acknowledge that she was removed from the assignment of Resident #2 and that Resident #2 had approached the musing station following the incident trying to apologize but she didn't engage in conversation with the Resident. Review of the facility policy titled, Abuse, Neglect and Exploitation Preventing and Reporting stated, The Administrator, Director of Nursing or facility appointed designee should report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, OLC, other state Agencies in accordance with state law. 8. The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. 13 c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. The facility Administrator was made aware of the concerns during the end of day meetings held on 9/9/2020 and again on 9/10/2020. No further information was provided. COMPLAINT DEFICIENCY.

Based on staff interview, clinical record review, hospital document review and during the course of a complaint investigation, the facility staff failed to provide necessary care and services for an identified change in a resident's condition for 1 resident (Resident #4) of 5 Residents in the survey sample. Resident #4, a diabetic, had a documented change in mental status and behavior for which he was sent from the facility to the emergency roiagnom on three occasions. On each emergency room visit, Resident #4's blood sugars were elevated and required insulin. Resident #4's facility clinical record showed no evidence of blood sugar monitoring or assessment throughout his stay in the facility, but was treated when sent to the emergency room or hospital. On Resident #4's last transfer to the emergency room of the local hospital, the documented blood sugar was 660 mg/dl. Normal blood glucose ranges from 70-100 mg/dl (milligrams per deciliter). The findings included: Resident #4, a [AGE] year old male, was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was hosptalized on [DATE] and readmitted to the facility on [DATE]. Resident #4's admission MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/7/11 coded Resident #4 with short and long term memory problems. The MDS assessment coded Resident #4 as being moderately impaired in daily decision making. Resident #4 was coded as independent in ambulation. Section N: Medications coded Resident #4 as receiving antipsychotic, antianxiety, and hypnotic medications during the ARD period. Section E: BEHAVIORS, under [MEDICAL CONDITION] was coded for [MEDICAL CONDITION] and Behavioral Symptoms (verbal and physical) were coded as occurring daily. Resident #4 was discharged to an acute care hospital on [DATE]. Review of the closed clinical record revealed Resident #4 had a [DIAGNOSES REDACTED]. (milligram) once a day for his diabetes. Resident #4's Care Plan, dated 3/26/2011, identified Resident #4 as being at risk for hypo/[MEDICAL CONDITION] and listed interventions of monitoring blood sugars as needed; med and labs as ordered; and encourage dietary compliance. A thorough review of the clinical record did not reveal any blood glucose monitoring by fingerstick (1) or lab order. The surveyor obtained hospital records for Resident #4 on 5/13/11 at approximately 8:45 a.m. Review of the Resident's facility and hospital clinical records revealed the following events: -3/21/11 at 2 p.m. until 3/22 3:30 p.m. Resident alert, ambulating, very upset, using foul language. On 3/22/11 at 3:30 p.m. - [MEDICATION NAME] 2.5 mg p.o. (by mouth) BID (twice a day) for [MEDICAL CONDITION]. -3/24 at 6:25 p.m.- Resident #4 was transported to the emergency room . A Fingerstick Blood Sugar (FSBS) was obtained on transport to the hospital and the reading was 132. -3/24/11 at 9:28 p.m. Resident #4 admitted to hospital , [DIAGNOSES REDACTED]. -3/25/2011 Resident #4's hospital consult read, under LABORATORY DATA, "Glucose 251." Under ASSESSMENT AND PLAN, " He will need better control of his diabetes for stroke prevention." -4/11/11 at 10:44 p.m. Resident #4 was sent to the ER. The Review of the Hear Radio Communication Sheet (form used by the hospital transport staff) read, "Pt. out of Control., Past Medical History: Diabetes, FSBS 373." -4-12-11 at 1:05 a.m. the emergency lab work read, "Glucose H (high) 335 " mg/dl (65-105). Resident #4's ER [DIAGNOSES REDACTED]. -4/21/11 at 2:30 a.m. Resident #4 was sent to the ER. Review of the Hear Radio Communication Sheet dated 4/21/11 @ 0233(2:33 a.m.) revealed a documented "FSBS of HIGH +500". Resident#4 's Level of Consciousness was described as "Awake not able to respond/talk. " Review of the hospital emergency records revealed Resident #4 arrived at the emergency roiagnom on [DATE] at 2:41 a.m. At 2:48 a.m. the nurse documented the Resident was awake, appears in no distress. The hospital laboratory results revealed the following blood sugar results: - 4/21/11 at 3:26 a.m. "GLUCOSE HHH 538" (range 70-110) 4/21/11 at 3:48 a.m. "GLUCOSE HHH 619" (range 65-105) Review of the hospital Psychiatry Consult: Clinical summary dated 4/21/11 revealed the following statement , "Glucose in the ED (emergency department) noted to be 619." Review of a hospital consult on 4/21/11 performed by MD (name of doctor), under HISTORY OF PRESENT ILLNESS stated, "On admission was found to have a blood sugar of 600 with normal [MEDICATION NAME] and [MEDICAL CONDITION] of 151". Under IMPRESSION, stated, " 1. Nonketotic hyperosmolar [MEDICAL CONDITION]. Severe but improving. 2. Known history of type 2 diabetes with worsening [MEDICAL CONDITION] probably related to [MEDICATION NAME]. Other possibility would [MEDICAL CONDITION] infection although that does not seem the case. 3. [MEDICAL CONDITION] problems to dehydration and above problems for acute [MEDICAL CONDITION] secondary to dehydration. 4. Dementia with problems being evaluated by psychiatry. " A thorough review of Resident#4's facility clinical record did not reveal any record of blood sugar monitoring after his hospitalization on [DATE]-[DATE] or his emergency room visit on 4/11/11-4/12/11. Review of a nursing progress note written after the ER visit on 4/12/11 read, "Report from hospital (MWH) ER called in with no new orders noted. Gave resident 5 units of insulin in ER but no further medications administered." Resident #4's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].o. (by mouth) BID (twice a day). On 4/1/11 the [MEDICATION NAME] was increased to 5 mg. twice a day. And on 4/11/11 the [MEDICATION NAME] was increased to 10 mg. twice a day. The Nursing 2011 Drug Handbook, p. 669-671 provided the following information regarding Zyprex ([MEDICATION NAME]) which read, "ALERT: Drug may cause [MEDICAL CONDITION]. Monitor patients with diabetes regularly. BLACK BOX WARNING: [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." On 5/12/11 at 12:00 p.m. an interview was conducted with the facility pharmacist, Employee#1 regarding the use and monitoring as it related to [MEDICATION NAME]. Employee #1 explained the [MEDICATION NAME] was used for psychotic episodes and behavior conditions. Employee #1 stated the medication needed to be monitored for effectiveness by checking labs (lipids and kidney function). He also said the medication should be started at a low dose then increased (titrated) for effectiveness. When the surveyor asked about the risk of increasing blood sugars in Residents with diabetes, Employee #1 stated, "All antipsychotic medication can cause [MEDICAL CONDITION]. Employee #1 stated a Resident should have baseline labs done before starting [MEDICATION NAME] and then an A1C lab (test revealing an average blood sugar level over a period of time) every three months to monitor blood sugar levels. He concluded with, "[MEDICATION NAME] wouldn't be preventative; this would be used in reaction to behaviors." On 5/13/11 at 11:15 a.m., the findings were discussed with the facility director of nursing and administrator. The director of nursing stated the physician didn't order blood sugar testing, therefore Resident #4 blood sugars weren't monitored. The administrator stated that if the physician didn't order blood sugars, he must have had his reasons. The administrator asked the surveyor to speak with the physician about the findings. On 5/13/11 at 12:05 p.m., an interview was conducted with the facility physician (Admin.#4) treating Resident #4. Admin. #4 discussed his course of care for Resident #4, and stated, "My major focus was to calm down the Resident. His dementia was the priority." Admin#4 also said he thought finger sticks would be too agitating and increase the Resident's behavior. Admin. #4 concluded by saying it was a fact the Resident had uncontrolled diabetes before he came in the facility, "This is my belief." On 5/13/11 at 2:45 p.m., the facility administration was informed of the findings of failure to assess and treat Resident#4's diabetic concerns that were identified by hospital visits on two occasions. According to the Handbook of Nursing Procedures pages 56-58, ".. often called an accucheck, it allows for fast accurate results for blood glucose monitoring obtained by the bedside. This allows for immediate intervention by the nurse. Normal blood glucose ranges from 70-100 mg/dl (milligrams per deciliter)". References: "After discharge (from the hospital), the patient should be followed closely to ensure that the acute problem has resolved and that the patient has made a successful transition to the outpatient environment." American Family Physician, Management of hospitalized Patient with Type 2 Diabetes Mellitus, Sandra H. Lilley, PHARM.D, March 1, 1998. The information below was obtained from the American Diabetes Association at the following web site: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/a1c/ ? "The A1C test measures your average blood glucose control for the past 2 to 3 months. ? It is determined by measuring the percentage of glycated hemoglobin, or HbA1c, in the blood. ? Check your A1C twice year at a minimum, or more frequently when necessary. ? It does not replace daily self-testing of blood glucose. ... The A1C test gives you a picture of your average blood glucose control for the past 2 to 3 months. The results give you a good idea of how well your diabetes treatment plan is working." Complaint Deficiency

Based on staff interview, clinical record review, hospital document review and during the course of a complaint investigation, the facility staff failed to ensure 1 resident (Resident #4) of 5 Residents in the survey sample was free of unnecessary medications. On 3/22/11 Resident #4 was started on the antipsychotic medication [MEDICATION NAME] with a [DIAGNOSES REDACTED]. [MEDICATION NAME] is classified as an antipsychotic medication. The Nursing 2011 Drug Handbook, p. 669-671 provided the following information regarding [MEDICATION NAME] ([MEDICATION NAME]) which read, "ALERT: Obtain baseline and periodic liver function tests results. ALERT: Drug may cause [MEDICAL CONDITION]. Monitor patients with diabetes regularly. In patients with risk factors for diabetes, obtain fasting blood glucose test results at baseline and periodically. BLACK BOX WARNING: Drug may increase risk of cardiovascular or infection related death in elderly patients with dementia. [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." "Warnings/Precautions ... May cause extreme and life-threatening [MEDICAL CONDITION]; use with caution in patients with diabetes or other disorders of glucose regulation; monitor." Information obtained from "Drug Information handbook for Nursing 2007, 8th Edition" on page 905. Resident #4, a diabetic, had a documented change in mental status and behavior for which he was sent from the facility to the emergency roiagnom on three occasions. On each emergency room visit, Resident #4's blood sugars were elevated and required insulin. Resident #4's facility clinical record showed no evidence of blood sugar monitoring or assessment throughout his stay in the facility, but was monitored and treated in the emergency room or hospital. On Resident #4's last transfer to the emergency room of the local hospital, the documented blood sugar was 660 mg/dl (milligrams per deciliter). The findings included: Resident #4, a [AGE] year old male, was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was hosptalized on [DATE] and readmitted to the facility on [DATE]. Resident #4's admission MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/7/11 coded Resident #4 with short and long term memory problems. The MDS assessment coded Resident #4, as being moderately impaired in daily decision making. Resident #4 was coded as independent in ambulation. Section N: Medications coded Resident #4 as receiving antipsychotic, antianxiety, and hypnotic medications during the ARD period. Section E: BEHAVIORS, under [MEDICAL CONDITION] was coded for [MEDICAL CONDITION] and Behavioral Symptoms (verbal and physical) were coded as occurring daily. Resident #4 was discharged to an acute care hospital on [DATE]. Review of Resident #4 ' s clinical records from the office of his Primary Care Physician (PCP) was performed on 3/11/2011. According to the director of nursing these progress notes were part of the information used for Resident #4's admission into the facility. The most current Progress Notes faxed to the facility on [DATE] and updated on 1/25/11 read as follows: " He has a nurse that comes most of the days and has someone who stays at night with him. No sundowning or wandering, tolerating [MEDICATION NAME] well. No more [MEDICAL CONDITION]. No new neuro symptoms. 1. Dementia 2. Type 2 Diabetes Mellitus 3. History of TIAs 4. Hypertension. Continue [MEDICATION NAME] (for dementia), [MEDICATION NAME] (for diabetes), [MEDICATION NAME] (for stroke), [MEDICATION NAME] (for hypertension), [MEDICATION NAME] (for hypertension), KCL (supplement), [MEDICATION NAME] (for [MEDICAL CONDITION] disease), [MEDICATION NAME] (for [MEDICAL CONDITION]). Gave flu shot. Follow up in 3 months." Review of Resident #4 admission orders [REDACTED]. There were no labs or blood sugar checks ordered. Reference: Nursing 2011 Drug Handbook, Lippincott Williams & Wilkins Glipzide, pg.1037-1038 [MEDICATION NAME] pg.1444 [MEDICATION NAME] pg. 380-382 [MEDICATION NAME] pg. 303-304 KCL pg. 1397-1399 [MEDICATION NAME] pg.939-941 [MEDICATION NAME] pg. 417-419 Tylenol pg. 718-720 [MEDICATION NAME] pg. 669-672 Ambien pg. 787-788 [MEDICATION NAME] pg. 696-697 PubMed Health <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 73/> [MEDICATION NAME] Review of Resident #4's Physician Telephone Orders revealed an ordered dated 3/22/11 and signed by the physician on 3/24/11 which read, "#3. [MEDICATION NAME] 2.5 mg (milligram) PO (by mouth) BID (twice a day) for [MEDICAL CONDITION]. [MEDICATION NAME] is classified as an antipsychotic medication. The Nursing 2011 Drug Handbook, p. 669-671 provided the following information regarding [MEDICATION NAME] ([MEDICATION NAME]) which read, "ALERT: Obtain baseline and periodic liver function tests results. ALERT: Drug may cause [MEDICAL CONDITION]. Monitor patients with diabetes regularly. In patients with risk factors for diabetes, obtain fasting blood glucose test results at baseline and periodically. BLACK BOX WARNING: Drug may increase risk of cardiovascular or infection related death in elderly patients with dementia. [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." The surveyor obtained hospital records for Resident #4 on 5/13/11 at approximately 8:45 a.m. Review of the Resident's facility and hospital clinical records revealed the following events: -3/21/11 at 2 p.m. until 3/22 3:30 p.m. Resident alert, ambulating, very upset, using foul language. On 3/22/11 at 3:30 p.m. - [MEDICATION NAME] 2.5 mg p.o. (by mouth) BID (twice a day) for [MEDICAL CONDITION]. 3/23/2011 - The Pharmacist (Employee #1) signed Resident #4 ' s MEDICATION REGIMEN REVIEW and completed a Consultation Report which read: " Resident #4 takes [MEDICATION NAME] for [MEDICAL CONDITION]. Federal nursing facility regulation requires that antipsychotic agents only be used when one or more of the following conditions exist. " This consultation sheet was signed by the physician on 4/1/11 and the following condition #9 was selected (circled); " Dementing illness with associated behavioral symptoms. " -3/24 at 6:25 p.m. - Resident #4 was transported to the emergency room . A Fingerstick Blood Sugar (FSBS) was obtained on transport to the hospital and the reading was 132 mg/dl. -3/24 at 6:32 p.m. - Resident #4 arrived at the hospital emergency room , [DIAGNOSES REDACTED]. -3/24/11 at 9:28 p.m. Resident #4's admitted to hospital. Admitting Physicians Plan dated 3/24/11 at 10:48 p.m., included the following in the treatment PLAN, " Diabetes Mellitus: I will continue his [MEDICATION NAME]. I will put him on diabetic diet and sliding scale insulin. " -3/25/2011 at 0019 (12:19 a.m.) Resident#4 was placed on the following INSULIN SLIDING SCALE PROTOCOL: Glucose Level FSBS (Finger Stick Blood Sugar Less than 80-----Call Physician 80-140 -------2 Units 141-180------3 Units 181-240------5 Units 241-300------7 Units 301-400-----10 Units Greater the 400-12 Units Review of Glucose Testing performed during Resident#4 ' s hospitalization (normal range 60-110) was as follows: 3/25/11 at 10:38 pm -251 Received 7 Units of Regular Insulin 3/25/11 at 11:57 p.m. 178 Received 3 Units of Regular Insulin 3/25/11 at 5:51 p.m 62 No Insulin given 3/25/11 at 8:34 p.m. 202 Received 5 Units of Regular Insulin 3/26/11 at 10:23 a.m. 136 Not Administered. Pt. Refused Breakfast -3/25/2011 Resident #4 ' s hospital consult read, under LABORATORY DATA, "Glucose 251." Under ASSESSMENT AND PLAN," He will need better control of his diabetes for stroke prevention." -3/26/2011 Resident #4 was discharged from the hospital and returned to the facility with the following DISCHARGE medication orders [REDACTED]. (Note: during this hospitalization Resident #4 was not ordered to receive [MEDICATION NAME]) -3/26/2011 at 11:00 p.m. nurses read that Resident #4 had returned from the hospital, " Tolerated dinner and meds without difficulty. " -3/27 at 2:30 p.m. nurses note read, " Resident wandered around throughout the resident room. He attempted to go outside numerous times. MD paged. Review of the Physician ' s Telephone Orders revealed a telephone order dated 3/27 and signed by the physician on 4/1/11 that read, " [MEDICATION NAME] 2-5 mg PO BID for [MEDICAL CONDITION]. " 3/28/2011 - A physician ordered was written, " add: DX (diagnosis): Dementing illness with associated behavioral symptoms r/t (related to) use of [MEDICATION NAME]. This order was signed by the physician on 4/1/11. 4/1/2011 at 10:10 a.m. - Nurses note read, " MD in facility. Assessed resident. Reviewed meds. New orders to follow. Admission complete. " The following physician orders [REDACTED].[MEDICATION NAME] mg po QHS PRN for [MEDICAL CONDITION]. 2. D/C (discontinue) [MEDICATION NAME] 2.5 BID 3. [MEDICATION NAME] 5 mg po BID for dementing illness with associated behavioral symptoms. 1. [MEDICATION NAME] 1 mg Q4 PRN for agitation. 2. [MEDICATION NAME] 5 mg NOW. " 4/1/2011 at 4:30 p.m. the director of nursing wrote the following note, " Resident has had weight change. MD aware. N.O. for resident to have finger foods and snack and beverage at 10a and 2pm. " -4/3/2011 at 5:00 a.m. Resident #4 fell to knees (Fall #1) -4/5/2011 - Care Plan Meeting with Daughter. -4/7/2011 at 10:45 nurse noted, " Resident became increasingly combative and not listening to staff." -4/8/2011 at 11:30 a.m. Resident found on floor (Fall #2) -4/11/2011 at 8:30 p.m. Nurse noted, " Resident became very abusive to staff repeatedly grabbing wrists and twisting during attempts to distract resident kicking at staff. MD paged. Returned call. N.O. (new order) [MEDICATION NAME] 5mg/ml IM NOW. -4/11/2011 at 9:50 p.m. Nurse noted, " Resident continues to be unsettled and fighting. MD paged . N.O. Send to MWH to eval and treat." -4/11/2011 at 10:00 p.m. Nurse wrote a physician order [REDACTED]. D/C [MEDICATION NAME] 5MG 2. [MEDICATION NAME] 10 mg po BID 3. [MEDICATION NAME] 1 mg IM q (every) 4 hours PRN- agitation. " -4/11/11 at 10:44 p.m. Resident #4 was sent to the ER. The Review of the Hear Radio Communication Sheet (form used by the hospital transport staff) read, "Pt. out of Control. Past Medical History: Diabetes, FSBS (finger stick blood sugar) 373." -4/12/11 at 1:05 a.m. the emergency lab work read, "Glucose H (high) 335 mg/dl (65-105)." Resident #4's ER [DIAGNOSES REDACTED]. -4/12/2011 at 8:25 a.m. Nurse noted, " Resident returned to facility at 4:40 a.m. Returned in stable condition. Alert and oriented x1. Pleasantly confused. Calm. Report from (MWH) name of hospital ER called in with no new orders noted. Gave resident 5 Units of Insulin in ER but no further medications administered." -4/14/2011 at 3:30 a.m. Resident #4 observed on hallway floor. (Fall #3) -4/15/2011 at 4:00 p.m. Nurse noted, " MD in facility today and aware of all med refusals. No new orders. " 4/15-4/20/2011- Per nursing documentation, Resident #4 continued to wander, increased agitation, increased aggression, increased combativeness. 4/21/11 at 2:05 a.m. Resident #4 was noted as being very aggressive, punching and hitting staff, spitting at staff, rolling on the floor screaming. All staff from both side of building trying to redirect resident and keep him safe. All attempts failed. Resident#4 was administered 1 mg [MEDICATION NAME] by mouth. MD was notified and ordered Resident be sent to the hospital. -4/21/11 at 2:30 a.m. Resident #4 was sent to the ER. Review of the Hear Radio Communication Sheet dated 4/21/11 @ 0233(2:33 a.m.) revealed a documented "FSBS of HIGH +500". Resident#4 ' s Level of Consciousness was described as " Awake not able to respond/talk. " Review of the hospital emergency records revealed Resident #4 arrived at the emergency roiagnom on [DATE] at 2:41 a.m. At 2:48 a.m. the nurse documented the Resident was awake, appears in no distress. The hospital laboratory results revealed the following blood sugar results: - 4/21/11 at 3:26 a.m. "GLUCOSE HHH 538" (range70-110) 4/21/11 at 3:48 a.m. "GLUCOSE HHH 619" (range 65-105) Review of the hospital Psychiatry Consult: Clinical summary dated 4/21/11 revealed the following statement, " Glucose in the ED (emergency department) noted to be 619". Review of a hospital consult on 4/21/11 performed by MD (Name of physician), under HISTORY OF PRESENT ILLNESS stated, " On admission was found to have a blood sugar of 600 with normal [MEDICATION NAME] and [MEDICAL CONDITION] of 151." Under IMPRESSION, stated, " 1. Nonketotic hyperosmolar [MEDICAL CONDITION]. Severe but improving. 2. Known history of type 2 diabetes with worsening [MEDICAL CONDITION] probably related to [MEDICATION NAME]. Other possibility would [MEDICAL CONDITION] infection although that does not seem the case. 3. [MEDICAL CONDITION] problems to dehydration and above problems for acute [MEDICAL CONDITION] secondary to dehydration. 4. Dementia with problems being evaluated by psychiatry. " A thorough review of Resident#4's facility clinical record did not reveal any record of blood sugar monitoring after his hospitalization on [DATE]-[DATE] or his emergency room visit on 4/11/11-4/12/11. Review of a nursing progress note written after the ER visit on 4/12/11 read, "Report from hospital (MWH) ER called in with no new orders noted. Gave resident 5 units of insulin in ER but no further medications administered." A review of the Resident #4's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].o. BID (twice a day). On 4/1/11 the [MEDICATION NAME] was increased to 5 mg twice a day. And on 4/11/11 the [MEDICATION NAME] was increased to 10 mg twice a day. On 5/12/11 at 12:00 p.m. an interview was conducted with the facility pharmacist, Employee#1 regarding the use and monitoring as it related to [MEDICATION NAME]. Employee #1 explained that the [MEDICATION NAME] was used for psychotic episodes and behavior conditions. Employee #1 stated the medication needed to be monitored for effectiveness by checking labs (lipids and kidney function). He also said the medication should be started at a low dose then increased (titrated) for effectiveness. When the surveyor asked about the risk of increasing blood sugars in Residents with diabetes, Employee #1 stated, "All antipsychotic medication can cause [MEDICAL CONDITION]." Employee #1 stated a Resident should have baseline labs done before starting [MEDICATION NAME] and then an A1C lab every three months to monitor blood sugar levels. Employee #1 concluded with, "[MEDICATION NAME] wouldn't be preventative; this would be used in reaction to behaviors." Review of the MEDICATION REGIMEN REVIEW record revealed reviews performed by Employee #1 on 3/23/11 and 4/13/11. On 5/13/11 at 11:15 a.m., the findings were discussed with the facility director of nursing and administrator. The director of nursing stated the physician didn't order blood sugar testing, therefore Resident #4 ' s blood sugars weren't monitored. The administrator stated that if the physician didn't order blood sugars, he must have had his reasons. On 5/13/11 at 12:05 p.m., an interview was conducted with the facility physician (Admin. #4) treating Resident #4. Admin. #4 discussed his course of care for Resident #4, and stated, "My major focus was to calm down the Resident. His dementia was the priority." Admin#4 also said he thought finger sticks would be too agitating and increase the Resident ' s behavior. Admin. #4 concluded by saying it was a fact the Resident had uncontrolled diabetes before he came in the facility, "This is my belief." Admin. #4 added that the resident must have been on antipsychotics before, how else would [MEDICATION NAME] be listed as one of his allergies [REDACTED]. Resident #4 ' s Care Plan dated 3/26/2011 identified the risk for hypo/[MEDICAL CONDITION] and listed interventions of monitoring blood sugars as needed, med and labs as ordered, and encourage dietary compliance. A thorough review of the clinical record did not reveal any blood glucose monitoring by fingerstick (1) or lab order. Also, there was no Care Plan to address Resident #4 ' s use of Psychoactive medications. Reviews of the nursing notes revealed the physician was consistently notified of Resident #4 behaviors and change of condition. The hospital consultations and emergency documentation revealed Resident #4 was sent a courtesy copy (cc) of consultations of Resident #4 ' s hospital care and discharge plans. Resident #4 experienced three falls and worsening psychotic behaviors during which time he did not receive a psychological evaluation nor were his blood sugars monitored to assess effectiveness of the medications he was receiving. On 5/13/11 at 2:45 p.m., the facility administration was informed of the facility 's failure to assess and monitor for medication effectiveness and necessity for Resident #4. According to the Handbook of Nursing Procedures pages 56-58, ".. often called an accucheck, it allows for fast accurate results for blood glucose monitoring obtained by the bedside. This allows for immediate intervention by the nurse. Normal blood glucose ranges from 70-100 mg/dl (milligrams per deciliter)." (1) References: "After discharge (from the hospital), the patient should be followed closely to ensure that the acute problem has resolved and that the patient has made a successful transition to the outpatient environment."American Family Physician, Management of hospitalized Patient with Type 2 Diabetes Mellitus, Sandra H. Lilley, PHARM.D, March 1, 1998. The information below was obtained from the American Diabetes Association at the following web site: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/a1c/ ? "The A1C test measures your average blood glucose control for the past 2 to 3 months. ? It is determined by measuring the percentage of glycated hemoglobin, or HbA1c, in the blood. ? Check your A1C twice year at a minimum, or more frequently when necessary. ? It does not replace daily self-testing of blood glucose. ... The A1C test gives you a picture of your average blood glucose control for the past 2 to 3 months. The results give you a good idea of how well your diabetes treatment plan is working." Complaint Deficiency