Every finding on record at Hillcrest Raleigh at Crabtree Valley

Based on record review and staff interviews, the facility failed to complete or transmit to CMS (The Centers for Medicare and Medicaid Services) database a discharge Minimum Data Set (MDS) assessment for 7 of 10 residents reviewed for discharge MDS assessments (Resident #20, #80, #109, #36, #58, #77, and #142).The findings included:1a. Resident #20 was admitted to the facility on [DATE].A review of a nurse progress note dated 1/20/26 indicated Resident #20 was sent to the hospital for evaluation following a health event.A review of Resident #20's Electronic Medical Record (EMR) revealed no discharge MDS was completed, and Resident #20 did not return to the facility.b. Resident #80 was admitted to the facility on [DATE].A review of nurse progress note dated 11/26/25 indicted Resident #80 was discharged home with family.A review of Resident #80's EMR revealed no discharge MDS assessment was completed, and Resident #80 did not return to the facility.c. Resident #109 was admitted to the facility on [DATE].A review of nurse progress note dated 11/22/25 indicated Resident #109 was discharged home with family.A review of Resident #109's EMR revealed no discharge MDS assessment was completed, and Resident #109 did not return to the facility.d. Resident #36 was admitted to the facility on [DATE].A review of a nurse progress note dated 1/23/26 indicated Resident #36 was discharged home with family.A review of Resident #36's EMR revealed a discharge MDS assessment was completed on 1/23/26 but was not transmitted to CMS.e. Resident #58 was admitted to the facility on [DATE].A review of nurse progress note dated 1/24/26 indicated Resident #58 was discharged to the hospital for evaluation following a health event.A review of Resident #58's EMR revealed a discharge MDS assessment was completed on 1/24/26 but was not transmitted to CMS.f. Resident #77 was admitted to the facility on [DATE].A review of nurse progress note dated 12/11/26 indicated Resident #77 was discharged home with family.A review of Resident #77's EMR revealed a discharge MDS assessment was completed on 12/11/25 but was not transmitted to CMS.g. Resident #142 was admitted to the facility on [DATE].A review of nurse progress note dated 10/30/25 indicated Resident #142 was discharged home with family the day she was admitted .A review of Resident #142's EMR revealed a discharge MDS assessment was completed on 10/30/25 but was not transmitted to CMS.An interview with the MDS Nurse on 5/13/26 at 11:32 AM was conducted. She stated she had been doing MDS assessments for the facility for over a year. The MDS Nurse stated anyone from admissions or any of the nurses could use the facility's internal documentation system to advise the MDS staff that a resident had discharged from the facility. The MDS Nurse indicated that they relied on their internal documentation system only and did not run overdue MDS reports. The MDS Nurse also stated they have a very high number of admissions and discharges in the facility. The MDS nurse stated that Residents #20, #80 and #109 were inadvertently overlooked and their discharge MDS assessments were not completed. She stated not transmitting the discharge MDS assessments for Residents #36, #58, #77 and #142 was an oversight.During an interview with the Administrator on 5/14/26 at 8:15 AM she indicated all discharge MDS assessments should have been completed and transmitted timely.

Based on observation, record review, and interviews with staff, Director of Nursing, and Medical Director, the facility failed to transfer Resident #1 safely with a mechanical lift which resulted in an avoidable injury. Resident #1 had right sided hemiplegia (severe paralysis on the right side of the body) and right foot drop (difficulty lifting the front part of the right foot). While Nurse Aide (NA) #1 and NA #5 were transferring Resident #1 her paralyzed right foot got caught in the recliner footrest. emergency room X-rays results noted a closed fracture of proximal end of the right tibia (fracture of the upper shin bone, just below the knee). Resident #1 was evaluated in the emergency department where nonoperative management with a knee immobilizer was determined and a follow-up with orthopedics. The deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with a diagnosis of right sided hemiplegia and hemiparesis (one-sided muscle weakness) following a cerebrovascular accident, aphasia (communication/language disorder), osteoporosis, neuropathy, and a viral infection that significantly weakened bones.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was coded as moderately cognitively impaired, with range of motion impairment affecting one upper extremity and both lower extremities. Resident #1 was non-ambulatory and dependent on staff for transfers.A physician's order dated 9/29/2025 directed that Resident #1 be placed in a reclining chair before lunch every Tuesday and Thursday for two to three hours or as tolerated.Resident #1 had a physician's order initiated on 9/29/2025 for the as needed administration of 325 milligrams of Acetaminophen given as two tablets every two hours for general discomfort.Review of a care plan focus area initiated on 12/4/2024 revealed Resident #1 had an activity of daily living self-care performance deficit related to hemiplegia and stroke. One of the interventions under this focus area was to transfer Resident #1 with a mechanical lift.An interview was conducted with Nurse Aide (NA) #1 on 12/3/2025 at 11:37 AM. NA #1 reported she worked on the 7:00 PM to 3:00 PM shift on 11/6/2025 and was assigned to care for Resident #1. After providing morning care to Resident #1, NA #1 requested the assistance of NA #5 with transferring Resident #1 to her reclining chair with a mechanical lift. NA #1 explained she was using the controls on the lift to raise Resident #1 up in the air while NA #5 was on the other side of the resident for the purpose of guiding Resident #1 into the recliner. NA #1 further explained that as she was lowering Resident #1 down onto the recliner, they heard Resident #1 say Ouch. NA #1 said she immediately stopped the mechanical lift, and it was noted Resident #1's right foot was in between the footrest and the seat of the recliner. Resident #1's foot was removed and she was lifted back up with the mechanical lift. Resident #1 did not express any other pain or vocalizations. Resident #1 was then lowered into the recliner with her legs positioned out and a pillow put underneath her lower legs. NA #1 reported that she did not think Resident #1 was injured or hurt in any way, so she did not notify the nurse of the occurrence on 11/6/2025. NA #1 indicated she found out the next day that Resident #1 had fractured her leg, and she felt obligated to report Resident #1's foot getting caught on the previous day.Interview with NA #5 on 12/3/2025 at 3:52 PM confirmed she assisted NA #1 with the transfer on 11/6/2025. NA #5 reported Resident #1 said Ouch during the transfer, and her right foot was observed caught in the crease of the recliner. The foot was repositioned, and Resident #1 was lowered into the chair without further complaint. NA #5 stated Resident #1 appeared content for the remainder of the shift.NA #3 worked on 12/6/2025 and was assigned to care for Resident #1 during the 3:00 PM to 11:00 PM shift. Interview with NA #3 on 12/3/2025 at 2:31 PM revealed Resident #1 appeared sleepy in the recliner, and NA #2 and NA #3 assisted Resident #1 with a transfer to bed using the mechanical lift. NA #3 reported Resident #1 was lifted into the air in a sling using the mechanical lift and transferred to bed without incident. NA #3 stated that when they started to reposition Resident #1 in bed for peri-care, it was noted her right leg was swollen and red. Nurse #1 was notified. NA #3 revealed that Resident #1 was always happy and smiling and was never moaning or yelling in pain. NA #3 did not recall the exact time Resident #1 was transferred back to bed on 11/6/2025 but knew it was before the evening meal.NA #2 worked on 11/6/2025 during the 3:00 PM to 11:00 PM shift and was not assigned to care for Resident #1. Interview with NA #2 on 12/3/2025 at 1:59 PM revealed she assisted NA #3 in transferring Resident #1 from the recliner to bed on 11/6/2025 using a sling and a mechanical lift. NA #2 reported the transfer of Resident #1 to the bed occurred without incident. NA #2 reported Resident #1 made unusual moaning sounds during repositioning while on the bed, and Nurse #1 was notified. NA #2 did not recall what time Resident #1 was transferred back to bed on 11/6/2025.Review of a health status note dated 11/6/2025 at 5:47 PM, written by Nurse #1, revealed staff had transferred Resident #1 from the recliner to bed using a mechanical lift at approximately 5:00 PM. Following the transfer, Resident #1 was observed with swelling, redness, and discoloration below the right knee. Due to aphasia, Resident #1 was unable to verbalize details of the incident but was able to respond to yes/no questions. When asked if she recalled hitting her leg during transfers, Resident #1 responded No. Resident #1 exhibited pain upon palpation of the affected area, and acetaminophen was administered with relief. The physician was notified and ordered diagnostic x-rays of the right knee and tibia/fibula. The Responsible Party was informed and agreed with the treatment plan.During an interview on 12/3/2025 at 11:13 AM, Nurse #1 reported Resident #1 had been seated in her recliner near the nurses' station prior to lunch on 11/6/2025 without signs of pain or injury. Nurse #1 stated that Resident #1 was laughing, smiling, and appeared happy as she sat in her recliner that morning and early afternoon. Nurse #1 stated Resident #1 appeared uncomfortable and was transferred back to bed by Nurse Aide (NA) #2 and NA #3 after 3:00 PM. Nurse #1 did not recall the exact time Resident #1 was noted to be uncomfortable on 11/6/2025 but knew it was after the start of the 3:00 PM to 11:00 PM shift. While providing incontinence care, NA #2 and NA #3 observed redness and swelling of Resident #1's right leg below the knee and notified Nurse #1. Nurse #1 confirmed the Responsible Party was immediately notified but stated she did not know the cause of the injury at that time. Nurse #1 confirmed that the Medical Director was called and x-rays were ordered. Nurse #1 stated she administered pain medication to Resident #1 after she observed the bruising as a preventative measure in case she felt any pain.Review of a health status note dated 11/6/2025 at 9:46 PM, written by Nurse #3, revealed Resident #1's right leg was assessed to have dark purple bruising on the right shin that was tender to touch. The physician was notified and an x-ray of the right shin was ordered to rule out fracture. An ice pack was applied, and the leg was elevated to reduce swelling and for comfort.During an interview on 12/3/2025 at 1:13 PM, Nurse #3 stated the x-ray was ordered on the evening of 11/6/2025 but was not performed until the next day in the facility.Initial X-ray results which were performed at the bedside on 11/7/2025 revealed Resident #1 had acute proximal tibia and fibula head fractures. An acute proximal tibia and fibula head fractures are a break in the upper parts of the shin and calf bones, near the knee joint.Review of the November Medication Administration Record revealed Resident #1 did not receive any as needed pain medication on the 11:00 PM to 7:00 AM shift ending on 11/7/2025.Nurse #5 was assigned to care for Resident #1 on 11/7/2025 for the 7:00 AM to 3:00 PM shift. Nurse #5 was interviewed on 12/3/2025 at 4:31 PM. Nurse #5 stated she received the information in a nursing report from the night shift on 11/7/2025 that Resident #1 slept through the night and had no complaints of pain or discomfort. Nurse #5 stated that Resident #1 was always very happy and smiling. Nurse #5 explained that after the x-ray results were received on 11/7/2025, the responsible party for Resident #1 requested she be sent to the emergency room for evaluation. Nurse #5 stated Resident #1 was not in any pain or discomfort from the fracture, but she did not want anyone to touch her leg.Review of the November Medication Administration Record revealed Resident #1 received Acetaminophen on 11/7/2025 at 8:58 AM for right lower leg pain per an administration note with the same date and time. Review of a health status note dated 11/7/2025 at 2:17 PM, written by the Director of Nursing, revealed x-ray results identified proximal tibia and fibula head fractures. The Responsible Party was notified and requested transfer of Resident #1 to the emergency room for evaluation and treatment.A subsequent health status note dated 11/7/2025 at 2:19 PM documented the Responsible Party requested clarification regarding the cause of the fracture. The Director of Nursing interviewed staff who had transferred Resident #1 from bed to recliner on 11/5/2025. One aide reported Resident #1 said ouch during the transfer, and her right foot was noted to be bent in the crease of the recliner footrest. The foot was repositioned, and no further complaints were noted.Review of an emergency department encounter dated 11/7/2025 revealed Resident #1 was diagnosed with a closed fracture of proximal end of the right tibia (the upper shin bone, just below the knee, was broken). Orthopedics was consulted and after discussion with the Responsible Party the decision was made for nonoperative management with a knee immobilizer and a follow-up with orthopedics. There were no additional orders for pain medication after the emergency room visit.Review of a health status note dated 11/7/2025 at 9:56 PM documented Resident #1 returned to the facility from the emergency room with a knee immobilizer in place to the right leg, acetaminophen administered as needed for pain, and ice application for 10 to 20 minutes while awake.Review of the November Medication Administration Record revealed Resident #1 received Acetaminophen on 11/7/2025 at 8:59 PM and 11/8/2025 at 9:26 AM with effective results.Interview with the Director of Nursing on 12/3/2025 at 12:15 PM revealed she was notified of Resident #1's bruising and swelling on 11/6/2025. The Responsible Party requested clarification regarding the injury. The Director of Nursing obtained statements from staff and confirmed NA #1 and NA #5 reported Resident #1's foot had been caught in the recliner during transfer with the mechanical lift 11/6/2025 on the 7:00 AM to 3:00 PM shift. The Director of Nursing further explained that NA #1 and NA #5 verbally told her what had happened and she had them write statements. The Director of Nursing stated it was likely this incident resulted in the fracture. The Director of Nursing confirmed the nurse aides should have been watching Resident #1's extremities while moving her in the mechanical lift due to her immobility. The Director of Nursing stated that Resident #1 was always happy and had not changed from her baseline since the fracture occurred. The Director of Nursing confirmed Resident #1's foot was caught in the recliner on 11/6/2025 and not 11/5/2025.An observation and interview were conducted with the Medical Director, of Resident #1's right leg as she was lying in bed on her back in bed on 12/3/2025 at 1:21 PM. Resident #1 was smiling and acknowledged she was happy to see the Medical Director. The Medical Director stated that Resident #1 had foot drop on the right side with an inability to lift her right foot. Resident #1's right foot was observed to turn inward and down while resting in bed. In a subsequent interview in another room directly after the observation, the Medical Director revealed Resident #1's comorbidities, including osteoporosis, neuropathy and a viral infection, resulting in weakened bones and diminished pain perception. The Medical Director stated that when Resident #1's right foot was caught in the recliner, the fracture below the knee occurred due to bone fragility and neuropathy, preventing her from perceiving pain as a healthy individual would.The facility submitted the following corrective action plan on 12/3/2025 with a completion date of 11/10/2025.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 11/6/2025, Resident #1 was being transferred with a mechanical lift by NA #1 and NA #5 during the 7:00 AM to 3:00 PM shift. During the transfer, Resident #1 stated ouch. Upon assessment, NA #5 noted the resident's right foot was slightly bent in the crease of the reclining chair where the footrest extends. NA #1 and NA #5 immediately stopped the transfer and repositioned the resident's foot onto the footrest. Resident #1 denied further pain or discomfort for the remainder of the shift. During routine care on the 3:00 PM to 11:00 PM shift, NA #2 and NA #3 noted slight redness and bruising to Resident #1's right lower extremity (RLE). Nurse #1 was notified. Resident #1 was assessed by Nurse #1 and acetaminophen was administered for potential unrecognized pain. The physician was notified and ordered an X-ray. On 11/7/2025, results showed a proximal tibial head fracture. The physician and the Responsible Party were informed. The physician issued a new order to send the resident to the emergency room for evaluation and treatment. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All current residents requiring mechanical lift transfers were identified by the Director of Nursing on 11/7/2025. Skin assessments were completed on all current residents requiring mechanical lift transfers to identify any potential skin impairments or injuries by the charge nurses on 11/7/2025. No additional unknown skin impairments or injuries were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. All nursing staff working on 11/7/25 were immediately re-educated on the proper use of mechanical lifts to include being mindful of the resident's position, balance, and limbs. The re-education also included reporting incidents to licensed nursing staff. All nursing staff scheduled to work all shifts between 11/8/25 and 11/10/25 were re-educated before starting their next shift. Remaining nursing staff, including full-time, part-time, and as needed employees, received reeducation prior to their next scheduled shift. This education was provided either in person to nursing staff by the staff development coordinator or through a series of 5-part text messages sent by the Director of Nursing with a required response of receipt on 11/7/2025. The 5-part text message included a series of text messages with detailed information on the use of the mechanical lift and the importance of reporting incidents and accidents to the nurse. The nursing staff were required to reply to the 5-part text messages on mechanical lift and reporting incidents and accidents with a yes to acknowledge the information was received. The nursing staff would not be able to work until they completed the in-service training on using the mechanical lift and reporting incidents and accidents either in person or via text message. New hires will receive mechanical lift training during orientation. Annual re-education on mechanical lift safety for licensed nurses and nurse aides will occur during the Educational Fair or as needed based on audit findings or identified needs by the Staff Development Coordinator. The Staff Development Coordinator was notified of this responsibility on 11/7/2025. Nurse Aide #1 and Nurse Aide #5 involved in the transfer incident with Resident #1 completed a Mechanical Lift Competency Assessment before returning to work on their next scheduled shift by the Director of Nursing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The interdisciplinary team decided to implement the Quality Assurance and Performance Improvement (QAPI) Plan regarding mechanical lift transfers on 11/7/25. The Director of Nursing (DON) or designee will conduct random observation audits of mechanical lift transfers on all shifts and different nursing staff members: Weekly x 4 weeks, Bi-weekly x 2 months and Monthly x 1 month. Monitoring will begin the week of 11/10/2025. Findings will be documented and reviewed for trends, compliance, and opportunities for improvement. The Interdisciplinary team will follow up on the scheduled QAPI meeting 1/21/2026. The QAPI meeting will include a review of completed audits of staff interviews/observations of mechanical lift transfers to confirm staff competency and compliance. The QAPI team will decide if additional education, competencies, or continued audits are needed based on findings. Compliance date of 11/10/2025. Validation of the corrective action plan was completed on 12/3/2025. The Quality Assessment and Performance Improvement (QAPI) Plan was reviewed, each intervention had corresponding documentation to support the actions taken by the facility. Staff members were observed while demonstrating the use of mechanical lifts. Two staff members managed the lift with one operating the mechanical component and the other in front for support and positioning of the resident. Staff members checked for positioning and safety of the lift pad, positioning of the resident's body in the lift pad and functioning of the equipment. Staff members were interviewed and reported they were provided with in-service training on resident transfers with the use of a mechanical lift and reporting of incidents and accidents. The training documentation was reviewed to confirm all nursing staff were trained as of 11/10/2025. Competency assessments on using the mechanical lift were reviewed for NA #1 and NA #5 and confirmed a return demonstration was required of them. QAPI data collection forms, used for auditing proper mechanical lift transfers, were reviewed for continued compliance after 11/10/2025. The compliance date of 11/10/2025 was validated.

Based on observations, staff interviews, and record review, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents with an approved disinfectant wipe for 2 of 3 residents whose blood glucose levels were checked (Resident #36 and Resident #81). This occurred while there was a resident with known bloodborne pathogens in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. Immediate Jeopardy began on 12/13/23 when Nurse #1 was observed attempting to perform blood glucose testing for two residents on her assigned hall using a shared glucometer. Nurse #1 used a hand sanitizing wipe (intended to remove light soil and dirt from hands) to clean the shared glucometer between the two residents instead of using an EPA-approved disinfectant wipe to clean/disinfect the shared glucometer. Immediate Jeopardy was removed on 12/15/23 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility's policy entitled Obtaining a Fingerstick Glucose [Sugar] Level (not dated) included: Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. --Preparation: 1. Assemble equipment and supplies needed. Equipment and Supplies: 2. Glucose meter (glucometer) with single use safety lancet (disposable); 3. Single use alcohol swab; and 4. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). --Steps in the Procedure: 5. Place the equipment on the bedside stand or overbed table. Arrange the supplies so that they can be easily reached. 6. Wash hands; Wear clean gloves. 7. If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. 8. Obtain a blood sample by using a new disposable safety lancet with each fingerstick. Place a drop of blood on the reagent strip. 9. If bleeding persists, apply a bandage. 10. Discard lancet into sharps container. 11. Remove gloves, discard appropriately. 12. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 13. Wash hands. The manufacturer's User Guide for the glucometer used at the facility included Important Safety Instructions. These instructions noted, in part, The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The Cleaning and Disinfecting Procedures for the Meter read in part, The [Brand Name] meter should be cleaned and disinfected between each patient. A list of products approved for cleaning and disinfecting the glucometer was provided by the manufacturer. The glucometer's manufacturer also noted, Other EPA registered wipes may be used for disinfecting the [Brand Name] system, however, these wipes have not been validated and could affect the performance of your meter . Two types of disinfectant wipes were available for use at the facility to disinfect a shared glucometer: Disinfectant Wipe #1 was listed as an approved product by the manufacturer of the glucometer for cleaning/disinfecting the facility's (Brand Name) glucometer; Disinfectant Wipe #2 was not specifically listed as approved by the manufacturer of the glucometer for cleaning and disinfecting the facility's glucometers. However, Disinfectant Wipe #2 was also an EPA-registered product effective against human immunodeficiency virus (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV). The directions for use printed on the manufacturer's label of Disinfectant Wipe #2 read in part: This product kills the following viruses in 2 minutes on pre-cleaned hard, non-porous surfaces at room temperature when used as directed. Special instructions for cleaning and decontamination against HIV-1, HBV and HCV indicated, Contact Time: Allow hard, non-porous surfaces to remain wet for 2 minutes to kill HIV-1, HBV, and HCV. The facility provided a listing of the education topics provided to Nurse #1. A form signed by Nurse #1 and dated 10/4/23 acknowledged annual training was received on 26 topics. The topics included, in part: Fasting Blood Sugar Checks and Insulin; Infection Control; and Blood-Borne Pathogens. A portion of the educational material received by Nurse #1 read: Each Med [Medication] Cart should have 2 Blood Sugar Glucometers. Nurses should alternate using machines when doing Accuchecks [blood glucose checks]. Machines should be cleaned with Germicidal wipes (white top). Leave Open to air to dry, before next use. An observation was conducted on 12/13/23 at 11:55 AM as Nurse #1 collected supplies (a vial of test strips, a lancet, and an alcohol wipe) and obtained a glucometer from the medication cart in preparation to conduct a blood glucose check for Resident #36. The glucometer was not labeled with a resident's name. Nurse #1 was accompanied as she carried the glucometer and supplies down to Resident #36's room. After entering the room, the nurse put the glucometer and supplies down on a paper towel placed on the resident's bedside tray table. While wearing gloves, the nurse wiped the resident's finger with an alcohol pad, used a lancet to obtain a drop of blood from his finger and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Nurse #1 discarded the trash and lancet, then returned to the medication cart with the glucometer. The nurse was observed as she pulled a (Brand Name) Hand Sanitizing Wipe from its container placed on top of the medication cart. She used this hand sanitizing wipe to wipe off the glucometer used to test Resident #36's blood glucose level. The nurse then collected supplies from the medication cart to check another resident's blood glucose and picked up the glucometer she had just wiped off with the hand sanitizing wipe. Nurse #1 was accompanied as she walked down the hall to do the blood glucose check for Resident #81. On 12/13/23 at 12:00 PM, the nurse reached the door of Resident #81's room. At that time, the nurse was asked to stop before entering the resident's room. The nurse was questioned as to whether the wipes used to clean the shared glucometer was an appropriate disinfectant wipe. She was asked to return to the medication cart. As Nurse #1 walked back to her medication cart located next to the nurses' station, the nurse reported she typically did not use the hand sanitizing wipes to clean a glucometer. Nurse #1 held up an alcohol wipe and stated she usually used an alcohol wipe to clean the glucometer between residents. The alcohol wipe held up by the nurse was an alcohol pad used to clean a resident's finger prior to drawing blood for the blood glucose check. At that time, the nurse was informed that an alcohol wipe was not an approved disinfectant for a glucometer. Upon reaching the medication cart on 12/13/23 at 12:01 PM, Nurse #1 asked the Registered Nurse (RN) Supervisor what disinfectant wipes she should use to clean/disinfect the shared glucometer between residents. The RN Supervisor came over to the medication cart and was observed as she looked in the drawers of the medication cart to see if disinfectant wipes were on the medication cart. No disinfectant wipes were found on the medication cart. The RN Supervisor left the nurses' station to obtain approved disinfectant wipes for the glucometer. While she was gone, a container of Disinfectant Wipes #2 was located at the nurses' station. After reviewing the manufacturer's labeling and directions for use for Disinfectant Wipes #2, Nurse #1 used these wipes, per manufacturer's directions, to disinfect the shared glucometer. On 12/13/23 at 12:05 PM, an interview was conducted with Nurse #1. Upon inquiry, Nurse #1 reported she used this shared glucometer to check the blood glucose levels of residents on her assignment earlier that morning. These residents were identified by their electronic medical records (EMRs) as Resident #36, #81, #264, #70 and #90. When asked if she usually cleaned the glucometer before or after use with the alcohol wipes, the nurse stated both. Upon request as to where the shared glucometer was stored, the nurse opened the top drawer of the medication cart revealing a second glucometer placed in a plastic basket with a bottle of test strips. Nurse #1 reported both shared glucometers were stored in the basket on the medication cart when they were not in use. The nurse stated while the second glucometer also worked, she had only used the one shared glucometer earlier that morning to complete the blood glucose checks. A follow-up interview was conducted on 12/14/23 at 8:00 AM with Nurse #1. During the interview, the nurse was asked to confirm what she used to clean/disinfect the shared glucometer between residents when she checked their blood glucose levels on the morning of 12/13/23. Nurse #1 stated she used the wipes with the white top (referring to Disinfectant Wipes #2). At that time, Nurse #1 was reminded that while walking back to the medication cart after being stopped from checking Resident #81's blood glucose on 12/13/23, the nurse held up an alcohol wipe and stated she usually used an alcohol wipe to clean the shared glucometer between residents. The nurse then stated she, didn't mean those alcohol wipes. Nurse #1 added that she meant she used the germicidal wipes with the white top. When reminded there were no approved disinfectant wipes found on her medication cart, the nurse stated she used the disinfectant wipes at the nursing station on the morning of 12/13/23. The RN Supervisor returned to the medication cart at 12:10 PM with a second container of Disinfectant Wipes #2. At that time, the RN Supervisor confirmed Disinfectant Wipes #2 were the correct wipes for disinfecting the facility's glucometers. On 12/13/23 at 12:20 PM, the facility's Director of Nursing (DON) was informed of the concern related to the facility's failure to use an EPA-approved disinfectant to clean/disinfect a shared glucometer. During the interview, the DON was informed [Brand Name] Hand Sanitizing Wipes were observed to be used to clean a shared glucometer between residents, but the nurse was stopped during the observation (before the shared glucometer could be used for a second resident). The DON was also informed Nurse #1 reported she typically used an alcohol wipe (not an EPA-approved disinfection product) to clean/disinfect a shared glucometer. At that time, the DON stated the nursing staff had been educated on multiple occasions on the proper disinfection of glucometers and the appropriate disinfection product that needed to be used. She reported the facility had two appropriate products for glucometer disinfection (referring to Disinfectant Wipe #1 and Disinfectant Wipe #2). An interview was conducted on 12/13/23 at 2:10 PM with the facility's Administrator. During the interview, the Administrator reported she had been informed of the concern related to the failure of a nurse to use an EPA-approved disinfectant between residents for a shared glucometer. She stated the appropriate disinfectant wipes had been passed out after the concern related to glucometer disinfection was identified so the EPA-approved disinfectant wipes would be available on each medication cart for use. At that time, the Administrator was asked for a listing of residents in the facility who were diagnosed with a known blood borne pathogen. A review of the EMR and medical diagnoses for current residents at the facility was conducted. One resident was identified as having diagnoses which included two blood borne pathogens (HIV and acute hepatitis B). The facility's Administrator and DON were informed of the immediate jeopardy on 12/13/23 at 2:20 PM. The facility provided the following plan for IJ removal. Credible Allegation of Compliance Demonstrating Removal of Immediate Jeopardy ---Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. -It was determined that the brand named hand-sanitizing wipes were on one medication cart on December 13, 2023. -Prior to December 13, 2023, the only glucometer cleaning wipes on the medication cart were manufacturer's approved equipment germicidal wipes. -It was determined based on investigation by the DON and her designee that Nurse #1 had only used the brand named hand-sanitizing wipes to clean the glucometer before using the glucometer for Resident #36. -Nurse #1 only was assigned to conduct blood glucose checks on 5 residents (#36, #81, #264, #70 and # 90) on December 13, 2023. -However, Nurse #1 who conducted the observed blood glucose checks reported to the surveyor that she normally used an alcohol wipe to clean the shared glucometer. The alcohol pad that is used to clean a resident's finger before blood is drawn, is not a manufacturer approved equipment germicidal wipe. -Any of the 5 residents for whom Nurse #1 was assigned to conduct a blood glucose check could have been impacted by the alleged non-compliance. -The medical records for the 5 residents were reviewed by the DON and her designee on December 13, 2023. (On December 13, 2023, there were 21 residents in the entire facility who required blood glucose checks.) No other nurses had the brand named hand-sanitizing wipes on their cart, all other nurses were observed with the correct germicidal wipes on their cart. -It was determined that none of the 5 residents who could have been checked by Nurse #1 had a diagnosis of a blood-borne pathogen. The resident referenced in the immediate jeopardy template as having a blood-borne pathogen did not receive blood glucose checks. ---Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. -All 6 medication carts were checked on December 13, 2023, by DON or designee. No other medication cart was found with the brand named hand-sanitizing wipes. -DON or designee determined on December 13, 2023, that all the medication carts had manufacturer recommended germicidal wipes for cleaning the glucometer. The medication cart used by Nurse #1 did not have the recommended germicidal wipes on her cart. The DON did confirm with Nurse #1 that the germicidal wipes were within her reach at all times. -On December 13, 2023, the brand named hand-sanitizing wipes were removed from use in the facility by DON or designee. -On December 13, 2023 in-service began by DON for all nurses and med aides, including Agency staff, pertaining to use of the glucometer and cleaning the glucometer with a germicidal EPA registered disinfectant wipe. -All nurses and medication aides will be in-serviced prior to the start of their shift -No nurse or medication aide will be permitted to perform blood glucose checks or use a glucometer until they have been in-serviced. -Starting December 13, 2023 DON or her designee will monitor staff to ensure compliance until shift supervisors are trained regarding in-services and monitoring. Once trained, shift supervisors will monitor and train staff (to include agency staff) prior to their shift. -On December 13, 2023, DON notified Wake County Health department, regarding the use of brand named hand-sanitizing wipes to clean a glucometer. -On December 14, 2023, DON or designee notified Wake County Health department, regarding the potential use of an alcohol based wipe rather than a manufacturer's approved equipment germicidal wipes to clean a glucometer -On December 13, 2023, DON notified Resident #36 and their responsible parties regarding the use of brand named hand-sanitizing wipes to clean a glucometer. -On December 14, 2023, DON or her designee notified Residents #81, #264, #70 and # 90 and all 5 resident's responsible parties of the potential use of an alcohol based wipe rather than a manufacturer's approved equipment germicidal wipes to clean a glucometer. -On December 13, 2023, DON notified the physician for Resident #36 regarding the use of brand named hand-sanitizing wipes to clean a glucometer. -On December 14, 2023, DON or her designee notified the physician for Residents #81, #264, #70 and # 90 of the potential use of an alcohol based wipe rather than a manufacturer's approved equipment germicidal wipes to clean a glucometer -Physician ordered monitoring of Resident #36 for signs and symptoms of adverse reactions. The immediate jeopardy was removed on 12/15/23. The facility's credible allegation of immediate jeopardy removal was validated on 12/15/23. Documentation of the County Health Department, physician, and residents' Responsible Party notification was provided and reviewed. The validation was also evidenced by nurse observations and interviews conducted on each hallway with regards to the required infection control practices for the use of shared glucometers. All nurses who were interviewed reported they had received the required in-service training. This training included the importance of using an approved disinfectant wipe and disinfecting a shared glucometer with the proper procedures in accordance with the manufacturer's instructions for the disinfectant. Observations were conducted on each hallway as blood glucose checks were conducted and glucometers were disinfected. Multiple observations also confirmed EPA-approved disinfectant wipes were stored on each medication cart and containers of the [Brand Name] Hand Sanitizing Wipes were no longer observed on the halls or medication carts. The credible allegation was validated, and the immediate jeopardy was removed on 12/15/23.

Based on observations, resident and staff interviews, and record review, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident (Resident #44) who was observed to have medications at bedside. The findings included: Resident #44 was admitted to the facility on [DATE]. His cumulative diagnoses included diabetes and polyneuropathy (a condition where multiple nerves located outside of the brain and spinal cord are damaged), and dry eye syndrome. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment revealed Resident #44 had intact cognition. A review of Resident #44's current care plan (revised 10/4/23) revealed the resident was not care planned for the self-administration of medications. A review of the resident's electronic medical record (EMR) revealed no physician orders were received for the resident to self-administer any medications. Further review of the EMR revealed there was no documentation of a medication self-administration assessment having been completed for this resident. An observation was conducted on 12/11/23 at 9:55 AM with Resident #44 as he was lying in bed with his bedside tray table placed in front of him. At that time, a bottle of (Brand Name) 4% lidocaine cream and (Brand Name) eye drops were observed to be placed on the bedside tray table within the resident's reach. A second observation was conducted on 12/11/23 at 4:15 PM of Resident #44 as he laid in bed. The observation revealed a bottle of (Brand Name) 4% lidocaine cream and (Brand Name) eye drops remained on the resident's bedside tray table and within his reach. An observation and interview was conducted with Resident #44 on 12/12/23 at 9:35 AM. The resident was observed to be lying in his bed. He was awake and alert. The observation revealed a bottle of (Brand Name) 4% lidocaine cream, (Brand Name) eye drops, and a bottle of fungicide for nails were placed on the resident's bedside tray table in front of him and within his reach. Upon inquiry, the resident reported it was difficult for him to put the eye drops in his eyes by himself most of the time, so the nurse would occasionally come by and take care of it for him. When asked about the 4% lidocaine cream, the resident reported staff would apply this to his butt when he asked them to. Additionally, an inquiry was made regarding the bottle of fungicide for nails observed at bedside. The resident reported he used this topical treatment on his fingernails himself. Accompanied by the Registered Nurse (RN) Supervisor, an observation was conducted on 12/12/23 at 5:13 PM of Resident #44 as he laid in his bed and of the resident's medications (4% lidocaine cream, eye drops, and fungicide for nails) still placed on his bedside tray table. The RN Supervisor was observed as she asked Resident #44 if he applied these medications (meds) himself. He stated he administered both his eye drops and the lidocaine to himself once in a while. Upon leaving the room, the RN Supervisor stated she did not notice the bottle of fungicide for nails on Resident #44's bedside table so did not specifically ask about it. The RN Supervisor was accompanied as she went to the nurses' station and reviewed the resident's paper medical record. Upon review of this record, she reported Resident #44 did not have a physician's order for these medications or an order allowing the resident to self-administer them. Additionally, the RN Supervisor noted the self-administration of medications were not care planned for Resident #44 and he did not have a waiver for the self-administration of medications in his paper chart. The RN Supervisor stated, They (the medications) shouldn't be at bedside. When asked what the facility's process involved related to a resident self-administering medications, the RN Supervisor reported the resident first needed to be assessed to determine if he/she was able to self-administer the medications. Once it was determined the resident could safely administer the medications, he/she would need to sign a waiver. The facility would need to obtain a physician's order for the medications as well as the self-administration of them. Also, the self-administration of meds needed to be care planned for the resident. A follow-up interview was conducted on 12/13/23 at 9:52 AM with the RN Supervisor. During the interview, the RN Supervisor reported it was determined that Resident #44 should not self-administer the medications observed to be at bedside, so they were removed from his room. An interview was conducted on 12/14/23 at 4:47 PM with the facility's Director of Nursing (DON). During this interview, the DON reported the facility had a process that needed to be followed to be sure it was safe for a resident to self-administer his/her medications. She stated if assessment of the resident showed he/she was able to safely self-administer a medication, the facility would need to obtain a physician's order for the self-administration of medications and would need to include it in the resident's care plan. The DON also reported the facility would need to provide a lock box to securely store any medications kept in the resident's room. She reported having a discussion with Resident #44 to ensure his current needs were being met with the medications ordered. She stated the resident told her he just thought it would be nice to have the medications in case of an emergency. The DON reported Resident #44 did not mind if the medications were removed from his room.

Based on record review and staff interviews, the facility failed to maintain accurate advanced directive (code status) information throughout the medical record for 1 of 29 residents reviewed for advanced directives (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE]. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. A review of the MDS assessment revealed Resident #9 was cognitively intact. A review of Resident #9's electronic medical record (EMR) was conducted on [DATE]. The banner at the top of Resident #9's EMR page indicated the resident had an advanced directive which indicated DNR (Do Not Resuscitate). However, a review of the resident's paper medical record revealed it did not include a signed DNR advanced directive. On [DATE] at 3:10 PM, an interview was conducted with the facility's Registered Nurse (RN) Supervisor. Upon review of Resident #9's paper medical record, the RN Supervisor reported there was not a golden rod (referring to a deep yellow paper) advance directive for a DNR code status in her paper chart. She reported if a golden rod advance directive for DNR status was not in the paper chart, it indicated the resident was a full code. The RN Supervisor reported she could also look in Resident #9's EMR to find the resident's advance directive. When told the EMR indicated Resident #9 was a DNR code status, the RN Supervisor suggested talking to the facility's social worker to inquire about the advance directive. An interview was conducted on [DATE] at 3:12 PM with Social Worker #1. When asked what Resident #9's advance directive was, Social Worker #1 confirmed the resident's EMR indicated she was a DNR code status. Upon further inquiry, the social worker reported she would need to look more into the resident's advance directive. A follow-up interview was conducted with Social Worker #1 and Social Worker #2 on [DATE] at 9:33 AM. During the interview, Social Worker #2 reported Resident #9 had an advanced directive to indicate she was a full code status. He explained the resident's advance directive was changed to a full code during her last care plan meeting on [DATE]. Social Worker #2 stated the inquiry made on [DATE] prompted the social workers to speak with Resident #9 to confirm what was said in her care plan meeting. The resident confirmed she was a full code, so her code status was changed to full code in her EMR on [DATE]. When asked who was responsible to change a resident's code status in the EMR, Social Worker #2 did not indicate any one person assumed this responsibility. He stated multiple disciplines had access to change a code status in the EMR and could do so. When asked if the advance directive indicated by a resident's paper chart should accurately reflect his/her code status in the EMR, Social Worker #2 responded by saying, Of course. A follow-up interview was conducted with the RN Supervisor on [DATE] at 10:06 AM. During the interview, the RN Supervisor was informed that the concern related to Resident #9's advance directive was reported to have been resolved by the social workers on [DATE]. When the RN Supervisor was told Resident #9's advance directive status had been changed on [DATE] at a care plan meeting to full code while her EMR still indicated she was a DNR code, the nurse stated, That's a big difference. An interview was conducted with the facility's Director of Nursing (DON) on [DATE] at 1:13 PM. During the interview, the DON was asked to review Resident #9's active physician orders in her EMR. The physician orders still showed there an active physician order for DNR/DNI (Do Not Resuscitate / Do Not Intubate) with a start date of [DATE]. The DON stated she had been made aware of the discrepancy found between Resident #9's paper chart and EMR advance directives. She recalled being told the social workers changed the DNR to CPR (cardiopulmonary resuscitation) on the banner in Resident #9's EMS. However, the DON reported the social workers may not have known to discontinue the physician's active order for DNR. She stated she would take care of this. During a follow-up interview conducted on [DATE] at 4:46 PM, the DON reported she would expect a resident's EMR, paper chart, and physician's orders to accurately document the same advance directive.

Based on record review and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) database for 26 of 26 residents reviewed for resident assessment (Resident #77, #84, #21, #88, #41, #18, #24, #92, #47, #44, #56, #47, #83, #75, #95, #28, #64, #81, #65 #36, #39, #94, #74, #19, #35, and #52). Findings included: a. Resident #77 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. b. Resident #84 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/17/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. c. Resident #21 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/19/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. d. Resident #88 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. e. Resident #41 had been admitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 11/3/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. f. Resident #18 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. g. Resident #24 had been admitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/20/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. h. Resident #92 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/10/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. i. Resident #47 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/11/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. j. Resident #44 had been readmitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/17/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. k. Resident #56 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/4/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. l. Resident #17 had been readmitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/30/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. m. Resident #83 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. n. Resident #75 had been admitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/23/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. o. Resident #95 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/22/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. p. Resident #28 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/9/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. q. Resident #64 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/22/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. r. Resident #81 had been admitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/20/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. s. Resident #65 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/22/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. t. Resident #36 had been readmitted on [DATE]. Their most recent Quarterly MDS assessment dated [DATE] was signed as completed on 10/24/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. u. Resident #39 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/10/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. v. Resident #94 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/15/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. w. Resident #74 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/10/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. x. Resident #19 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. y. Resident #35 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/18/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. z. Resident #52 had been admitted on [DATE]. Their discharge MDS assessment dated [DATE] was signed as completed on 8/11/23. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 12/12/23 did not indicate this assessment had been accepted. On 12/13/23 at 8:48 AM an interview with the MDS Nurse was conducted. The MDS Nurse stated these assessments had been completed but something had happened with the transmission. She explained the facility used a vendor to transmit the MDS assessments. The vendor sends back the validation report and indicates if any of the assessments were rejected. After reviewing the validation reports, she explained that the assessments either had been rejected or had not been transmitted and should not have had the status changed in the system to accepted. On 12/13/23 at 10:15 AM an interview with the Administrator was conducted. She stated she had been unaware of the MDS transmission problems. She explained she would have to make some calls to the vendor who transmits the assessments and figure out what happened and why they were not accepted into the CMS database.

Based on observation and staff interviews, the facility failed to label and date leftover food items in two of three nourishment refrigerators (100 hall and 200 hall) and failed to store perishable items in one of three nourishment rooms located on the 300 hall. The facility also failed to allow cups and dessert bowls to air dry prior to assemblage and stacking for two of two observations. These practices had the potential to affect residents. Findings Included: 1. An observation of the nourishment room on the 200 hall was conducted on 9/13/22 at 3:46 PM, and the refrigerator/freezer were inspected. The following items were found inside the freezer without a date or label: one open half gallon vanilla ice cream container, one open half gallon strawberry ice cream container, one open container of rainbow sherbet, and a half full chocolate milkshake in a fast-food cup with lid. An observation of the 300 hall nourishment room on 9/13/22 at 3:49 PM was conducted. On either side of the sink, the following perishable items were found on the counter: half eaten delivery food order in a plastic bag to the left of the sink with a receipt dated 9/13/22 at 9:21 AM, one opened half full fruit juice can in front of the condiment shelves, and two unopened yogurts in a plastic bag warm to the touch on the right side of the sink beside the microwave. During an interview with Nurse #1 on 9/13/22 at 3:52 PM, she revealed the dietary department and nursing staff managed the 300 hall nourishment room. She stated she was not sure why the leftover food and opened can of juice was on top of the counter. Nurse #1 indicated those items should have been discarded. An observation of the 200 hall nourishment room and interview were conducted with the Certified Dietary Manager (CDM) on 9/13/22 at 3:57 PM. She confirmed the two ice cream containers, one sherbet container, and fast-food cup did not have a label or date recorded. The CDM indicated all items should have been discarded. She then removed all items from the freezer and placed them in the trash can. An observation of the 300 hall nourishment and interview with the CDM were conducted on 9/13/22 at 4:00 PM. She revealed the two yogurt containers were not from kitchen and did not have a date, so she discarded them. The leftover meal and juice can were no longer on the counter. The CDM was notified those items were in the trash can, and she stated they belonged to staff. She further stated that she usually performed sweeps of the nourishment rooms in the afternoons. An interview with the CDM and observation of the 100 hall nourishment room on 9/13/22 at 4:03 PM were conducted. The CDM stated she had already swept/checked this area. A frozen meal that contained two separate portions with one portion removed did not have a label or date on it. The CDM discarded the item. The CDM stated nourishment rooms are for resident food items only and the frozen meal should have been labeled and dated. The Administrator was interviewed on 9/16/22 at 1:56 PM. She stated nourishment rooms were used by families. Staff monitored them multiple times throughout day. The Administrator indicated staff could check on the nourishment rooms one minute and then a family could have brought in a milkshake to store. She stated the facility had an outside food policy, and labels and markers were included in those rooms, along with a poster instructed to label/date the food. The Administrator indicated not all families complied with the policy. Personal refrigerators were not allowed in resident rooms due to safety hazards, and she tried to make the facility a homelike environment. 2. An observation of the kitchen and interview with the CDM were conducted on 9/13/22 at 10:49 AM. Nine plastic cups were observed to be stacked wet and ready for use on the beverage cart in front of the tray line. The CDM stated her expectation was that all dishware was to be air dried before use. She then removed all the juice cups to be rewashed. At 10:52 AM, six additional plastic cups were found with wet nesting at another beverage cart. The CDM indicated that she was training a new employee working in the dish area that had started last week. An observation of the kitchen and interview with the CDM were conducted on 9/15/22 at 8:38 AM. On a cart to the left of the steam table, six plastic dessert containers and one ceramic dessert bowl were observed to have displayed wet nesting. The CDM indicated these items were ready to use. During a follow-up interview with the CDM on 9/16/22 at 2:50 PM, the CDM revealed the ceramic and plastic dessert containers were wet due to the condensation from the steam table. She indicated that she had witnessed during dinner meal on 9/15/22 that the dishes near the steam table developed condensation. Therefore, dishes will no longer be placed in that area to prevent development of condensation. During an interview with the Administrator on 9/16/22 at 1:56 PM, she revealed there were a lot of new staff that had been hired in the kitchen that have worked for less than a month. The Administrator stated many of the new hires were learning how to work in a health care environment and with time, they will get better and become more educated.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, the last day of the look-back period) for 12 of 40 residents reviewed for MDS (Residents #2, #19, #29, #77, #72, #40, #20, #28, #16, #47, #164 and #32). Findings included: 1. Resident #2 was admitted to facility on 3/23/22. On 9/15/22 Resident #2 ' s quarterly minimum data set (MDS) assessment with an ARD of 6/28/22 was observed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 2. Resident #19 was admitted to the facility on [DATE]. On 9/15/22 Resident #19 ' s quarterly MDS assessment with an ARD of 7/1/22 was observed as in progress and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as in progress it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 3.Resident #29 was admitted to the facility on [DATE]. On 9/15/22 Resident #29 ' s quarterly MDS assessment with an ARD of 8/2/22 was observed as in progress and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as in progress it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 4. Resident # 77 was admitted to the facility on [DATE]. On 9/15/22 Resident #77 ' s quarterly MDS assessment with an ARD of 7/11/22 was observed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 5. Resident #72 was admitted to the facility on [DATE]. On 9/15/22 Resident #72 ' s quarterly MDS assessment with an ARD of 6/29/22 was observed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 6. Resident #40 was admitted to the facility on [DATE]. On 9/15/22 Resident #40 ' s quarterly MDS with an ARD of 8/5/22 was observed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 7.Resident #20 was admitted to the facility on [DATE]. On 9/15/22 Resident #20 ' s quarterly MDS with an ARD of 7/5/22 was observed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 8. Resident # 28 was admitted to the facility on [DATE]. On 9/15/22 Resident #28 ' s quarterly MDS assessment with an ARD of 8/26/22 was observed as completed on 9/15/22. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who explained the quarterly MDS assessment was completed late. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 9. Resident #16 was admitted to the facility on [DATE]. On 9/15/22 Resident #16 ' s quarterly MDS assessment with an ARD of 6/29/22 was observed as in progress and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as in progress it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 10. Resident # 47 was admitted to the facility on [DATE]. On 9/15/22 Resident #47 ' s quarterly MDS assessment with an ARD of 6/15/22 was listed as open and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated when an MDS was listed as open it was not completed. MDS Nurse #1 explained the quarterly MDS assessment was late, she was aware of the completion date and was working on getting caught up. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 11. Resident #164 was admitted to the facility from a hospital on 5/5/21. His cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident ' s Minimum Data Set (MDS) assessments revealed an annual MDS had an Assessment Reference Date (ARD) of 4/29/22. Resident #164 ' s most recent MDS was a quarterly assessment with an ARD of 7/25/22. The quarterly MDS dated [DATE] was still open on the date of the review (9/14/22) and was not signed or dated by the Registered Nurse (RN) Assessment Coordinator to verify the assessment had been completed. An interview was conducted on 9/15/22 at 10:40 AM with MDS Nurse #1 and MDS Nurse #2. During the interview, the MDS nurses reviewed Resident #164 ' s quarterly MDS dated [DATE] and confirmed it was still open. Upon further inquiry, MDS Nurse #1 confirmed this assessment was past the required time frame for completion. During the onsite visit, MDS Nurse #1 reported they had a plan and were working towards a goal to catch up on the MDS assessments. The nurses did not provide any additional information and when asked, the nurses did not share the anticipated date of completion for this plan. After the survey, a partial plan of correction was received that did not include identified residents or a completion date. An interview was conducted on 9/15/22 at 11:25 AM with the facility's Director of Nursing (DON). During the interview, the DON stated she would expect MDS assessments to be completed in a timely manner. 12. Resident #32 was admitted to the facility from a hospital on 5/25/22. Her cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident ' s Minimum Data Set (MDS) assessments revealed an admission MDS had an Assessment Reference Date (ARD) of 5/31/22. Resident #32 ' s most recent MDS was a quarterly assessment with an ARD of 8/4/22. The quarterly MDS dated [DATE] was still open on the date of the review (9/15/22) and was not signed or dated by the Registered Nurse (RN) Assessment Coordinator to verify the assessment had been completed. An interview was conducted on 9/15/22 at 10:40 AM with MDS Nurse #1 and MDS Nurse #2. During the interview, the MDS nurses reviewed Resident #32 ' s quarterly MDS dated [DATE] and confirmed it was still open and past due. During the onsite visit, MDS Nurse #1 reported they had a plan and were working towards a goal to catch up on the MDS assessments. The nurses did not provide any additional information and when asked, the nurses did not share the anticipated date of completion for this plan. After the survey, a partial plan of correction was received that did not include identified residents or a completion date. An interview was conducted on 9/15/22 at 11:25 AM with the facility's Director of Nursing (DON). During the interview, the DON stated she would expect MDS assessments to be completed in a timely manner.

Based on observation and staff interview the facility failed to provide privacy curtains wide enough for full visual privacy around the beds in 2 of 8 rooms on the 100 Hall. (Room 104 and Room 110) The findings included: a. An observation on 9/16/22 at 10:07 AM noted that the privacy curtain for Room #108 did not go completely around bed B. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for bed A was wide enough. An interview and observation were conducted with NA #1 on 9/16/22 at 10:10 AM. NA #1 stated that because there was a window and she closed the blinds, she did not have to have a full privacy curtain. b. An observation on 9/16/22 at 10:58 AM revealed Room #110 did not have a privacy curtain that extended around bed B. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for bed A was wide enough. An interview and observation were conducted with the Maintenance Director on 09/16/22 11:14 AM. The visual privacy curtains were observed in room #104 B and room #110 B. The Maintenance Director stated upon visualization of the privacy curtains they were too short. He further stated that sometimes housekeeping put up the wrong size curtains. The Maintenance Director stated that he would notify the Housekeeping Director to have her look at all privacy curtains and have them changed. An Interview was conducted with the Administrator on 09/16/22 03:37 PM. The Administrator stated there were a lot of new staff and the facility was facing situations unseen before. She stated monitoring was constant and the housekeeping staff hung the wrong curtains.

Based on record review and staff interviews, the facility failed to complete admission Minimum Data Set (MDS) assessments for 2 residents within 14 days of admission/readmission (Resident #320 and Resident #68) and failed to complete an annual MDS assessment for 1 resident (Resident #38) within 14 days of the Assessment Reference Date (ARD, the last day of the look-back period) for 3 of 17 residents reviewed for MDS. Findings included: 1.Resident #320 was admitted to facility on 9/1/22. On 9/16/22 Resident #320 ' s admission MDS assessment with an ARD of 9/7/22 was observed as in progress and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated the admission MDS assessment dated [DATE] for Resident #320 was late and should have been completed no later than 9/14/22 and she was working on it. She explained that they have needed another MDS Nurse for several months and that was what caused the assessments to be behind. MDS Nurse#1 stated it was important to complete the required assessments timely. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She stated it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware there were assessments that were late. 2. Resident #68 was admitted to the facility on [DATE], discharged on [DATE] and reentered on 9/2/22. On 9/16/22 Resident #68 ' s admission MDS assessment with an ARD of 9/8/22 was observed as in progress, and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated the admission MDS dated [DATE] for Resident #68 was late and should have been completed. She explained that they have needed another MDS Nurse for several months and that was what caused the assessments to be behind. The MDS Nurse stated it was important to complete the required assessments timely. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She indicated that it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware that there were assessments that were late. 3. Resident #38 was admitted on [DATE]. On 9/16/22 Resident #38 ' s annual Minimum Data Set assessment with an ARD of 7/4/22 was observed as in progress and incomplete. An interview was conducted on 9/16/22 at 1:30 PM with MDS Nurse #1 who stated the admission MDS dated [DATE] for Resident #68 was late and should have been completed. She explained that they have needed another MDS Nurse for several months and that was what caused the assessments to be behind. The MDS Nurse stated it was important to complete the required assessments timely. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She indicated that it was her expectation that all MDS assessments were completed on time. The Administrator revealed it had been a challenge to keep MDS assessments up to date and she was aware that there were assessments that were late

Based on record review and staff interviews, the facility failed to complete the required Significant Change in Status Assessments (SCSA) for 1 of 17 residents (#115) reviewed for assessments. The findings included: Resident #115 was admitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #115 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required limited assistance with bed mobility. She was independent with eating, no weight loss was noted and had a current weight of 120 pounds (#). She was noted as occasionally incontinent of bladder and always continent of bowel. Care plans dated 5/27/22 noted a self-care deficit problem related to muscle weakness and unsteady gait. The goal indicated Resident #115 would show an increase in functional ADL ' s, improve balance and independence with ADL ' s. Approaches included assist with transfers, toileting, bathing and hygiene and physical and occupational therapy evaluation and treatment. Nutritional status was also addressed in the care plan with a goal: Will show no significant weight change thru next review. There was no indication that the care plan was updated and revised. Review of Resident #115 ' s 6/16/22 physical therapy discharge summary revealed she was independent with bed mobility. Review of Resident #115 ' s medical record revealed resident ' s weights were: 6/17/22-94#, 6/24/22-91#, 6/27/22-89#, 6/29/22- 86#. A progress note dated 6/28/22 indicated Resident #115 was experiencing periods of confusion and was incontinent of bowel and bladder. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursingt progress note on 7/11/22 indicated resident #115 had severe decline, was refusing medications, fluid, and food, had a change in cognition and was unable to reposition herself in bed. A death in facility MDS tracker dated 7/16/22 was observed in the record. No other MDS assessments were observed in Resident #115 ' s record. An interview with MDS Nurse #1 on 9/16/22 at 1:30 PM revealed that she was aware of the indications of when a Significant Change in Status (SCSA) MDS assessment should be completed. She stated that the SCSA should have been completed for Resident #115 when her condition declined. An interview was conducted with the Administrator on 9/16/22 at 4:24 PM. She indicated that it was her expectation that all MDS assessments were completed accurately and timely.

Based on record review and staff interviews the facility failed to develop a resident centered baseline care plan to address dementia, mobility needs and falls (Resident #320 and Resident #319) on admission for 2 of 17 residents reviewed for baseline care plans. The findings included: 1. Resident #320 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #320 ' s 9/1/22 physical therapy evaluation revealed resident presented with weakness, confusion with cognitive challenges, severe lower extremity swelling with impaired ability to stand and transfer. Physical therapy recommended the use of a gerichair (reclined lounge chair with elevated footrests) for safety. Review of Resident #320 ' s baseline care plan dated 9/2/22 did not include information about his impaired cognition or the recommended use of a gerichair. An interview conducted with the Nursing Supervisor on 9/15/22 at 4:12 PM revealed Resident #320 had dementia, required a gerichair and frequent monitoring due to high fall risk. An interview on 9/16/22 at 12:26 PM with MDS Nurse #1 revealed that the baseline care plan was initiated by the nurse on the floor within the first couple of days after admission. MDS Nurse #1 stated that she looked over the baseline care plans and updated them as needed. She further indicated that dementia, impaired cognition, falls interventions and use of gerichair should be included in the baseline care plan which is to be developed 48 hours after admission. An interview at 4:24 PM on 9/16/22 with the Administrator revealed that the baseline care plans should be developed within 48 hours, should be person centered and include areas such as falls interventions, equipment needed and dementia that are significant to each resident ' s care. 2. Resident #319 was admitted to the facility on [DATE]. Resident #319 ' s medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #319 ' s physical therapy evaluation dated 9/9/22 revealed he was a high fall risk with a recent fall with hip and rib fractures and had difficulty with bed mobility and transfers. Review of Resident #319 ' s baseline care plan dated 9/9/22 revealed the following interventions for falls/safety: evaluate cognitive status and gait steadiness, proper footwear, and ambulation device, maintain safe environment, and wander risk assessment. An observation of Resident #319 on 9/13/22 at 12:41 PM revealed resident was sitting on the edge of the bed, which was in a high position, when he suddenly got up unassisted and fell to the floor hitting his head. Fall mats were observed on the floor on the far side of the bed. Staff assessed Resident #319 for injury, assisted him in to a gerichair (reclined lounge chair with elevated footrests) and brought him to the common area for observation. An interview conducted with the nursing supervisor on 9/15/22 at 4:12 PM revealed Resident #319 was a high fall risk, should have his bed in low position, a gerichair was being used for safety and he was to be monitored frequently to prevent falls. An interview on 9/16/22 at 12:26 PM with MDS Nurse #1 revealed that the baseline care plan was initiated by the nurse on the floor within the first couple of days after admission. MDS Nurse #1 stated that she looked over the baseline care plans and updated them as needed. She further indicated that dementia, impaired cognition, falls interventions and use of gerichair should be included in the baseline care plan which is to be developed 48 hours after admission. An interview at 4:24 PM on 9/16/22 with the Administrator revealed that the baseline care plans should be developed within 48 hours, should be person centered and include areas such as falls interventions, equipment needed and dementia that are significant to each resident ' s care.

Based on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the timeframe for a [CONDITION(S)] medication (any drug that affects brain activities associated with mental processes and behavior) ordered to be given on an as needed (PRN) basis for 2 of 2 residents reviewed who received a PRN [CONDITION(S)] medication (Resident #32 and Resident #115). The findings included: 1. Resident #32 was admitted to the facility on [DATE]. Her cumulative diagnoses included non-traumatic brain dysfunction. The resident ' s most recent completed Minimum Data Set (MDS) assessment was an admission assessment dated [DATE]. At that time, Resident #32 was assessed to have intact cognitive skills for daily decision making. This MDS assessment indicated the resident received an antianxiety medication on 5 out of 7 days during the look back period. Resident #32 ' s paper medical record included physician ' s orders dated 8/22/22 for the resident to receive comfort care. An order was also received on 8/22/22 to initiate 0.5 milligrams (mg) [MEDICATION(S)] (an antianxiety medication, which is also a controlled medication) to be given by mouth every 4 hours as needed (PRN) for agitation. A review of the resident ' s electronic medical record (EMR) revealed the order for 0.5 mg [MEDICATION(S)] to be given as one tablet by mouth every 4 hours as needed was input into the computer system on 8/22/22. This order was discontinued on 8/23/22 with a new order put into the computer that read: [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg tablet. Take one tablet by mouth every 4 hours as needed. Order Date: 8/23/22; Start Date: 8/23/22. No stop or discontinue date was included in the resident ' s EMR orders or on the resident ' s August 2022 Medication Administration Record (MAR). Resident #32 ' s Controlled Medication Utilization Record (a declining inventory record) for 0.5 mg [MEDICATION(S)] documented one dose of [MEDICATION(S)] was taken from the inventory and administered to the resident on each of the following dates/times: 8/24/22 at 6:30 PM, 8/25/22 at 1:00 AM, 8/26/22 at 6:30 PM, 8/27/22 at 9:00 PM, 8/29/22 at 12:00 PM and 8/29/22 at 4:00 PM. Resident #32 ' s physician ' s orders in the EMR and the orders on the September 2022 MAR continued to read: [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg tablet. Take one tablet by mouth every 4 hours as needed. Order Date: 8/23/22; Start Date: 8/23/22. No stop or discontinue date was included with the order. The resident ' s Controlled Medication Utilization Record for 0.5 mg [MEDICATION(S)] documented one dose of [MEDICATION(S)] was taken from the inventory and administered to Resident #32 on each of the following dates/times: 9/2/22 at 6:00 PM, 9/3/22 at 6:00 PM, 9/7/22 at 7:00 PM, 9/9/22 at 7:00 PM, and 9/12/22 at 7:00 PM. An interview was conducted on 9/16/22 at 10:40 AM with Nurse #1. During the interview, Nurse #1 confirmed she had input the order for Resident #32's PRN [MEDICATION(S)] into the computer. Upon inquiry, the nurse stated she did not know that an order for PRN [MEDICATION(S)] required a stop date even if a resident was on comfort care. A follow-up interview was conducted upon Nurse #1 ' s request on 9/16/22 at 11:45 AM. The nurse reported after talking about Resident #32's PRN [MEDICATION(S)], she recalled having consulted with the Nurse Supervisor about the order. She reported the Nurse Supervisor was going to check with the Medical Doctor (MD) about the order. Nurse #1 stated at the time she put the order for PRN [MEDICATION(S)] into the computer, she did not have a stop date. The nurse reported she just found documentation in the medical records for clarification of Resident #32 ' s PRN [MEDICATION(S)] order. An M.D. (Medical Doctor) Fax Order Sheet signed and dated 9/5/22 included a hand-written notation which read, Please continue [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg po (by mouth) q (every) 4 hours prn agitation x (for) 30 days. When asked, Nurse #1 confirmed a stop date for the PRN [MEDICATION(S)] was not in the computer system at the time of the review on 9/16/22. An interview was conducted on 9/16/22 at 12:15 PM with the Nurse Supervisor. The Nurse Supervisor recalled the time when Nurse #1 discussed Resident #32 ' s PRN [MEDICATION(S)] order with her. The Supervisor reported she caught the resident ' s MD while he was in the building to complete the information for the [MEDICATION(S)] order on an M.D. Fax Order Sheet. The Supervisor stated she asked the MD, Can we extend it? She noted his response on the form but couldn't input it into the computer because her computer was down at the time. Upon further inquiry as to what she meant by extending the [MEDICATION(S)] order, the Supervisor stated she was not aware that no stop date had been put in with the initial order and thought Nurse #1 was asking if the stop date for this medication could be extended past 14 days since Resident #32 was now on comfort care. When asked, the Supervisor reiterated she thought the nurse had put in a 14-day stop date for the PRN [MEDICATION(S)] ordered. An interview was conducted with the facility's consultant pharmacist on 9/16/22 at 8:40 AM. During the interview, concern with regards to Resident #32 ' s PRN [MEDICATION(S)] being ordered without a stop date was discussed. The pharmacist reported she would expect an order written for PRN [MEDICATION(S)] to have a stop date included in the order. She reported her September visit to conduct a monthly medication regimen review for Resident #32 wasn ' t due so she had not yet had an opportunity to review this order. An interview was conducted on 9/16/22 at 10:30 AM with the facility's Director of Nursing (DON). During the interview, the DON reported she talked with the nurse who input the order for PRN [MEDICATION(S)] without a stop date and did re-educate her. The DON reported she would have expected this initial PRN [MEDICATION(S)] order to be put into the computer with a stop date of 14 days even though the resident was on comfort care measures. 2. Resident # 115 was admitted to the facility on [DATE]. Resident #115 was placed on comfort care on 6/28/22. Resident #115 ' s 5/24/22 admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and had no behaviors. Resident #115 received a [CONDITION(S)] medication, antidepressant, 6 out of 7 days during the 7-day assessment look back period. Resident #115 ' s paper medical record revealed a physician order written on 6/28/22 for [MEDICATION(S)] a [CONDITION(S)] medication classified as an antianxiety medication) 2 grams per milliliter administer 0.25 milliliters every 4 hours as needed for anxiety with no stop date indicated. Review of Resident #115 ' s paper medication administration record (MAR) for July 2022 revealed the resident received as needed doses of [MEDICATION(S)] on 7/6/22, 7/7/22, 7/8/22 and 7/16/22. An interview on 9/16/22 at 8:45 AM was conducted with the facility ' s consultant pharmacist. The pharmacist reported that she would expect an order written as needed for [MEDICATION(S)] to include a stop date not to exceed 14 days. An interview on 9/16/22 at 10:30 AM with the facility ' s Director of Nursing (DON) revealed that she would expect a PRN (as needed) order for [MEDICATION(S)] would include a stop date of 14 days.

Based on observations, staff interviews and record reviews, the facility failed to: 1) Label an opened, injectable medication with the minimum information required (including the name of the resident) stored in 1 of 2 medication storage rooms observed (Pinehurst Med Room); 2) Label medications with the date they were opened to allow the shortened expiration date to be determined in 2 of 2 medication storage rooms observed (Pinehurst Med Room and Triangle Med Room); 3) Discard expired medications stored in 1 of 2 medication storage rooms observed (Pinehurst Med Room); and 4) Store a medication in accordance with the manufacturer ' s storage instructions in 1 of 2 medication storage rooms observed (Triangle Med Room). The findings included: 1. An observation was conducted on 9/14/22 at 4:00 PM of the Pinehurst Medication Storage Room in the presence of Nurse #3. The observation revealed one - 10 milliliter (ml) opened vial of 70/30 [MEDICATION(S)] insulin was stored in the manufacturer box in the refrigerator. Neither the vial of insulin nor the manufacturer box were labeled with a resident's name. Both the vial and the box had a hand-written date on them to indicate the vial was opened on 5/2/22. The manufacturer box also had a hand-written notation on it which read, expired 5/30. Upon request, Nurse #3 confirmed that neither the insulin vial nor the box were labeled with a resident ' s name. She also acknowledged the insulin was expired at the time of the observation on 9/14/22. An interview was conducted on 9/15/22 at 11:08 AM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect a vial of insulin to be labeled with a resident ' s name if it had been pulled from the house stock. If the label had come off, she would expect the nursing staff to discard the vial of insulin and reorder it for the resident. Expired insulin needed to be discarded. 2-a. An observation was conducted on 9/14/22 at 4:00 PM of the Pinehurst Medication Storage Room in the presence of Nurse #3. The observation revealed two opened multi-dose vials of [MEDICATION(S)] PPD injectable medication (used for skin testing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither the vials nor the manufacturer boxes they were stored in were labeled as to when the vials had been opened. Upon request, Nurse #3 examined the vials and manufacturer boxes. The nurse confirmed no date was written on the vials or boxes to indicate when they had been opened. Nurse #3 reported she would discard the vials of the [MEDICATION(S)] PPD injectable medication due to not knowing when the vials had been opened. The manufacturer's storage instructions and labeling on the box for a multi-dose vial of [MEDICATION(S)] PPD injectable medication indicated that once opened the product should be discarded after 30 days. An interview was conducted on 9/15/22 at 11:08 AM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect nursing staff to write the date opened and expiration date on both the vial and box of [MEDICATION(S)] PPD as soon as the seal for the injectable medication was broken. 2-b. An observation was conducted on 9/14/22 at 3:47 PM of the Triangle Medication Storage Room in the presence of Nurse #2. The observation revealed one opened multi-dose vials of [MEDICATION(S)] PPD injectable medication (used for skin testing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither the vial nor the manufacturer box it was stored in was labeled as to when the vial had been opened. Upon request, Nurse #2 examined the vial and manufacturer box. The nurse confirmed no date was written on the vial or box to indicate when it had been opened. Nurse #2 stated, I can discard that one. The manufacturer's storage instructions and labeling on the box for a multi-dose vial of [MEDICATION(S)] PPD injectable medication indicated that once opened the product should be discarded after 30 days. An interview was conducted on 9/15/22 at 11:08 AM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect nursing staff to write the date opened and expiration date on both the vial and box of [MEDICATION(S)] PPD as soon as the seal for the injectable medication was broken. 3. An observation was conducted on 9/14/22 at 4:00 PM of the Pinehurst Medication Storage Room in the presence of Nurse #3. The observation revealed one bottle of R-[NAME] ' s Magic Mouthwash (a compounded medication) with approximately 250 milliliters (ml) remaining in the bottle was stored in the refrigerator. This medication was labeled as having been dispensed from the pharmacy for Resident #121 on 6/25/22. The expiration date written on the label was 7/8/22. Upon request, Nurse #3 examined the medication bottle and confirmed the mouthwash was expired. An interview was conducted on 9/15/22 at 11:08 AM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect expired medications to be discarded. 4. An observation was conducted on 9/14/22 at 3:47 PM of the Triangle Medication Storage Room in the presence of Nurse #2. The medication room refrigerator temperature was confirmed by Nurse #2 to be 41 degrees (o) Fahrenheit (F). The observation of the med room refrigerator revealed two bottles of 40 milligrams (mg) / 5 milliliters (ml) famotidine for oral suspension (a medication used to treat [CONDITION(S)]) dispensed by pharmacy for Resident #120 on 9/13/22 was stored in the med room refrigerator. Both bottles were reconstituted. The medication ' s package insert was included in a plastic bag with the two bottles of the famotidine suspension. The package insert provided storage instructions which indicated both the dry powder and a reconstituted suspension should be stored at 25o Celsius (C) or 77 o F with excursions permitted to 15 - 30o C or 59 - 86 o F. A review of Resident #120 ' s electronic medical record revealed he had a current order for 40 mg/5ml famotidine oral suspension to be given as 2.5 ml orally twice daily for [CONDITION(S)]. An interview was conducted on 9/15/22 at 11:08 AM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON reported she would have expected the famotidine oral suspension to have been stored on the medication cart (not in the refrigerator).

Based on observations, record review, staff and resident interviews the facility ' s Quality Assessment and Performance Improvement Committee (QAPI) failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification and complaint survey of 9/07/2018. This was for 1 recited deficiency in the area of accuracy of assessments (F-641). The deficiency was re-cited during the annual recertification and complaint survey of 9/12/2019. The continued failure of the facility during 2 federal surveys of record showed a pattern of the facility ' s inability to sustain an effective QAPI program. Findings included: This tag is cross referred to: 1. F - 641 - Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect the restorative nursing services provided for 2 of 3 sampled residents reviewed for range of motion (Resident #39 and Resident #44) and failed to reflect the discharged resident going to an assisted living facility (Resident #94). During the recertification and complaint survey of 9/20/2018 the facility was cited for failure to accurately code the MDS assessment to reflect the active [DIAGNOSES REDACTED].#18). During an interview with the Administrator on 9/12/2019 at 2:30 pm she revealed it was her expectation that MDS's would be completed withour error.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect the restorative nursing services provided for 2 of 3 sampled residents reviewed for range of motion (Resident #39 and Resident #44) and failed to reflect the discharged resident going to an assisted living facility (Resident #94). The findings included: 1) Resident #39 was admitted to the facility on [DATE] from a hospital. Her cumulative [DIAGNOSES REDACTED]. A review of the resident ' s record entitled, Restorative Care from (MONTH) 2019 was conducted. Directions for completion of the form were as follows: Use one page for each program. Document the restorative program, describe the specific problem, document the goal in measurable and quantifiable terms, and document the interventions. Record restorative minutes of service using the grid. Enter initials and signatures. Complete a weekly evaluation by documenting the resident ' s response and progress towards goals on the back. The progress notes may be written by the Restorative Aide and cosigned by the Licensed Nurse or they can be written by the Licensed Nurse. Upon review, the record indicated Resident #39 began receiving services from the restorative nursing program on 7/12/19. She received at least 15 minutes of restorative nursing services on each of the following dates during the remainder of July: 7/14/19, 7/15/19, 7/16/19, 7/18/19, 7/21/19, 7/22/19, 7/23/19, 7/24/19, 7/26/19, 7/29/19, 7/30/19, and 7/31/19. Further review of Resident #39 ' s Restorative Care records from (MONTH) 2019 included the following, in part: --Program: Bed mobility or sitting balance -Problem: Patient is at risk for decreased bed mobility and/or sitting balance if she does not perform these tasks regularly. -Goal: Patient to complete rolling side to side in bed 3 times with 5 repetitions and supine times one at stand by assist. Or, patient to complete sitting in unreclined geri-chair forward reaching with one upper extremity 5 times 10 repetitions each. -Interventions: Work with patient on rolling side to side in bed and supine with sit; or, if patient in unreclined geri-chair complete forward reaching with upper extremities. -Weekly Progress Notes were written by the Restorative Aide on 7/14/19, 7/21/19, and 7/28/19. -A Monthly Review/Nursing Evaluation was signed by the Restorative Nurse and dated 8/1/19. The review indicated the resident ' s plan of care was appropriate; no changes to the Restorative Program were recommended. --Program: Range of Motion (ROM) -Problem: Patient is at risk for decreased ROM and strength if she is not exercised regularly. -Goal: Patient will complete seated in the geri-chair or supine in bed active/active assist ROM all planes for bilateral lower extremities with 2 sets of 10 repetitions each. Active ROM means the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint. Active assisted ROM means the use of the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment. -Interventions: Patient will complete bilateral lower extremity active/active assist ROM exercise all planes 2 times 10 repetitions. -Weekly Progress Notes dated 7/14/19, 7/21/19, and 7/28/19 were written by Restorative Aide #2. A Monthly Review/Nursing Evaluation was signed by the Restorative Nurse and dated 8/1/19. The review indicated the resident ' s plan of care was appropriate; no changes to the Restorative Program were recommended. A review of Resident #39 ' s Restorative Care records from (MONTH) 2019 was also completed. These records indicated the resident continued to receive services from the restorative nursing program throughout the month. At least 15 minutes of services were documented as provided on 8/1/19 (the last day of the 7-day look back period for the most recent Minimum Data Set or MDS assessment). The resident ' s most recent Minimum Data Set (MDS) assessment was a Significant Change MDS dated [DATE]. The MDS revealed Resident #39 had intact cognitive skills for daily decision making. She required supervision for eating, extensive assistance from staff for bed mobility, locomotion on the unit, and dressing. The resident was totally dependent on staff for transfers, toileting, and personal hygiene. Section O of the MDS assessment did not indicate the resident had been involved in the facility ' s restorative nursing program within the 7-day look back period. A review of Resident #39 ' s comprehensive care plan included a Problem/Need related to her increased risk of a decrease in range of motion (Problem onset: 8/9/19). An interview was conducted on 9/11/19 at 2:35 PM with Restorative Aide (RA) #1, RA #2, and the facility ' s Restorative Nurse. During the interview, RA #2 reported Resident #39 received services from the restorative nursing program and was typically part of her assignment. She stated restorative nursing services were routinely offered 6 days a week for this resident and generally included 2 sets of 10 exercises for her upper and lower extremities either while lying in bed or sitting in a chair. An interview was conducted on 9/11/19 at 3:57 PM with MDS Nurse #2 (who was also the Restorative Nurse). During the interview, the nurse was asked to review Section O of Resident #39 ' s MDS dated [DATE]. When asked if the MDS was coded correctly to reflect the Restorative Nursing services provided for this resident, the nurse stated it was not. An interview was conducted on 9/12/19 at 8:59 AM with the facility ' s MDS Coordinator. During the interview, the MDS Coordinator reported Section O of Resident #39 ' s MDS was found to be inaccurate. She reported it was modified in accordance with the guidelines. An interview was conducted on 9/12/19 at 11:22 AM with the facility ' s Director of Nursing (DON). During the interview, the concerns identified with coding of the restorative nursing program on the MDS assessments were discussed. When asked, the DON stated her expectation was for the MDS to be accurate. 2) Resident #44 was admitted to the facility on [DATE] with reentry on 8/23/17 from a hospital. His cumulative [DIAGNOSES REDACTED]. A review of Resident #44 ' s Restorative Referral dated 7/6/18 was conducted. The resident was referred to the restorative nursing program for Range of Motion (ROM). The restorative category and services were noted to include: 1) active assist ROM (AAROM) right upper extremity, AAROM right lower extremity, and AAROM bilateral lower extremities. Active assisted ROM refers to the use of the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment; and, 2) passive ROM (PROM) left upper extremity and PROM right lower extremity. Passive ROM refers to the movement of a joint through the range of motion with no effort from the patient. Further review of Resident #44 ' s records revealed a Rehabilitation Screen dated 2/5/19 was completed. The resident was noted to be functioning at baseline. The resident ' s most recent Rehabilitation Screen was completed by a Registered Occupational Therapist (OTR) and dated 7/18/19. The screen ' s observations/concerns noted the patient was currently dependent on staff for assistance with all of his Activities of Daily Living (ADLs) and was functioning at baseline. A review of the resident ' s record entitled, Restorative Care from (MONTH) 2019 was conducted. Directions for completion of the form were as follows: Use one page for each program. Document the restorative program, describe the specific problem, document the goal in measurable and quantifiable terms, and document the interventions. Record restorative minutes of service using the grid. Enter initials and signatures. Complete a weekly evaluation by documenting the resident ' s response and progress towards goals on the back. The progress notes may be written by the Restorative Aide and cosigned by the Licensed Nurse or they can be written by the Licensed Nurse. Upon review, the records indicated Resident #44 received at least 15 minutes of restorative nursing services on each day during the month of July, with the exception of the following dates: 7/5/19, 7/6/19, 7/7/19, 7/11/19, 7/13/19, 7/14/19, 7/19/19, and 7/25/19. Further review of Resident #44 ' s Restorative Care records from (MONTH) 2019 included the following, in part: --Program: AAROM -Problem: Patient is at risk for decline in strength and contracture development. -Goal: Patient will tolerate 10 repetitions of active assist right should flexion (the bending of a limb or joint)/extension (a straightening movement that increases the angle between body parts), elbow flexion/extension, wrist finger flexion/extension. -Interventions: Right upper extremity 10 repetitions in all available planes. Right knee extension and hip flexion times 10 repetitions; PROM left upper extremity and hip flexion/abduction (the movement of a limb or other part away from the midline of the body)/adduction (the movement of a limb or other part toward the midline of the body) times 10 repetitions each. -Weekly Progress Notes dated 7/7/19, 7/14/19, 7/21/19, and 7/28/19 were written by Restorative Aide #2. The progress note dated 7/7/19 read, Resident participated 4 days of his restorative exercise 10 reps (repetitions) on PROM B (bilateral) LE (lower extremity) and UE (upper extremity) in all planes to prevent contractures. The progress note dated 7/14/19 read: Resident participated 4 days of his restorative program in PROM B (bilateral) LE and UE 10 reps in all planes to prevent contractures. The progress note dated 7/21/19 read: Resident participated 6 days of his restorative program in B (bilateral) UE and LE. PROM 10 reps in all planes to prevent contractures. The progress note dated 7/28/19 read: Resident participated 6 days of his restorative exercise in his PROM 10 reps in all planes to prevent contractures. -A Monthly Review/Nursing Evaluation was signed by the Restorative Nurse and dated 8/1/19. The review indicated the resident ' s plan of care was appropriate; no changes to the Restorative Program were recommended. The resident ' s most recent Minimum Data Set (MDS) assessment was an annual MDS dated [DATE]. The MDS revealed Resident #44 had severely impaired cognitive skills for daily decision making. He was totally dependent on staff for all of his Activities of Daily Living (ADLs). Section O of the MDS assessment reported the following restorative nursing program was performed for at least 15 minutes a day in the last 7 calendar days: active ROM on 6 out of the last 7 days. A review of Resident #44 ' s comprehensive care plan included the following area of focus, in part: --8/9/19 Restorative: ROM; the resident was at risk for a decline in strength and contracture development. (Problem onset: 8/9/19). An interview was conducted on 9/11/19 at 2:35 PM with Restorative Aide (RA) #1, RA #2, and the facility ' s Restorative Nurse. During the interview, RA #2 reported Resident #44 was typically part of her assignment. She stated restorative nursing services were routinely offered 6 days a week for this resident. Upon further inquiry, the facility ' s Restorative Nurse reported the resident received PROM for all joints in his upper and lower extremities. An interview was conducted on 9/11/19 at 3:36 PM with MDS Nurse #2 (who also served as the Restorative Nurse). During the interview, the nurse was asked to review Section O of Resident #44 ' s MDS dated [DATE]. During the interview, MDS Nurse #2 was asked if the MDS was coded correctly to reflect the Restorative Nursing services provided for this resident. Upon review of the MDS and based on the restorative program information, she reported the MDS should have been coded to indicate the resident received PROM (not AROM). An interview was conducted on 9/12/19 at 8:59 AM with the facility ' s MDS Coordinator. During the interview, questions regarding the type of services received from the restorative nursing program and coding of the MDS assessment were discussed. Accompanied by the MDS Coordinator, an interview was conducted on 9/12/19 at 9:10 AM with the OTR identified as having completed the last evaluation of Resident #44 on 7/18/19. During the interview, Resident #44 ' s Restorative Referral and Rehab Screenings were reviewed. The OTR reported the AAROM (active assisted ROM) on the initial restorative care plan was no longer appropriate. She stated the resident was only able to receive PROM services at this point in time. An interview was conducted on 9/12/19 at 11:22 AM with the facility ' s Director of Nursing (DON). During the interview, the concerns identified with the coding of restorative nursing program services on the MDS assessments were discussed. When asked, the DON stated her expectation was for the MDS to be accurate. 3. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Date Set ((MDS) dated [DATE] revealed in Section A that Resident #94 was discharged to acute hospital. Record Review on 9/11/ 2019 at 3pm revealed that Resident #94 was discharged to an Assisted Living Facility (ALF) on 7/19/2019. An interview was conducted with the MDS coordinator on 9/11/2019 at 8:30am. She reported the MDS nurses were responsible for coding all MDS assessments accurately. She reported the MDS for Resident #94 should have reflected the residents discharge to an ALF. During an interview with the Administrator on 9/12/2019 at 2:30 pm revealed it was her expectation that MDS's were completed without error.

Based on record review and staff interviews, the facility failed to completely transcribe a physician ordered medication ([MEDICATION NAME] 5 milligrams) for 1 of 6 residents (Resident #1) whose medications were reviewed. Findings included: The hospital discharge summary dated 8/29/19 read, in part, Continue these medications which have changed-[MEDICATION NAME] 10mg (milligrams)-take 3 tablets (30mg total) by mouth once daily for 2 days, then 2 tabs (tablets) (20mg) daily for 3 days, then 1 (10mg) daily for 3 days, then back to 5mg dose. Resident #1 was admitted to the facility on [DATE]. Review of a 5 day MDS (Minimum Data Set-a tool used for resident assessment) dated 9/5/19 revealed Resident #1 was cognitively intact and had adequate vision, hearing and clear speech. Limited assistance was required for all Activities of Daily Living and active [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] 10mg tabs-1 tab (10mg) was received 9/4/19, 9/5/19, and 9/6/19. No other doses of [MEDICATION NAME] were received between 9/7/19 and 9/12/19. The MAR indicated [REDACTED]. A review of hospital records dated 9/11/19 revealed Resident #1 was brought to the Emergency Department on 9/11/19 for a reported 2 day history of shortness of breath with a non-productive cough and increased generalized weakness. The hospital record revealed a physician note dated 9/11/19 which read, in part, Patient's chronic [MEDICATION NAME] was NOT continued at SNF (Skilled Nursing Facility). Resume usual dose of 5mg (milligrams). Resident #1 was not in the facility at the time of the investigation, however, an interview was conducted with a family member (FM) on 9/12/10 at 12:00PM. She stated the chronic dose of [MEDICATION NAME] was not included on the MAR indicated [REDACTED]. An interview was conducted with Nurse #3 on 9/12/19 at 12:25PM. She stated, We follow the hospital discharge summary orders until we hear otherwise from our facility doctor. MAR indicated [REDACTED]. On 9/12/19 at 12:45PM an interview was attempted with Nurse #4 who was the second verification nurse for Resident #1's (MONTH) medications. A voicemail was left, but no call was returned. An interview was conducted with the Director of Nursing on 9/12/19 at 12:55PM. She stated, The discharge summary is faxed to our pharmacy. We verify the medications with the physician and them then we fill out a physician order [REDACTED]. At the end of the month each nurse is assigned specific charts to review. They check the medication record on hand against the orders on the chart for accuracy. The medications are checked by 2 nurses for accuracy. My expectation is for them to be transcribed correctly and checked for accuracy. We are a really busy facility because we have such a high patient turnover ratio, but that's no excuse. The medications should be accurate. I don't know why the missed 5mg [MEDICATION NAME] wasn't picked up on the MAR by (Nurse #4).

Based on observations, staff interviews and record reviews, the facility failed to discard expired medications on 1 of 4 medication carts observed (PP Hall Med Cart 1); and failed to store medications as indicated by the manufacturer on 2 of 4 medication carts observed (TG Hall Med Cart 1 and TG Hall Med Cart 2). The findings included: 1-a) In the presence of Nurse #1, an observation was conducted of the PP Hall Med Cart 1 on 9/10/19 at 12:00 PM. The observation revealed an opened vial of [MEDICATION NAME] dispensed by the pharmacy on 8/6/19 and labeled for use by Resident #91 was stored on the medication cart. The insulin vial was dated as having been opened on 8/6/19; no shortened expiration date was written on the vial. At the time of the observation, Nurse #1 reported the opened vial of insulin was expired and needed to be discarded. The shortened expiration date for the opened vial of insulin was calculated to be 9/3/19. Nurse #1 stated the insulin vial should have been discarded 28 days after opening. A review of the manufacturer ' s storage instructions indicated once opened (in use), vials of [MEDICATION NAME] should be used within 28 days. A review of Resident #91's physician orders [REDACTED]. An interview was conducted on 9/12/19 at 11:15 AM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported nursing staff was expected to date insulin when it was opened and to store insulin appropriately. She acknowledged both [MEDICATION NAME] and Humalog insulins had shortened expiration dates once opened and needed to be discarded 28 days after opening. An interview was conducted on 9/12/19 at 1:25 PM with the facility ' s consultant pharmacist. During the interview, the medication storage concerns identified from observations were discussed. When asked, the pharmacist reported she would expect insulins to be dated with a shortened expiration date. She also stated [MEDICATION NAME] and Humalog insulin would need to be discarded when expired (28 days after opening). 1-b) In the presence of Nurse #1, an observation was conducted of the PP Hall Med Cart 1 on 9/10/19 at 12:00 PM. The observation revealed an opened vial of Humalog insulin dispensed by the pharmacy on 8/2/19 and labeled for use by Resident #79 was stored on the medication cart. The insulin vial was dated as having been opened on 8/4/19 with a shortened expiration date of 9/2/19 written on the vial. At the time of the observation, Nurse #1 reported the opened vial of insulin was expired and needed to be discarded. She stated the insulin vial should have been discarded 28 days after opening. A review of the manufacturer ' s storage instructions indicated opened vials of Humalog insulin should be used within 28 days. A review of the resident's physician orders [REDACTED]. An interview was conducted on 9/12/19 at 11:15 AM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported nursing staff was expected to date insulin when it was opened and to store insulin appropriately. She acknowledged both [MEDICATION NAME] and Humalog insulins had a shortened expiration date once opened and needed to be discarded 28 days after opening. An interview was conducted on 9/12/19 at 1:25 PM with the facility ' s consultant pharmacist. During the interview, the medication storage concerns identified from observations were discussed. When asked, the pharmacist reported she would expect insulins to be dated with a shortened expiration date. She also stated [MEDICATION NAME] and Humalog insulin would need to be discarded when expired (28 days after opening). 2) Accompanied by Nurse #2, an observation of the TG Hall Med Cart 1 was conducted on 9/10/19 at 12:10 PM. A bottle of 0.5% [MEDICATION NAME] ophthalmic suspension (a steroid-containing eye drop) dispensed from the pharmacy on 6/3/19 for Resident #39 was observed to be lying down on its side in the drawer of the medication cart. The position of the eye drop container in the med cart was shown to the nurse, along with the manufacturer labeling on the bottle which indicated the medication needed to be stored in an upright position. The manufacturer recommendations for storage of [MEDICATION NAME] ophthalmic suspension indicated the bottle of eye drops should be stored in the upright position. A review of Resident #39's physician orders [REDACTED]. An interview was conducted on 9/12/19 at 11:15 AM with the facility ' s Director of Nursing (DON). When asked about the storage of ophthalmic suspension eye drops, the DON stated, It should be stored in (an) upright position. An interview was conducted on 9/12/19 at 1:25 PM with the facility ' s consultant pharmacist. During the interview, the medication storage concerns identified from observations were discussed. Upon inquiry, the pharmacist reported she would expect ophthalmic suspensions to be stored in an upright position. 3) Accompanied by Nurse #3, an observation of the TG Hall Med Cart 2 was conducted on 9/10/19 at 12:13 PM. During the observation, a bottle of 0.1% fluorometholone ophthalmic suspension (a steroid-containing eye drop) was observed to be lying down on its side in a drawer of the med cart. The eye drops were dispensed from the pharmacy on 9/2/19 and labeled for Resident #25. Manufacturer labeling on the bottle of the eye drops read in part, Store in an upright position. An interview conducted with Nurse #3 at the time of the observation confirmed the eye drops were lying down on its side in the drawer of the med cart. The nurse also confirmed the instructions on the bottle of the fluorometholone eye drops (partially covered by a pharmacy sticker) indicated the container needed to be stored in an upright position. A review of the manufacturer recommendations for the storage of fluorometholone ophthalmic suspension indicated the bottle of eye drops should be stored in an upright position. A review of Resident #25's physician orders [REDACTED]. An interview was conducted on 9/12/19 at 11:15 AM with the facility ' s Director of Nursing (DON). When asked about the storage of ophthalmic suspension eye drops, the DON stated, It should be stored in (an) upright position. An interview was conducted on 9/12/19 at 1:25 PM with the facility ' s consultant pharmacist. During the interview, the medication storage concerns identified from observations were discussed. Upon inquiry, the pharmacist reported she would expect ophthalmic suspensions to be stored in an upright position.

Based on record review, observations, resident interviews, staff interviews, resident interviews and Physician's Assistant (PA) interview the facility failed to properly insert an indwelling urinary catheter for Resident #408 which resulted in excruciating pain, bleeding and trauma to the urethra and failed to keep the urinary drainage bag tubing from touching and dragging on the floor. This was evident in 2 of 3 residents reviewed for urinary catheters (Residents #408 and, Resident #4 ). Findings included: 1. Resident #408 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #408 was alert, oriented and cognitively intact with no behaviors present. The resident was noted to have an indwelling urinary catheter and required extensive assistance from staff for bed mobility and toileting. Review of the care area assessment (CAA) dated 8/30/18 for urinary incontinence/indwelling urinary catheter revealed the resident had [MEDICAL CONDITION], and [MEDICAL CONDITION]. The CAA stated the resident was admitted to the facility with a urinary catheter and had [MEDICAL CONDITION], which would be care planned. Review of the written care plan dated 8/29/18 included in part the use of a urinary catheter. The interventions included to change the urinary catheter and bag per the policy. physician's orders [REDACTED]. Laboratory work dated 8/28/18 revealed the resident INR was 2.7 and PT was 32.0 (The INR and PT values show how long it takes for blood to clot while taking [MEDICATION NAME] (an anticoagulant medication. Recommended therapeutic range for the INR after a [MEDICAL CONDITIONS] is 2 to 3. A usual PT level is 12 to 13 seconds)). A urology note dated 9/4/18 revealed Resident #408 was seen for urinary catheter removal and a voiding trial. Instructions were provided to have Resident #408 drink plenty of fluids and try to void. If Resident #408 was unable to void, the facility could insert another urinary catheter or have the resident return to the urologist office for a urinary catheter placement. As a follow up to urology's recommendation, a physician's orders [REDACTED]. Review of the laboratory results dated [DATE] revealed an elevated INR over 8.0 and PT value of 96 seconds. The physician was contacted on 9/4/18 and ordered the (3mg) [MEDICATION NAME] medication to be held, 5 mg of Vitamin K to be given (to help the blood to clot and prevent excessive bleeding), and to recheck INR and PT on 9/5/18. The INR and PT were completed on 9/5/18 and the results indicated a high INR 4.1 and PT 48. The physician was notified on 9/5/18 of the results and ordered to continue to hold [MEDICATION NAME] (3mg) medication. Per the Medication Administration Record [REDACTED]. On review of the resident's chart, there was no nursing notes regarding the insertion of the urinary catheter dated 9/5/18. Observation and interview with Resident # 408 was conducted on 9/05/18 at 9:40 AM. Resident #408 had bright red colored liquid that resembled blood in the urinary catheter's tubing. The urinary drainage bag was empty. Resident #408 stated they (referring to the nurse) put his urinary catheter back in this morning (referring to 9/5/18) and they didn't know how to do it properly. He stated it was painful and had never had blood in his urinary catheter tube before the nurse reinserted today (referring 9/5/18). Continued interview with Resident #408 who stated he was going to see the urologist today about it and was worried about the catheter. Nurse #1 was interviewed on 9/5/18 at 10:15 AM. She stated the resident went to the urologist on 9/4/18 and removed the urinary catheter. Nurse #1 stated the urologist recommended if the resident did not void the urinary catheter could be reinserted. Continued interview with Nurse #1 who indicated Resident #408 requested the catheter be reinserted. Nurse #1 stated Nurse #2 reinserted the urinary catheter around 7:00 AM on 9/5/18. Nurse #1 stated she thought the urinary catheter was bleeding from trauma. She added that the resident had been up and down a lot today to the bathroom. She stated she called urology around 9:00 AM about the status of the catheter after she noticed blood in the tube of the urinary catheter drainage bag. She stated now the resident wanted his catheter to be taken out. Nurse #1 stated Nurse #2 only told her that Resident #408 had not voided, which was why the catheter had to be replaced. Nurse #2 (who inserted the urinary catheter) was interviewed via phone on 9/5/18 at 11:47 AM. She stated the urologist stated (per note) to put the urinary catheter back in. She stated Resident #408 reported to her that he voided around 1:00 AM on 9/5/18. Continued interview with Nurse #2 revealed around 3:00 AM, the resident stated he had the urge to void but could not void. She stated between 7:00 AM and 7:30 AM on 9/5/18, she inserted the urinary catheter (during shift change) with no concerns noted. She stated the urine she got back after inserting the urinary catheter was dark yellow in color. She stated there was no resistance noted on insertion of the catheter. She also stated that she didn't see any blood or anything like that after insertion. She stated she lubricated the urinary catheter, inserted the catheter and inflated the balloon. She stated she also secured the catheter to the resident's leg. Another interview with Nurse #1 stated on 9/5/18 at 10:50 AM, the urologist was called again and was aware of the bleeding. Nurse #1 indicated the urology physician stated to her the bleeding was from trauma and not to remove the catheter as the urologist would look at it during the appointment today. Record review of the consultation note dated 9/5/18 from the PA at the urology office revealed the resident's catheter was incorrectly placed, balloon was inflated inside the urethra causing bleeding and [MEDICAL CONDITION]. The urinary catheter was removed and replaced correctly. Traumatic Foley will cause bleeding from the penis, this is expected. The note continued to say that the resident did not require a visit to the emergency room and to leave the urinary catheter in place and return to the clinic in 1 month. The Director of Nursing (DON) was interviewed on 9/5/18 at 3:17 PM. She stated the resident went to a urology today and the Physician's Assistant (PA) had written a note. She stated she called the PA and asked if the resident could have pulled the catheter out. She stated the PA stated it was a possibility but that she would not change her note to reflect that. She also added that nurse #2 knew how to insert in urinary catheter. Further interview with Nurse #1 on 9/5/18 at 3:52 PM stated that resident had a new urinary catheter inserted during the urology visit but the facility was not to remove it. She stated she did not go into Resident #408's room when the urinary catheter was reinserted by Nurse #2. The DON stated on 9/5/18 at 4:34 PM that urology took out the urinary catheter out yesterday and the resident was not able to void so they replaced the urinary catheter at the facility. She stated that was all she knew. The resident was interviewed again on 9/5/18 at 4:47 PM stated this morning he wanted the urinary catheter in. He stated Nurse #2 and himself were the only 2 people in the room when the catheter was inserted. Resident #408 stated he kept telling the nurse that it hurt too much and that it was being done incorrectly, bleeding started right away. Resident #408 stated the nurse saw it and told him that it was just from the trauma but didn't know if any urine came out after the urinary catheter was inserted. On 9/7/18 at 1:43 PM a telephone interview with the PA at the urology office stated the resident had [MEDICAL CONDITION] and the resident was unable to void after removal of the catheter so the catheter was replaced at the facility. Continued interview with the PA indicated Resident #408 was in excruciating pain and bleeding when he arrived for his appointment. The PA stated there was about 1 inch to 1.5 inches of catheter in the urethra and there was no way the catheter had been in the bladder. During this continued interview the PA stated facility called her about the note she had written, and the facility suggested that maybe the resident had pulled on the urinary catheter causing it to come out of the bladder. The PA stated Resident #408 was alert, and oriented and able to recall previous lab values. She stated it was very unlikely that the resident pulled the catheter out of the bladder as he would have had to pull very hard to get the catheter down that far into the urethra. She added that when the facility inserted urinary catheter was removed, a 10 milliliter (ml) catheter balloon was deflated, and 450 ml of urine was drained from the bladder. She stated the resident bled about 10 ml of blood and bright red urine was noted after a new catheter was inserted. This PA stated the resident could expect bleeding for 7 to 10 days, and would require the urinary catheter for a month to let the urethra heal from the trauma and was concerned because Resident #408 was on a blood thinner. The Administrator was interviewed on 9/5/18 at 4:49 PM. She stated she would expect for the nurses to stay current on their practices regarding urinary catheter care (The administrator did not clarify what she meant regarding practices.) 2. Resident #4 was readmitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve conditions. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The MDS coded Resident #4 as requiring extensive assistance from staff for toilet use and had a urinary appliance. There were with no behavioral issues coded. The Care Area Assessment (CAA) associated with the 8/27/18 MDS triggered a problem area of urinary incontinence and indwelling catheter. The notes stated resident had [MEDICAL CONDITION] due to a [MEDICAL CONDITION] bladder with issues in the past of urinary tract infections. A decision was made to develop a care plan to address the above issues. Review of the written care plan dated 8/21/18 with a target date of 11/21/18 (unclear if 11/27/18) indicated in part an approach to keep drainage bag below the bladder level and off the floor. Observation on 09/05/18 at 10:05 AM revealed the urinary catheter drainage tube was positioned directly on the floor while Resident #4 was sitting in a wheelchair at nurses' station. When the resident moved to his room the urinary tubing dragged on the floor. Observation on 09/05/18 at 10:44 AM revealed the urinary catheter drainage tube was positioned directly on the floor while sitting in a wheelchair. An attempt to interview Resident #4 was unsuccessful regarding the catheter. Observation on 09/06/18 at 12:40 PM revealed Resident #4 was sitting in a wheelchair by the nurses' desk with his urinary catheter drainage tube positioned directly on the floor. Observation on 09/06/18 at 4:00 PM revealed the urinary catheter drainage tube continued to be positioned on the floor and looped in the manner to cause the dark colored urine with a red clot to stagnate in the middle of the loop. At this time Nursing Shift Supervisor (SS) #1 observed the positioning of the tubing. Interview on 09/06/18 at 4:20 PM with Nursing Assistant (NA) #2 stated the tubing should be off the floor and the facility used a band to stabilize the catheter. Interview on 09/07/18 at 9:29 AM with the Director of Nurses stated her expectations were the urinary catheter tubing not drag or touch the floor and position the tubing, so urine would be free flowing.

Based on observation, record review, staff interviews and resident interviews the facility failed to assess the ability of a resident to self-administer medications that were kept at the bedside for 3 of 3 sampled residents (Resident #250, Resident #251 and Resident #409) reviewed for self-administration of medications. Findings included: 1.Resident #250 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The five-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #250 was cognitively intact. A review of Resident #250's care plan dated 8-27-18 revealed the resident was not care planned to self-administer medication. The physician's orders were reviewed from 8-18-18 to 9-7-18 and there were no orders noted for Resident #250 to self-administer her own medication. An observation was made on 9-4-18 at 2:15pm of 2 prescription medications left in Resident #250's room on her over the bed table. The 2 medications were; [MEDICATION NAME] 50mcg nasal spray-2 sprays each nostril daily at 9:00am, [MEDICATION NAME] 42mcg nasal spray-2 sprays each nostril three times a day 9:00am, 1:00pm and 9:00pm. During an interview with Resident #250 on 9-4-18 at 2:15pm she stated the nurse left them on her table, so she could take the medication after she ate and that the nurse would come back later in the afternoon to pick them up. The resident also stated that had been the practice since she arrived at the facility. An observation was made on 9-5-18 at 9:52am of Resident #250 having her prescription nasal sprays on her over the bed table. An interview with Nurse #4 occurred on 9-7-18 at 9:45am. The nurse stated that she did watch Resident #250 take her oral medication but that she left the prescribed nasal sprays on the residents table so she could take them when she was ready. She also stated she had watched Resident #250 use the nasal sprays in the past, so she felt comfortable that the resident could administer her own medication but denied ever seeing an assessment for the resident to ever administer her own medication. During an interview with the Director of Nursing on 9-7-18 at 9:10am she stated she expected the nurses to watch the residents take their medication and not leave the medication in the room. She also stated she expected the nurse to go back later to administer the medication if the resident requested a later time. An interview with the Administrator occurred on 9-7-18 at 2:00pm. The Administrator stated she expected the nurses not to leave medication at the resident's bed side. 2. Resident #251 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. There was no Minimum Data Set available for Resident #251. A review of the base-line care plan for Resident #251 dated 8-31-18 revealed that there were no goals for the resident to administer her own medication. The physician orders were reviewed from 8-31-18 to the last order written on 9-3-18 and there were no orders noted for Resident #251 to administer her own medication. An observation was made on 9-6-18 at 9:45am of Resident #251's prescribed [MEDICATION NAME] 50mcg nasal spray-2 sprays each nostril twice a day at 9:00am and 9:00pm sitting on her over the bed table. During an interview with Resident #251 on 9-6-18 at 9:45am she stated the nurse had left the medication ([MEDICATION NAME]) on her table, so she could take it after she ate and that the nurse usually came back later to pick it up. The resident also stated the nurse left the [MEDICATION NAME] every morning, so she could take it after she ate. During an interview with the Director of Nursing on 9-7-18 at 9:10am she stated she expected the nurses to watch the residents take their medication and not leave the medication in the room. She also stated she expected the nurse to go back later to administer the medication if the resident requested a later time. An interview with nurse #5 occurred on 9-7-18 at 9:20am. Nurse #5 stated she had left the [MEDICATION NAME] in Resident #251's room on 9-6-18 because my hands were full, and I did not remember to go back and get it. The nurse denied that she would leave any medication in a resident's room for the resident to take later. An interview with the Administrator occurred on 9-7-18 at 2:00pm. The Administrator stated she expected the nurses not to leave medication at the resident's bed side. 3. Resident #409 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's current medication list revealed an order was written on 8/23/18 for 50 micrograms (mcg) [MEDICATION NAME] metered spray (a steroidal nasal spray) with instructions to use two sprays in each nostril every day. No physician orders were noted for Resident #409 to self-administer her own medication. A review of Resident #409 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. Section G of the MDS assessment indicated she required supervision for eating, limited assistance for walking in her room and personal hygiene, and extensive assistance from staff for bed mobility, transfers, dressing, and toileting. Resident #409 was totally dependent on staff for locomotion on and off the unit. A review of the resident's care plan dated 8/31/18 was completed. The resident's care plan did not address the self-administration of medications. During a 100 Hall Medication Cart check conducted on 9/6/18 at 8:44 AM, an empty vial labeled for Resident #409 ' s [MEDICATION NAME] nasal spray was observed to be stored on the med cart. Nurse #4 was assigned to the medication cart. Upon inquiry as to why [MEDICATION NAME] nasal spray was not stored in the container, Nurse #4 stated, I have to get that back from her. When asked if the resident administered the nasal spray to herself, the nurse reported she did. An observation was made on 9/6/18 at 8:50 AM as the resident was lying on the bed in her room. A bottle of [MEDICATION NAME] nasal spray was sitting on the resident ' s tray table next to the bed. After the observation was made, Nurse #4 entered the room, took the bottle of [MEDICATION NAME] off of the tray table, and asked the resident, Are you done? The resident stated, Yes. The nurse took the [MEDICATION NAME] and exited the room. An observation and interview was conducted on 9/7/18 at 8:10 AM with Resident #409. During the interview, the resident was asked about the medication observed sitting on her tray table the previous morning. The resident stated the nurse usually left the nasal spray in her room so she could take her time to use it. An interview was conducted on 9/7/18 at 9:10 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated she expected nurses to watch the residents take their medication and not leave the medication in the room. She also stated she expected the nurse to go back later to administer the medication if the resident requested a later time. A telephone interview was conducted on 9/7/18 at 9:45 AM with Nurse #4. During the interview, the nurse was asked how she knew whether or not it was okay for Resident #409 to self-administer the [MEDICATION NAME] nasal spray. Nurse #4 stated the resident was alert and oriented times three (oriented to person, place and time). The nurse also reported having watched the resident use the nasal spray correctly in the past. An interview was conducted on 9/7/18 at 10:32 AM with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator was asked what the facility ' s process was to assess a resident ' s ability to self-administer medications. The MDS Coordinator reported the nursing staff would do an assessment in the electronic medical record, talk with the resident ' s physician, obtain an order, and care plan the resident for the self-administration of medications. Upon review of Resident #409 ' s electronic medical record, the MDS Coordinator reported there was not a Nursing Assessment for Resident #409 ' s self-administration of medication. A follow-up interview was conducted 9/7/18 at 3:45 PM with the DON. During the interview, the DON was asked what process would be implemented if a resident wished to self-administer medications. The DON responded by stating a self-administration of medication assessment would be completed and the request would be put to the interdisciplinary team for consideration. After that, the resident ' s physician approval for the self-administration of medication would need to be obtained and an order received. And finally, the self-administration of medication would need to be care planned for the resident.