Every finding on record at Ignite Medical Resort Katy, LLC

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident, for 1 of 6 residents (Resident #25) and 1 (wound care cart) of 4 carts reviewed for medication administration and storage.1. The facility failed to ensure the timely administration of physician-ordered medications for Resident #25. Eleven scheduled morning medications ordered for 07/15/2026 were not administered at their ordered times and were administered more than one hour late after nursing staff incorrectly assumed the resident was out of the facility for a medical appointment without verifying her whereabouts.2. The wound care cart had inside of its drawer the following supplies: (a) A used bottle of Hibiclens Antiseptic (substance applied to skin, to destroy or slow down the growth of germs and prevent infection). The expiration date read September 2024.(b) A bottle of curad Iodoform packing strip 1 inch x 5yard (100% antiseptic cotton gauze strips used for open wounds to help with drainage and prevent wound from closing too soon) with a expiration date that read 02-24-25.This failure had the potential to affect the therapeutic effectiveness of multiple medications, including cardiovascular, anti-infective, antianxiety, anticonvulsant, diuretic, and antiplatelet medications, and could have contributed to progression of the resident's medical conditions. Findings included:Record review of Resident #25's face sheet, dated 7/15/26, reflected a [AGE] year-old female who had been admitted on [DATE] for a short-term stay following heart surgery. Diagnoses included hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), heart disease, anxiety disorder, rheumatoid arthritis (joint damage), fibromyalgia (body pain, tiredness, trouble sleeping), and urinary tract infection (UTI).Record review of Resident #25's comprehensive care plan, dated 6/25/26, identified multiple clinical concerns, including impaired skin integrity related to a sternal incision with staples, altered respiratory status, pain, risk for falls, urinary tract infection, and the use of numerous medications, including opioid, antianxiety, antidepressant, anticonvulsant, diuretic, and antiplatelet therapies.Record review of Resident #25's Physician Orders last captured 07/15/2026, Resident #25 was receiving the following:-Fluconazole Tablet 200 MG give 1 tablet by mouth one time a day for candidiasis/UTI for 14 days with a start date of 07/11/2026 and end date of 07/25/2026.-Alprazolam Tablet 1 mg give 1 tablet by mouth two times a day for anxiety with a start date of 06/25/2026.-Gabapentin capsule 100 mg give 1 capsule by mouth two times a day for nerve pain with a start date of 06/25/2026.-Metoprolol Tartrate 25 mg give 1 tablet by mouth two times a day for hypertension with a start date of 06/30/2026.-Amiodarone HCl tablet 1 mg give 1 tablet by mouth one time a day for abnormal heart rhythm with a start date of 06/26/2026.-Amlodipine Besylate tablet 5 mg give 1 tablet by mouth one time a day for hypertension with a start date of 06/26/2026.-Aspirin Oral Tablet Chewable 81 mg give 1 tablet by mouth one time a day for anticoagulant with a start date of 06/26/2026.-Clopidogrel Bisulfate tablet 75 mg give 1 tablet by mouth one time a day for blood clot prevention with a start date of 06/26/2026.-Folic Acid Tablet 1 mg give 1 tablet by mouth one time a day for acid reflux with a start date of 06/26/2026.-Furosemide tablet 20 mg give 1 tablet by mouth one time a day for fluid retention with a start date of 06/26/2026.-Lidocare external patch for arm/neck/leg 4% apply to back topically one time a day for costal (rib) pain with a start date of 06/26/2026.Record review of the July 2026 Medication Administration Record (MAR), reviewed on 7/15/26 at 11:08 a.m., revealed that Resident #25 had not received 11 scheduled morning medications. The medications included Fluconazole for UTI/candidiasis (bacterial infection) 200 mg; Alprazolam for anxiety 1mg tablet, Gabapentin for pain 100mg, and Metoprolol for high blood pressure 25mg scheduled for 8:00 a.m.; and Amiodarone for abnormal heart rhythm 200 mg, Amlodipine Besylate for high blood pressure 5 mg, Aspirin for anticoagulant (prevent blood clot) 81 mg, Clopidogrel Bisulfate for blood clot prevention 75 mg, Folic Acid for acid reflux 1mg tablet, Furosemide for fluid retention 20 mg tablet, and Lidocare external patch 4% apply to back scheduled for 9:00 a.m.During an observation and interview with Resident #25 on 7/15/26 at 10:47 a.m., the resident stated she had not received her morning medications. She reported that she normally received her medication on time and did not know why they had not been administered that morning. At 10:52 a.m., the resident activated her call light to ask staff why she had not received her medication.During an observation and interview on 7/15/26 at 10:54 a.m., RN AM stated he did not administer the resident's morning medications because he believed she was away from the facility at an appointment. He stated he did not verify the resident's location and could not recall who informed him she was at an appointment. After the interview, RN AM obtained Resident #25's vital signs and administered the medications.During a follow-up interview on 7/15/26 at 11:13 a.m., RN AM stated the medications were administered late because he believed the resident was not in the building. He acknowledged that medications should be administered as ordered and stated he was unsure how to proceed because the resident was not in her room at the time of his med pass. During an interview on 7/15/26 at 4:40 p.m., the Director of Nursing (DON) stated RN AM confirmed that Resident #25's medications were administered late. The DON stated she counseled the nurse regarding the importance of administering medications as ordered and notified the physician of the late administration. The DON stated it was her expectation that staff follow facility policy for medication administration. She further stated delayed medication administration could place residents at risk depending on the medication involved and could contribute to progression of disease.2.Observation on 07/14/26 at 10:50AM of the facility wound care cart revealed a bottle of curad iodoform packing strip date on the bottle 02-4-25 and a bottle of used Hibiclens with expiration date of September 2024. Interview on 07/14/26 at 10:15AM with LVN AC said he worked at the facility from 7AM-7PM. LVN AC said it was the responsibility of the wound care nurse (s) to ensure there were no expired products on the wound care cart. LVN AC said the wound care nurse was at the facility earlier that morning. LVN AC said expired container of Hibiclens and iodoform packing strips could further deteriorate the resident wound placing the resident at risk for infections. Interview on 07/14/26 at 10:22AM with RN CX said she had been working at the facility full time from 7AM-7PM for 11months. RN CX said it was the responsibility of the wound care nurse for checking the wound care cart for any expired medications. RN CX said if this was not being done, it placed the resident who had wounds at risk for infections. RN CX said she was not taking care of any residents that required the treatment of Hibiclens or iodoform packing. RN CX said she understood that before providing treatment for a resident, that the nurse should be checking the expiration date first. Attempted interview on 07/14/26 at 11:10AM via phone with Wound Care Nurse A no answer, left a voicemail.Interview on 07/14/26 at 12:43PM with the DON said the wound care nurse was supposed to check the wound care cart daily for any expired wound care supplies before using the wound care cart. The DON said it was herself and the ADON that done audit random cart checks once a week looking for any expired wound care supplies, the cleanliness of the wound care cart, and organization. The DON said outdated wound care supplies left on the cart placed the resident at risk for compromised treatment and it decreased the efficacy of the treatment plan. The DON said she had not checked the wound care cart this week. The DON said the wound care nurse was LPN-ZZ. Interview on 07/14/26 at 1:04PM via phone with LPN ZZ said she had been working at the facility for 2-1/2 years and had been the wound care nurse for 1-1/2 years. LPN ZZ said she checked the wound care cart once a week and that the last time she checked the wound care cart was last week. LPN ZZ said when she last checked the wound care cart, she did not observe any outdated wound care supplies. LPN ZZ said expired wound care supplies placed the resident at risk of not receiving the intended care as ordered which could lead to infections or the wound could further deteriorate. Interview on 07/14/26 at 3:40PM with the ADON said it was the wound care nurse who was responsible for checking the wound care cart for any expired wound care supplies daily. The ADON said it was herself and the DON who were responsible for making sure that this was being done. The ADON said she had not checked the wound care cart in about 3 weeks. The ADON said expired wound care supplies left on the cart placed the resident at risk for infections. Record review of the facility's policy titled Administration of Medications last revised 04/2023, it read in part, .13.If medication is not administered, record reason on the eMAR and notify physician or nurse practitioner. 14. If the medication is given at a time different form the scheduled time, indicate the reason in the comment section of the eMAR.Record review of the facility's policy titled Physician's Orders last revised or reviewed 05/2023, it read in part, .Policy:All medications will be administered as ordered by a health care professional authorized by the state to order medications.Procedure: All medications administered to residents at Ignite Medical Resorts will be ordered by health care professionals who have the authority to order medications under state law. Orders for medications will include:oName and strength of the medicationoDosage and frequency of administrationoRoute of administrationoDuration of administration if applicable.The policy for medication storage was requested from the Administrator on 07/14/26 via email at 2:27PM and again verbally on 07/14/26 at 4:45PM. The Administrator said he was unable to locate this policy and would continue to search for policy on medication storage. The Administrator did not provide policy on medication storage.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition service. 1. There was a metal bowl of lemon that was not fully covered in the fridge and a bottle of cranberry juice that was not labelled after opening observed 07/13/2026. 2. [NAME] G did not follow infection control protocols when measuring food temperature when she wiped her nose without changing gloves and changed her gloves without washing her hands in between until surveyor intervention. 3.Cook G did not use alcohol wipes to clean the thermometer in between testing food temperature. These failures could place residents at risk of foodborne illness and disease. Findings included: During an observation and interview on 07/13/2026 at 8:45a.m., there was a metal bowl of about 15 cut lemon wedges in a metal bowl with the plastic wrap pulled off with about a quarter of the lemons exposed to the air. There was a bottle of cranberry blend juice that was opened and not labeled. The DM said staff were in the process of putting items used away from that morning but that it should have been labelled after opening. The DM went outside and used the label machine to print out a label for the bottle. The DM said new staff had two weeks of training with the front desk, and then she would train them on cooking and contamination prevention in the kitchen. In an interview with the DON and Administrator on 07/14/2026 at 5:33p.m, the Administrator said that labeling food items was to keep food from being spoiled, and if foods were not labelled, staff could potentially serve something expired. The Administrator said the DM was responsible for labeling and storage in the kitchen. During an observation on 07/15/2026 at 11:40a.m., [NAME] G was standing at the hot plate station with black gloves on. An unknown staff member said something to [NAME] G, and she went to get two cups, one with water and one filled with ice. She used the thermometer to measure the cauliflower temperature, then dipped the thermometer in water and ice. She went to get a paper towel from the dispenser behind her and wiped the thermometer clean and then used the thermometer in the rice. She continued to use this method to clean the thermometer. [NAME] G changed her gloves in between the gravy and pureed beef and only washed her hands after the RD instructed her to do so. [NAME] G measured the puree mashed potatoes and wiped her nose with the back her gloved left hand. After surveyor intervention, she took off her gloves, threw them away, washed with soap and dried her hands, and then put on new gloves. The RD asked [NAME] G and the DM if the facility had alcohol wipes and the DM responded that the kitchen ran out and they did not have any onsite. In an interview with [NAME] G on 07/15/2026 at 12:56p.m., she said the kitchen ran out of the alcohol wipes earlier in the week, and she was using water and towels to wipe the thermometer. [NAME] G said not using alcohol wipes could put residents at risk of food contamination and in general making the food dirty. [NAME] G said she knew that she was supposed to wash or sanitize her hands in between changing gloves, but she got nervous and it was her fault. She stated, not sanitizing her hands between gloves and after wiping her nose with her hands, could cause contamination. [NAME] G said her last in-service on hygiene was three weeks ago. In an interview with the RD on 07/15/2026 at 1:50p.m., she said [NAME] G did change her gloves after the RD intervened. The RD did not answer what harm could come to residents if staff did not sanitize their hands in between glove changes, or if they wiped their nose on their glove, and did not change gloves. The RD said alcohol wipes were standard practice to sanitize the thermometer, and if the kitchen did not have wipes, they could have used sanitizer on the thermometer. Not practicing food hygiene could cause cross-contamination. The RD said items should have been labelled after opening. In an interview with the DON on 07/15/2026 at 2:02p.m., she said alcohol wipes were used between food temperature checks with the thermometer to prevent cross-contamination. The DON was not told that alcohol wipes were out and would deliver wipes from the nursing side to the kitchen immediately. The DON said washing hands before changing gloves was to avoid contamination, but since the cook did not touch the food with contaminated gloves, then there was no harm done. In an interview with the DM on 07/15/2026 at 2:27p.m., she said that she ran out of wipes on 07/13/2026, and had ordered more which would have been delivered on 07/17/2026. She did not know where else she could order. The DM said the DON gave her some and she did not know she could ask nursing for alcohol wipes. The DM said in the meantime staff could wash the thermometer under running water and use a paper towel to wipe the thermometer. The DM saw [NAME] G wipe her nose before measuring food temperatures. The DM said she constantly in-serviced staff to wash hands or sanitize hands between changing gloves and to avoid touching their face, ear and avoid wiping sweat while on the line, meaning being at the food station. The DM said not following the infection control protocols could lead to contamination. In an interview with the Administrator on 07/15/2026 at 3:27p.m., he said the kitchen needed to have alcohol wipes to prevent cross-contamination between temperature readings. The Administrator said there was nothing wrong with the cook not washing her hands in between glove changes since there was someone there instructing her since the problem was caught before it was too late, but he would ensure the kitchen did additional training so that staff were prepared for food temperature checks even if there was an RD there or not. Record review of the facility's policy titled Frozen Foods last revised in 2017, read in part, .Appropriate storage procedures are followed: -If taken out of original container, food is tightly wrapped and labeled with the name of the item and the use by date. Opened products that have not been properly sealed and dated are discarded. Record review of the facility's policy titled Correct Use of Thermometer last revised or reviewed 05/2026, it read in part, Procedure: Food temperatures will be taken using a sanitized stem type thermometer.[NAME] test the temperature of a hot food before serving, insert the thermometer into the middle of the food item. Wait for the thermometer to record the maximum temperature. Read the temperature and remove thermometer from food item and immediately wipe and sanitize with alcohol wipe. Record review of the facility's policy titled Hand Hygiene last revised or reviewed April 2023, it read in part, .Hand-washing may also be used for routinely decontaminating hands in the following clinical situations: After removing gloves. Indications for Alcohol-Based Hand Rub (ABHR) o If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situations: . After removing gloves.Before and after food preparation. Gloves and Hand-Hygiene o Gloves reduce hand contamination by 70 - 80 percent, prevent cross-contamination and protect residents and health care personnel from infection understand-ing that the use of gloves does not eliminate the need for hand hygiene: o Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. o Decontaminate hands after removing gloves by appropriate hand hygiene.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 of 6 (Resident #25) reviewed for resident rights. -The facility failed to ensure a drop of blood was promptly cleaned up from the floor of Resident #25's room on 7/13/25. This failure placed residents, staff, and visitors at risk for potential exposure to bloodborne pathogens and cross-contamination. Findings included: Record review of Resident #25's face sheet, dated 7/15/26, reflected a [AGE] year-old female who had been admitted on [DATE] for a short-term stay following heart surgery. Diagnoses included hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), heart disease, anxiety disorder, rheumatoid arthritis (joint damage), fibromyalgia (body pain, tiredness, trouble sleeping), and urinary tract infection (UTI). Record review of Resident #25's care plan last captured 07/15/2026, she was on EBP related to a surgical incision with staples to sternum (chest) with interventions including provide EBP as indicated. During an observation and interview with Resident #25 on 7/13/26 at 11:11 a.m., a drop of what appeared to be blood was observed on the floor along the pathway between the bathroom and the bed. Resident #25 stated, The blood leaked from between my legs when I was walking from the bathroom. I tried to clean it up, but I couldn't bend over. Resident #25 reported the bleeding had occurred earlier that morning when she first woke up. The blood remained on the floor at the time of the observation. During an interview with RN CX and Resident #25 on 7/13/26 at 11:25 a.m., RN CX stated the spot on the floor had been thought to be ketchup when surveyor pointed it out. Resident #25 stated she had not eaten ketchup that morning and reported the substance on the floor was blood that had dripped while she was walking from the bathroom. RN CX stated she had been unaware Resident #25 was bleeding and reported the blood would be cleaned from the floor. During an interview with the Administrator and Director of Nursing (DON) on 7/14/26 at 5:00 p.m., the Administrator stated staff were expected to clean blood once it had been identified. He stated certified nursing assistants (CNAs) completed rounds every two hours to check on residents and observe the environment. The DON stated the presence of blood on the floor presented an infection control risk. During an interview with the Administrator on 7/15/26 at 8:25 a.m., he stated he had spoken with RN CX regarding the blood on the floor in Resident #25's room. According to the Administrator, RN CX stated it had appeared to be only a dot on the floor. The Administrator asked whether the finding would result in an infection control citation. During a follow-up interview with Resident #25 on 7/15/26 at 10:47 a.m., she stated that on the morning of 7/13/26, after using the restroom, she had noticed blood when wiping herself. She stated blood had dripped onto the floor as she walked from the bathroom to her chair. Resident #25 said she went to therapy some time after exiting the restroom and when she came back, a female nurse did enter her room but she could not remember the nurse's name. Resident #25 reported she had informed a nurse and believed the bleeding was related to her urinary tract infection. She stated a nurse came to assess her after the surveyor notified staff that blood was present on the floor. During an interview with Housekeeper BG on 7/15/26 at 2:55 p.m., conducted through translation services, Housekeeper BG stated her responsibilities included cleaning the facility and resident rooms twice daily. She stated if blood was observed on the floor, her supervisor would be notified for guidance. Housekeeper BG reported she knew how to properly clean blood but could not recall when training related to maintaining a clean and sanitary environment had last been received. During a follow-up interview with the Administrator on 7/15/26 at 3:30 p.m., he stated the drop of blood could have been missed because it was only a small dot located away from the resident and, in his opinion, would not have harmed other residents. When asked whether the blood could have been tracked outside the room, no response was provided. Record review of the facility's policy approved 9/2022, it read in part, .Cleaning and Disinfection -Routine cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, resident rooms.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a residents' medical, nursing, and mental and psychosocial needs, that were identified in the comprehensive assessment for 1of 8 residents (Resident #14) reviewed for care plans.The facility failed to develop a care plan to address Resident #14 having continuous oxygen via canula on 7/13/26.This failure could place residents at risk for confusion, oxygen toxicity or carbon dioxide buildup, and unwanted hospitalization. Record review of Resident #14's face sheet, dated 07/13/2026 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #14's diagnoses included atrial fibrillation( irregular heart beat), atherosclerotic ( buildup of fatty deposits, cholesterol and other substances ( called plaque) inside the artery wall, heart disease of native coronary artery without angina pectoris(chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood), type 2 diabetes mellitus (too much sugar in the blood), fracture of unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing, pressure ulcer of left ankle, stage 4,( multiple ligaments and three sides of the ankle bone are broken or tone, completely destroying the ankle joint's stability) muscle wasting and atrophy, not elsewhere classified, unspecified site other abnormalities of gait and mobility, other lack of coordination. Record review of Resident #14's admission MDS, dated [DATE], reflected that the resident had a BIMS score of 10, which indicated that the resident's cognition was moderately impaired. Record review of Resident #14's Physician orders reflected the following order Summary dated 6/11/26:admission Protocol: may administer supplemental oxygen as needed. BP/Pulse/Resp/Temp/02 Sats every shift for BP/Pulse/Resp/Temp/02 Sats. Record review of Resident #14's care plan, dated 06/14/2026, reflected that the resident was not care-planned for continuous oxygen.Observation on 07/13/2026 at 8:14 AM, revealed Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Observation on 7/14/26 at 8:30 AM, revealed Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Observation on 7/15/26 at 9:30 AM, 10:30 AM, 11:30 AM, revealed Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Interview with Resident #14 on 7/13/26 at 8:40AM, he said he was admitted with oxygen from the hospital on 6/11/26. He has been on oxygen it continuously since then. Resident #14 said, he was not sure why he was on oxygen but I felt good . Interview on 07/15/2026 at 1:04 PM with LVN AP regarding Resident #14's continuous oxygen, LVN AP said, Resident #14 should not be given continuous oxygen if there was not doctor's order. LVN AP said she would have to check oxygen order for Resident #14's parameters. LVN AP said she knew that giving oxygen without the parameters from the doctor's could lead to confusion and not following the facility policy.Interview on 07/15/2026 at 4:42 PM, LVN AP MDS nurse said it must have been an oversight on her part why Resident #14 was not care planned for continuous oxygen. LVN AP MDS nurse said the purpose for care planning Resident #14 for oxygen was to identify any care issues, possible outcomes, monitor for signs and symptoms of complications, and report to the physician. LVN AP said she does a quick check and see how often residents with prn oxygen on admission and if Resident #14 didn't have oxygen at home or don't have a diagnosis requiring oxygen, she would start weaning resident off oxygen. LVN AP said she was told there was no continuous oxygen order. Resident #14 was using oxygen from the hospital, and she thought they were going to wean him off while in the facility. LVN AP said Resident #14 was continually wearing the oxygen when she walked by his room. She thought the facility would titrate oxygen, that's what they normally do. She doesn't look at every single resident on O2. LVN AP said she depend on IDT team, therapy and DON to jump in and ensure whether resident needs O2 or not and get a diagnosis if needed. LVN AP said, Resident #14 could be getting too much oxygen in the brain and brain when controlled by oxygen can't breathe without it. The MDS nurse said it was the DON that ultimately ensured that the care plans were being done accurately.Interview with the DON on 7/15/26 at 5:00PM after reviewing Resident #14 care plan, said she would have to ask the MDS nurse why the resident was not being care planned for continuous oxygen.Record review of the facility's policy on Care Plans, revised 04/2024. General: Each resident will have a care plan that is current, individualized and consistent with their medical regimen. Policy: reflected in part . 3.The comprehensive care plan is develop within 7 days of CAA completion. A member of the IDT will provide the resident and or representative with a summary of the baseline care plan or a copy of the baseline care plan in writing in a language that can be understood and verbally in a language that can be understood.Record review of the facility's policy on Administration of oxygen, not dated. Policy: This facility provides oxygen therapy for every user if prescribed by the resident's attending physician. Oxygen therapy will be administered or supervised by suitably qualified staff.

Based on observation, interview, and record review the facility failed to ensure that residents had diagnoses, receive treatment and care in accordance with professional standards of practice and the residents' choices for 2 of 5 residents (Resident #14 and Resident #74) reviewed for quality of care. The facility failed to ensure that Resident #14 had diagnosis for oxygen use, received treatment and care in accordance with professional standards of practice. The facility failed to ensure Resident #74 had diagnosis for the use of indwelling Foley catheter ((tubing inserted into the bladder to drain urine). This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Record review of Resident #14's face sheet, dated 07/13/2026 revealed a 89 -year- old male admitted to the facility on [DATE]. Resident #14 diagnoses included atrial fibrillation( irregular heart beat), atherosclerotic ( buildup of fatty deposits, cholesterol and other substances ( called plaque) inside the artery wall, heart disease of native coronary artery without angina pectoris(chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood), type 2 diabetes mellitus (too much sugar in the blood), fracture of unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing, pressure ulcer of left ankle, stage 4,( multiple ligaments and three sides of the ankle bone are broken or tone, completely destroying the ankle joint's stability) muscle wasting and atrophy, not elsewhere classified, unspecified site other abnormalities of gait and mobility, other lack of coordination. Record review of Resident #14 admission MDS, dated [DATE], reflected that the resident had a BIMS score of 10, which indicated that the resident's cognition was moderately impaired. Record review of Resident #14's Physician orders reflected the following order Summary dated 6/11/26:admission Protocol: may administer supplemental oxygen as needed. BP/Pulse/Resp/Temp/02 Sats every shift for BP/Pulse/Resp/Temp/02 Sats. Record review of Resident #14 care plan, dated 06/14/2026, reflected that the resident was not care plan for continuous oxygen.Observation on 07/13/2026 at 8:14 AM, throughout the day Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Observation on 7/14/26 at 8:30 AM, throughout the day Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Observation on 7/15/26 at 9:30 AM, 10:30 AM, 11:30 AM, Resident #14 was resting in bed with continuous oxygen at 4L/min via nasal canula.Interview with Resident #14 on 7/13/26 at 8:40AM, he said he was admitted with oxygen from the hospital on 6/11/26, he has been on oxygen it continuously since then, Resident #14 said, he was not sure why he was on oxygen but I felt good Interview on 07/15/2026 at 4:42 PM, LVN AP MDS nurse said it must have been an oversight on her part why Resident #14 was not care plan for continuous oxygen. LVN AP MDS nurse said the purpose for care planning Resident #14 for oxygen was to identify any care issues, possible outcomes, monitor for signs and symptoms of complications, report to the physician. Resident #14 was using oxygen from hospital, and she thought they were going to wean him off while in the facility. LVN AP said Resident #14 was continually wearing the oxygen when she walked by his room. She thought the facility would titrate oxygen, that's what they normally do. She doesn't look at every single resident on O2 (Oxygen). LVN AP said she depends on IDT team, therapy and DON to jump in and ensure resident needs O2 or not and get a diagnosis if needed.Interview with the DON on 7/15/26 at 5:00PM after reviewing Resident #14 admission diagnoses and care plan, the DON said she would have to ask the MDS nurse why the resident was not being care planned for continuous oxygen and why there was no diagnosis for the use of oxygen. The DON said that she was going to notify the doctor and start weaning Resident #14 off oxygen use. The DON said the risk using continuous oxygen could be nasal dryness, nosebleeds and oxygen toxicity. Record review of Resident #74's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, hyperlipidemia (high fat blood), type 2 diabetes mellitus with hyperglycemia ( when body does not produce enough insulin to correct sugar built up in the blood), cardiogenic shock(a life-threatening medical emergency where your heart is suddenly too weak to pump enough blood to supply your body's vital organs, like your brain and kidney), essential (primary) hypertension(, muscle wasting and atrophy,( shrinkage or wasting away of a body part, tissue or organ muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination.Record review of Resident #74's admission MDS, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated the resident's cognition was moderately impaired. Resident #74's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #74's urinary continence was not rated due to indwelling catheter. Record review of Resident #74's care plan, dated 07/07/2026, revealed:Focus: Resident #74 admitted with an indwelling foley catheter with no diagnosis. Goal: The resident will be and remain free from catheter-related trauma through the review date;Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds; Monitor and document for pain or discomfort due to the catheter.Observation on 07/14/2026 at 3:00 PM during catheter care revealed Resident #74 sitting in her wheelchair by her bed side, by CNA AV before transferring to bed revealed her foley catheter tubing had blood thin urine with no leg strap securing the catheter.Interview on 07/14/2026 at 4:35 PM, the ADON stated the CNA AV just reported to her Resident 74 did not have the catheter leg strap on, but they were getting one for her now. The ADON, RN stated she was not aware that Resident #14 did not have diagnoses for the use of indwelling catheter. The ADON did not know why Resident #74 had blood thin urine. The ADON stated the catheter strap was important because there was a risk of the catheter pulling, moving, and hurting the resident. The ADON said using indwelling catheter could cause UTI.Interview and observation on 07/15/2026 at 5:06 PM, the DON stated her expectations for catheters were to be secured with leg strap. She stated the risk was the catheter could pull and cause trauma. The DON said she was not aware of Resident #74 not having diagnoses for the use of F/C. The DON then checked the hospital without any diagnoses for used of indwelling F/C. The DON called the prescriber on 7/15/26 at 5:35 PM and added diagnosis of Urine Retention.

Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #74) reviewed for incontinent care. -The facility failed to ensure Resident #74's Foley catheter tubing (tubing inserted into the bladder to drain urine) was secured to her leg to prevent stress or pulling on the catheter site on 7/14/26.-The facility failed to ensure CNA AV followed proper infection control procedure by preventing Resident # 74's Foley bag and tubing from touching the floor and following proper PPE use and hygiene after providing incontinent care.-The facility failed to ensure the ADON followed proper use of PPE and infection control procedure while checking Resident #74's F/C on 7/13/26.These failures could place residents at risk for pain, infection, injury and hospitalization. Record review of Resident #74's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, hyperlipidemia (high fat blood), type 2 diabetes mellitus with hyperglycemia ( when body does not produce enough insulin to correct sugar built up in the blood), cardiogenic shock(a life-threatening medical emergency where your heart is suddenly too weak to pump enough blood to supply your body's vital organs, like your brain and kidney), essential (primary) hypertension(, muscle wasting and atrophy,( shrinkage or wasting away of a body part, tissue or organ muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination.Record review of Resident #74's admission MDS, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated the resident's cognition was moderately impaired. Resident #74's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #74's urinary continence was not rated due to indwelling catheter. Record review of Resident #74's care plan, dated 07/07/2026, revealed:Focus: Resident #74 admitted with an indwelling foley catheter with no diagnosis. Goal: The resident will be and remain free from catheter-related trauma through the review date.Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds; Monitor and document for pain or discomfort due to the catheter.Observation on 07/14/2026 at 3:00 PM during catheter care for Resident #74 sitting in her wheelchair by her bed side, by CNA AV before transferring to bed revealed her foley catheter tubing, bag and blood thin urine under her wheelchair not secured in place with a leg strap. Foley bag and the tube were touching the floor. CNA AV washed her hands, donned clean gloves, and undid Resident #74's brief that was soiled with a large bowel movement. CNA AV used wet wipes to clean perineal area 4 times, doff gloves and did not wash hands or use hand sanitizer 4 times before donning clean gloves. C NA AV did not open labia to clean F/C tubing from insertion site, C NA AV cleaned F/C tubing outside the insertion site, she position Resident #74 to her left side, then cleaned her buttocks 3 times, doff gloves each time without washing hands or using hand sanitizer 3 times before donning clean gloves. C NA AV used the soiled gloved hands picked up a clean brief and placed it under resident and fastened it. Cover the Resident #74 with clean linen and open resident #14 door and to the soiled utility room.Interview on 07/14/2026 at 4:20 PM, CNA AV stated Resident #74 did not have a leg strap on during the catheter care. CNA AV stated the resident was supposed to have a leg strap on to secure the tubing. CNA AV stated the risk of the resident not having a leg strap was the catheter will move and pull on the resident. The CNA AV stated the nurse was the one responsible for making sure there was a leg strap on the resident. CNA AV stated she will notify the nurse right now. CNA AV stated she was not sure why she was not wearing one. CNA AV revealed she was nervous and forgot to don PPE and wash hands during incontinent/catheter care. CNA AV said donning PPE and washing hands should be done each time to prevent cross-contamination.Interview and observation on 07/14/2026 at 4:35 PM, the ADON came in Resident #14's room, donned clean gloves and touched F/C without donning PPE. The ADON stated CNA AV just reported to her Resident #74 did not have the catheter leg strap on, but they were getting one for her now. The ADON stated she was not sure why the resident's catheter was not secured with a leg strap and why Resident #74 had blood-tinged urine. The ADON stated the catheter strap was important because there was a risk of the catheter pulling, moving, and hurting the resident. The ADON said she forgot to don PPE. Interview on 07/14/2023 at 5:06 PM, the DON stated her expectations for catheters were to be secured with leg strap. She stated the risk was the catheter could pull and cause trauma. The DON stated it was the responsibility of both the CNA and the nurse to put on the leg strap. The DON stated the CNAs do catheter care, if they see there was no strap they should put it on. The nursing staff should ensure Resident #74's Foley was not touching the floor to prevent the bag and the tube from being contaminated with germs which could travel Resident #74 bladder, and the resident would get an infection (UTI). She said the nurse monitored the aides and should ensure Resident #74's Foley bag and tube were off the floor. She stated the nurse was also responsible for ensuring there was a strap. The DON stated the Plan was to in-service to make sure the CNAs know they can also replace the leg strap. The DON stated her expectations for the ADON and CNA AV to don PPE. She stated washing hands and donning clean gloves should be done each time to prevent cross-contamination. She stated CNA AV was checked off on Foley care and the ADON was an agency nurse, and she had her skills check - off in the computer.Interview on 07/14/2026 at 5:33 PM, the Administrator stated his expectation was that the catheters were secured in place. The Administrator stated he did not know why this occurred. He stated the risk of not securing the tube was it could result in infection or trauma. The Administrator stated the nursing staff should ensure Resident #74's Foley should not touch the floor. The Administrator stated his expectation was for the staffs are to wear PPE before performing care to the resident with EBP signs posted on their doors and perform hand hygiene after changing gloves to prevent infection.Record review of the facility's policy titled Catheter Care Policy, dated 08/16/2017, revealed in part: .The purpose of this policy is to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infection .Record review of the undated facility policy on infection control, standard precautions read .Record review of the facility policy on hand hygiene dated 05/2024 read . staff will perform hand hygiene when indicated, using proper technique . hand hygiene technique when using water and soap .

Based on observation, interview, and record review the facility must ensure medication error rates are not 5% or greater. The facility had a medication error of 12% based on 4 errors out of 33 opportunities, which included 2 (Resident #21 and Resident #43) of 4 residents reviewed for medication error. RN Z administered to Resident #21 the following medications amlodipine 5mg, hydrochlorothiazide 12.5mg, and losartan potassium 50mg out of order parameters on 07/14/26. The parameters were to hold these medications if the SBP was less than 110, DBP less than 60, or heart rate was less than 60. Resident #21 SBP was 132, DBP was 80, and heart rate was 49. RN Z administered the medication losartan potassium 50mg to Resident #43 on 07/14/26 when the parameter said to hold the medication if Resident #43's blood pressure was less than 110/60 or pulse was less than 60. Resident #43's blood pressure was 143/80 and heart rate was 55. This failure placed residents at risk for low blood pressure, decreasing the heart's ability to pump blood to the body to function properly that will lead to decline in health. Findings included: Record review of Resident #21's face sheet dated 07/14/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included peripheral vascular disease (a slow progressive disorder of the blood vessels {hollow tubes that carry oxygen to parts of the body} outside of the heart and brain that mostly affects the arteries and veins in the legs casing reduce blood flow, hypertension (high blood pressure), and acute kidney failure (sudden loss of the kidneys to filter waste product, excess fluid from the body). Record review of Resident #21's admission MDS dated [DATE] reflected a BIMS score of 14 indicating that resident cognition was intact. Record review of Resident #21's Comprehensive Care Plan dated 06/21/26 revealed that resident was being care planned for receiving diuretic therapy with an intervention to administer medications as ordered by the physician. Further review revealed that Resident #21 was being care planned for having altered cardiovascular status r/t hypertension with an intervention that included to monitor vital signs. notify the MD of significant abnormalities. Record review of Resident #21's Physician Order Summary Report for the month of July 2026 reflected the following orders: -Dated 06/20/26 Hydrochlorothiazide (diuretic used to treat high blood pressure and to reduce fluid) oral table 12.5mg give 1 tablet by mouth one time a day for HTN (elevated blood pressure) hold if SBP < 110 or DBP < 60 or HR <60. -Dated 06/20/26 Cozaar oral tablet 50 mg/Losartan potassium (used to treat high blood pressure, enlarged heart, and protect kidneys of patients with type 2 diabetes who have protein in the urine) give 1 tablet by mouth one time a day for HTN hold if SBP < 110 or DBP < 60 or HR < 60. -Dated 06/20/26 Amlodipine Besylate (used to treat high blood pressure) oral tablet 5mg give 1 tablet by mouth one time a day for HTN hold if SBP < 110 or DBP < 60 or HR < 60 Observation of medication pass on 07/14/26 at 8:38AM revealed RN Z took Resident #21's vital signs that included resident blood pressure reading of 132/80 and a heart rate of 49. RN Z proceeded to administer resident morning medications that included amlodipine 5mg tablet by mouth, hydrochlorothiazide 5mg 1 tablet by mouth, and Losartan potassium tablet 50mg by mouth. Record review of Resident #43's face sheet dated 07/14/26 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 06/23/26. Resident diagnoses included hypertension (high blood pressure), old myocardial infarction (a finding that suggest a heart attack in one or more areas of the heart), leukemia (cancer of the body's blood-forming tissue such as the bone marrow{soft tissue with many blood vessels found in the center of bones}, and chronic kidney disease (when the kidneys are damaged or have a problem in cleaning the blood the way it should), stage 2 mild. Record review of Resident #43's admission MDS dated [DATE] Section C-Cognitive Patterns for Staff Assessment for Mental Status indicated resident cognitive skills for daily decision making was moderately impaired. Record review of Resident #43's Comprehensive Care Plan dated 06/08/26 revealed that resident was being care planned for altered cardiovascular status r/t coronary artery disease, hypertension with intervention to monitor vital signs.notify the MD of significant abnormalitiesRecord review of Resident #43's Physician Orders, Resident #43 had orders with a start date of 06/23/2026 for Losartan Potassium Oral tablet 50 mg, give 1 tablet by mouth one time a day for hypertension hold if BP less 110/60 and pulse less than 60.Observation of medication pass on 07/14/26 at 8:55AM by RN Z for Resident #43 revealed RN Z took the resident's vital signs. Resident #43's blood pressure was 143/80 and heart rate was 55. RN Z proceeded to administer resident's morning medications that included Losartan potassium tablet 50mg one tablet by mouth.Interview on 07/14/26 at 1:20PM with RN Z said she had reviewed the ordered parameters regarding Resident #21 and Resident #43's blood pressure medications before administering the medications but chose to use her nursing judgment instead of notifying the physician of both resident's heart rate reading. RN Z said in the past when a resident's heart rate was out of the ordered parameters, she had informed the physician who said to go ahead and give the medication. RN Z said she could not remember what physician had told her to go ahead and administer the medication outside of the order parameters and what resident it was because it occurred a long time ago. Further interview with RN Z said she should have held the medications and called the physician. RN Z said she placed the resident at risk for decrease in blood pressure and heart rate. Interview on 07/14/26 at 3:00PM with the DON said all the nurses have done skill competencies that included medication pass. The DON said she had been working at the facility since May 22, 2026. The DON said usually it was the DON and the ADON that check the nurses off on medication pass. The DON said all nursing staff should be following ordered parameters given by the physician regarding medication administration to maintain compliance with physician orders and if not, the facility was out of compliance in following the physician orders. The DON said RN Z placed Resident #21 and Resident #43 at risk for decrease in blood pressure or heart rate.Interview on 07/14/26 at 3:15PM with Resident #43's Nurse Practitioner said giving resident blood pressure medications outside of the ordered parameters placed resident at risk for bradycardia (low heart rate) and that the parameters were order for a reason one being to guide the nursing staff in the care of the resident to prevent any unwanted outcomes. The NP said she would have preferred to be called before the medication was administered for further guidance on how to proceed involving Resident #43's plan of care.Interview on 07/14/26 at 3:27PM with Resident #21's Physician Assistant said when parameters were given regarding blood pressure medications, the nursing staff should be following those parameters as ordered. The Physician Assistant said when blood pressure medications were administered outside of the ordered parameters, it placed the resident at risk heart rate further decreasing. The Physician Assistant said some residents due to their decreased cognizant level would not be able to communicate how they are feeling and that a side effect could be dizziness which could increase their risk of falls. The Physician Assistant said this was even more why parameters should be followed for the safety of the residents. The Physician Assistant said he would want to be called before the nurse decides to administer the blood pressure medication outside of the ordered parameters. Record review of the facility policy on Physician Orders revised May 2023 reflected in part: .All medications will be administered as ordered by a healthcare professional authorized by the state to order medications. Record review of the facility policy on Administration of Medications revised April 2023 reflected in part: .Vital signs are taken as required prior to medications and written on MAR. Medications with supplementary documentation and/or hold parameters must be reviewed and within range to administered prior to administering medication.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 2 (Resident #74 and Resident #14) of 3 residents reviewed for administration. RN BQ did not document Resident #14 or Resident #74's pressure ulcer treatment being done on 7/11/26 and 7/12/26.This failure could possibly lead to resident injury due to inaccurate documentation and reflection of resident health and care. Findings included:Resident #14Record review of Resident #14's face sheet dated 07/13/2026 revealed an 89 -year- old male admitted to the facility on [DATE]. Resident #14 diagnoses included atrial fibrillation( irregular heart beat), atherosclerotic ( buildup of fatty deposits, cholesterol and other substances ( called plaque) inside the artery wall, heart disease of native coronary artery without angina pectoris(chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood), type 2 diabetes mellitus (too much sugar in the blood), fracture of unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing, pressure ulcer of left ankle, stage 4,( multiple ligaments and three sides of the ankle bone are broken or tone, completely destroying the ankle joint's stability) muscle wasting and atrophy, not elsewhere classified, unspecified site other abnormalities of gait and mobility, and other lack of coordination.Record review [SH35.1]of Resident #14's admission MDS assessment, dated 06/15/2026, reflected that the resident had a BIMS score of 10[SH36.1], which indicated that the resident's cognition was moderately impaired. Record review of Resident #14's Physician orders reflected the following order summary dated 6/26/26: left heel DTI (deep tissue injury), cleanse with wound cleanser, pat dry, apply skin prep cover with foam dressing every day shift Right heel DTI (deep tissue injury) , cleanse with wound cleanser, pat dry, apply skin prep cover with foam dressing every day shift Record review of Resident #14's Medication Administration Record for July 2026 revealed: No initials confirming that treatment was done on 7/11/26 and 7/12/26.Resident #74 Record review of Resident #74's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, hyperlipidemia (high fat blood), type 2 diabetes mellitus with hyperglycemia ( when body does not produce enough insulin to correct sugar built up in the blood), cardiogenic shock(a life-threatening medical emergency where your heart is suddenly too weak to pump enough blood to supply your body's vital organs, like your brain and kidney), essential (primary) hypertension(, muscle wasting and atrophy,( shrinkage or wasting away of a body part, tissue or organ muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination.Record review of Resident #74's admission MDS, dated [DATE], revealed a BIMS score of 13 out of 15[SH37.1], which indicated the resident's cognition was moderately impaired. Resident #74's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #74's urinary continence was not rated due to indwelling catheter.Record review of Resident #74's Physician orders reflected the following order summary dated 7/8/26: left heel DTI ( deep tissue injury), cleanse with wound cleanser, pat dry, apply skin prep cover with foam dressing every day shift, Left Trochanter hip and left wrist (surgical incision) , cleanse with wound cleanser, pat dry, apply skin prep cover with foam dressing every day shift.Record review of Resident #14's Medication Administration Record for July 2026 revealed: No initials confirming that treatment was done on 7/11/26 and 7/12/26.An attempted interview via telephone with RN BQ on 7/15/26 at 3:17 PM, who worked the 6am to 6pm weekend normal shift as the treatment nurse., revealed RN BQ did not respond,; a message was left on the voicemail. An interview with the DON on 7/15/26 at 3:20pm, she said RN BQ should have documented [SH39.1]Resident #14 and Resident #74's treatments. The DON said that not accurately documenting that information could delay the resident's treatment. When asked what risk it could have posed to residents if treatment were not documented, the DON said it would delay wounds healing well,. She stated she would conduct individual in-services for weekend nurses on documentation.Requested for policy on documentation on 7/15/26 at 2:30 PM. none was provided before the exit on 7/15/26.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 Staff (ADON and CNA AV reviewed for infection control. -1. The facility failed to ensure ADON followed proper use of PPE and infection control procedure while checking Resident #74's F/C on 7/13/26.-2. The facility failed to ensure CNA AV followed proper use of PPE and proper hygiene after she provided care for Resident #74. -3. The facility failed to keep Resident # 74 Foley bag and tubing from touching the floor.These failures could place residents at risk for infection. Record review of Resident #74's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, hyperlipidemia (high fat blood), type 2 diabetes mellitus with hyperglycemia ( when body does not produce enough insulin to correct sugar built up in the blood), cardiogenic shock(a life-threatening medical emergency where your heart is suddenly too weak to pump enough blood to supply your body's vital organs, like your brain and kidney), essential (primary) hypertension(, muscle wasting and atrophy,( shrinkage or wasting away of a body part, tissue or organ muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination.Record review of Resident #74's admission MDS assessment, dated 07/12/2026, revealed a BIMS score of 13 out of 15, which indicated the resident's cognition was moderately impaired. Resident #74's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #74's urinary continence was not rated due to indwelling catheter. Record review of Resident #74's care plan, dated 07/07/2026, revealed:Focus: Resident #74 admitted with an indwelling foley catheter with no diagnosis. Goal: The resident will be and remain free from catheter-related trauma through the review date;Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds; Monitor and document for pain or discomfort due to the catheter.Observation on 07/14/2026 at 3:00 PM during catheter care for Resident #74 revealed the resident sitting in her wheelchair by her bedside, by CNA AV before transferring to bed revealed her foley catheter tubing, bag and blood-tinged urine under her wheelchair. Her foley bag and the tube were touching the floor. CNA AV washed hands, donned clean gloves, undo Resident #74's brief that was soiled with large BM, CNA AV used wet wipes to clean perineal area 4 times, doff gloves and did not wash hands or use hand sanitizer 4 times before donning clean gloves. CNA AV did not open labia to clean F/C tubing from insertion site, CNA AV cleaned F/C tubing outside the insertion site, she position Resident #74 to her left side, then cleaned her buttocks 3 times, doff gloves each time without washing hands or using hand sanitizer 3 times before donning clean gloves. CNA AV used the soiled gloved hands picked up a clean brief and placed it under resident and fastened it. Cover the Resident #74 with clean linen and open resident #14 door and to the soiled utility room.Interview on 07/14/2026 at 4:20 PM, CNA AV revealed she was nervous and forgot to don PPE and wash hands during incontinent/catheter care. CNA AV said donning PPE and washing hands should be done each time to prevent cross-contamination.Interview and observation on 07/14/2026 at 4:35 PM, the ADON stated the CNA AV just reported to her Resident #74 did not have the catheter leg strap on. The ADON came in Resident #14's room, donned clean gloves and touched F/C without donning PPE, the ADON stated she was not sure why the resident's catheter was not secured with a leg strap and why Resident #74 had blood-tinged urine. The ADON stated the catheter strap was important because there was a risk of the catheter pulling, moving, and hurting the resident. The ADON said she forgot to don PPE. Interview on 07/14/2023 at 5:06 PM, the DON stated her expectations for the ADON and CNA AV to don PPE. She stated washing hands and donning clean gloves should be done each time to prevent cross-contamination. The DON said Resident #74's Foley bag and the tube should not touch the floor to prevent the bag and the tube from being contaminated with germs which could travel Resident #74 bladder, and the resident would get an infection (UTI). She said the nurse monitored the aides and should ensure Resident #74's Foley bag and tube were off the floor. She stated CNA AV was checked off on Foley care and ADON was an agency nurse, and she had her skills check - off in the computer. Interview on 07/14/2026 at 5:33 PM, the Administrator stated his expectation was for the staffs are to wear PPE before performing care to the resident with EBP signs posted on their doors and perform hand hygiene after changing gloves to prevent infection.Record review of the undated facility policy on infection control, standard precautions read .Record review of the facility policy on hand hygiene dated 05/2024 read . staff will perform hand hygiene when indicated, using proper technique . hand hygiene technique when using water and soap .

Based on observation and interview the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (Dumpster A and Dumpster B) reviewed for garbage disposal.-The facility failed to ensure the Dumpsters A and B's doors were closed and secured on 07/13/26. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation and interview on 07/13/2026 at 8:45a.m., there were two dumpsters side by side outside the kitchen exit door. The Dumpster A's left side door was completely opened and both of Dumpster B's doors were completely open. The DM said that the dumpsters should not have been open because there were dirty items such as diapers in there and it should be closed. In an interview with the DON and Administrator on 07/14/2026 at 5:33p.m., the DON said the doors to the dumpsters should not have been opened. The Administrator said it was an infection control issue. A dumpster policy was requested on 07/14/2026 at 1:39p.m. by email to the Administrator and DON. The Administrator responded by email on 07/14/2026 at 2:27p.m. that the facility did not have a policy specific to dumpsters.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the status for 1 (CR#1) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure CR#1's admission MDS assessment accurately reflected he had a Foley catheter. The failure could place residents at risk of receiving inadequate care and services due to inaccurate assessments.Record review of CR#1's face sheet dated 6/26/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and discharge on [DATE]. His diagnoses included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), chronic kidney disease stage V (damage kidney that cannot filter blood properly), acute kidney failure (a sudden loss of kidney function that happens a few hours a day). Record review of CR#1's physician's assessment dated [DATE] revealed an order for a bladder scan and if urine was more than 300 ml to insert a Foley catheter. Further record review revealed the bladder scans were done between 5/18/2026, 5/20/2026 and 5/21/2026 for CR#1 and it revealed the following: On 5/18/2026 revealed 375 ml.On 5/20/2026 revealed 10 ml and 100 mlOn 5/21/2026 revealed 0 and 150 ml. Record review of the hospital notes dated 5/26/2026 revealed In the ER, work-up is significant for stable vital signs. He was found to have hematuria in his Foley bag with imaging demonstrating malposition of Foley catheter. The patient reported some discomfort since Foley catheter was replaced last week. Foley catheter was replaced in the ER after which symptoms resolved. Record review of CR#1's initial MDS dated [DATE] revealed he was coded as moderately impaired for cognition for decision making. For H0300 and H0400: Bowel and bladder, he was coded as frequently incontinent. Indicating he did not have an indwelling catheter. Record review of CR 1's physician's order for May 2026 revealed no order for the insertion of a Foley catheter or instruction for Foley care in the physician's order. Record review of CR#1's progress notes dated between 5/18/26 and 5/26/2026 revealed no documentation that a foley catheter was inserted while CR#1 was a resident at the facility in May 2026. In an interview with the ADON on 6/29/2026 at 1:25pm she looked through CR#1's clinical records and said there was an order for a bladder scan but did not see any documentation where the foley was inserted. She said she was going to check the physician's order again. Asked at that time if the foley was inserted by the physician. She said it could be inserted by physician or the RN. In an interview on 6/29/2026 at 2:00pm the MDS Coordinator said she did not see any order for a foley and that was why it was not coded on the MDS. She said if the resident had a foley in the ER then it was inserted at the facility. She reviewed CR#1's record and saw the result of the bladder scan and that the foley was inserted on 5/22/2026. Further interview with the MDS Coordinator revealed that if the foley was documented in the physician order for output and the CNA was documenting output it would populate into the MDS and she would code the MDS and update the care plan. She said if there was a breakdown in communication between the physician and the nurses then the MDS would not be coded correctly. In an interview with the Administrator, he said he spoke with the physician, and she was aware that CR#1's foley was inserted. He said the NP told him the blood in the urine started the day of fall. He said the NP was in the building the day the resident was found on the floor and she assessed the resident and the resident was sent to the hospital. He said he was going to in-service the staff on documentation and proper communication. The facility's policy on accuracy of resident's assessment was requested on 06/29/26 at 2:20 PM. The MDS coordinator said the facility followed the RAI manual

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 3 out of 7 residents (Resident #1, Resident #2, and Resident #5) reviewed for ADLs.- The facility failed to provide scheduled showers and/or bed baths three times a week for Resident #1, Resident #2, and Resident #5, for the weeks of 1/12/26-1/16/26 and 1/19/26-1/23/26.This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.Findings included:1. Record review of Resident #1's undated face sheet revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of acute respiratory failure (not enough oxygen), malignant neoplasm of mouth (cancer of the mouth), pulmonary fibrosis (lungs are scarred, thick, and stiff, making it difficult to breathe), tracheostomy (hole into windpipe to breath), type 2 diabetes mellitus (body does not produce insulin or resists it), c-diff (diarrhea caused by bacteria), dysphagia (trouble swallowing), and gastrostomy (hole into stomach for nutrition).Record review of Resident #1's admission MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 which indicated normal cognition. The resident had an impairment on both sides of her upper and lower extremities. According to the assessment, the resident was dependent (helper does all of the effort and resident does none of the effort to complete the activity) for showers/baths. The resident was always incontinent of bowel and bladder. The assessment also revealed the resident had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The resident had a PEG (hole into stomach) tube for nutrition, had a tracheostomy, and was on oxygen.Record review of Resident #1's Care Plan dated 12/19/25, revealed a Focus: The resident had ADL self-care performance deficits and limitations in physical mobility due to acute respiratory failure with trach placement (Initiated: 12/19/25). The goal was that the resident would improve self-care and mobility by the review date (Initiated: 12/19/25, Target Date: 3/29/26). The interventions were dependence for oral care, substantial/max assist (helper does more than half the effort) for upper body dressing, and substantial/max assist for lower body dressing. Showers/baths were not on the care plan. Focus: The resident was incontinent of bowel and bladder (Initiated: 12/19/25). The goal was for the resident to have minimal complications related to incontinence episodes through the review date (Initiated: 12/19/25, Target Date: 3/29/26). Interventions were changing the briefs as needed, cleaning the peri-area (area where genitals are) with each incontinence episode, checking every 2-3hrs and PRN for incontinence, washing/rinsing/drying the perineum (where genitals are), changing clothing PRN after incontinence, and providing skin care with each incontinence episode.Record review of Resident #1's Progress Note from 1/13/26 by APRN B said, .Requiring max assist with ADLs and transfers. Musculoskeletal [muscles and bones]: Severe weakness.In an observation and interview on 1/21/26 at 11:02am, Resident #1 was sitting up in bed with a trach and oxygen connected to it at 10L. The resident was unable to speak due to the trach and used a communication board to say she only received a bed bath 1 time a week. She said she would like to get at least 2 baths a week. Her family member, who was also in the room, said they had spoken to the ADM about it, and he said they were working on hiring more staff.Record review of Resident #1's Progress Notes from 1/2/26 through 1/20/26 revealed no refusals of baths/showers.Record review of Resident #1's Shower Sheets in the EMR on 1/21/26, revealed she was scheduled to receive her showers/baths on Mon/Wed/Fri on the night shift from 7pm-7am. The Shower Sheet revealed the question, Task Completed? that was to be answered each shift for her shower/bath. The answers to the question were: yes, no, resident not available, resident refused, or not applicable. For the past 30 days there were only 2 entries, one on 1/13/26 and one on 1/17/26. The entry on 1/13/26 at 3:19am was checked off for Not Applicable and the entry for 1/17/26 at 3:44am was also checked off for Not Applicable. Entries that documented she had received a bath on 1/12/26, 1/14/26, 1/16/26, 1/19/26, and 1/21/26 were missing.Record review of Resident #1's paper Shower Sheets provided by the facility after exit, on 1/21/26 at 6:00pm, revealed the resident had a bed bath on 1/13/26 at 2:00pm, 1/16/21 at 4:22pm, 1/19/26 at 2:51pm, and 1/21/26 at 10:00am. 2. Record review of Resident #2's undated face sheet revealed she was a [AGE] year old female admitted [DATE] with diagnoses of diverticulitis (inflammation/infection of pockets in intestine) of large intestine with perforation (hole) and abscess (infection), type 2 diabetes mellitus (body does not produce insulin or resists it), heart failure (heart does not pump effectively), abscess (infection) of spleen, acute respiratory failure (lungs are not delivering oxygen), ESRD (kidneys stop working), dependence on renal dialysis (machine has to filter blood), gastrostomy (hole into stomach for nutrition), and colostomy (opening in abdomen for stool to collect in bag).Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, which indicated normal cognition. The resident had impairment on both sides of her lower extremities and used a wheelchair. According to the assessment, the resident was dependent for showers/baths. The resident had a colostomy and was always incontinent of bladder. The assessment also revealed the resident had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The resident had a PEG tube for nutrition, was on oxygen, and received hemodialysis (machine filters blood).Record review of Resident #2's Care Plan dated 1/9/26 revealed a Focus: The resident had ADL self-care performance deficits and limitations in physical mobility (Initiated: 1/9/26). The goal was to improve self-care and mobility function by the next review date (Initiated: 1/9/26, Target Date: 4/19/26). The interventions were needing substantial/max assist with baths/showers. Focus: The resident was incontinent (Initiated: 1/9/26). The goal was for the resident to have minimal complications related to incontinence episodes through the review date (Initiated: 1/9/26, Target Date: 4/19/26). Interventions were changing the briefs as needed, cleaning the peri-area with each incontinence episode, checking every 2-3hrs and PRN for incontinence, washing/rinsing/drying the perineum, changing clothing PRN after incontinence, and providing skin care with each incontinence episode.In an observation and interview on 1/21/26 at 11:31am, Resident #2 was lying on her side in bed with oxygen via a nasal cannula on. She had family at her bedside with her. Resident #2's family member said the only bath she had received so far was on 1/16/26, and she only received it because she had to ask for it. The resident said she would like baths at least twice a week to help prevent any infections, because she was immunocompromised.Record review on 1/21/26 at 3:05pm of the 100 hall Shower Sheet binder, revealed there were no paper Shower Sheets for Resident #2 in the binder, and no indications of any refusals. Record review of Resident #2's Progress Notes from 1/9/26 through 1/20/26 revealed no refusals of baths/showers.Record review of Resident #2's Shower Sheets in the EMR as of 1/21/26, revealed she was scheduled to receive her showers/baths on Tue/Thu/Sat, during the day shift from 7am to 7pm. The Shower Sheet revealed the question, Task Completed? that was to be answered each shift for her shower/bath. The answers to the question were: yes, no, resident not available, resident refused, or not applicable. For the past 30 days there was No Data Found, meaning there were no entries for the month of January, and she was supposed to have a bath every Tue/Thu/Sat.Record review of Resident #2's paper Shower Sheets provided by the facility after exit, on 1/21/26 at 6:00pm, revealed the resident had a bed bath on 1/13/26 at 3:00pm, 1/15/26 at 11:00am, and 1/21/26 at 5:00pm. 3. Record review of Resident #5's undated face sheet revealed he was a [AGE] year old male admitted [DATE] with diagnoses of right hip fracture, afib (irregular heart beat), cardiac pacemaker (device to control heart beat), muscle weakness, and abnormalities of gait (walking) and mobility (getting around).Record review of Resident #5's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident had impairment on both sides of his lower extremities and used a wheelchair. According to the assessment, the resident was substantial/max assistance (helper does more than half the effort) with showers/baths. The resident was always incontinent of bowel and bladderRecord review of Resident #5's Care Plan dated 12/25/25 revealed a Focus: The resident had ADL self-care performance deficits and limitations in physical mobility r/t right femur fracture (right hip fracture), pain management, and fall (Initiated: 12/25/25). The goal was to improve self-care and mobility function by the next review date (Initiated: 12/25/25, Target Date: 4/2/26). The interventions were needing substantial/max assist with baths/showers. Focus: The resident was incontinent of bowel and bladder (Initiated: 12/25/25). The goal was for the resident to have minimal complications related to incontinence episodes through the review date (Initiated: 12/25/25, Target Date: 4/2/26). Interventions were changing the briefs as needed, cleaning the peri-area with each incontinence episode, checking every 2-3hrs and PRN for incontinence, washing/rinsing/drying the perineum, changing clothing PRN after incontinence, and providing skin care with each incontinence episode.In an observation and interview on 1/21/26 at 11:28am, Resident #5 was lying in bed. He said the only complaint he had was not receiving baths three times a week. He said he had to get a bed bath because he could not walk and said he did not remember the last time he had received a bed bath.Record review of Resident #5's Progress Notes from 12/31/25 through 1/19/26 revealed no refusals of baths/showers.Record review of Resident #5's Shower Sheets in the EMR as of 1/21/26, revealed he was scheduled to receive his showers/baths on Tue/Thu/Sat during the day shift from 7am to 7pm. The Shower Sheet revealed the question, Task Completed? that was to be answered each shift for her shower/bath. The answers to the question were: yes, no, resident not available, resident refused, or not applicable. For the past 30 days there four entries, on 1/8/26 at 6:17pm, 1/10/26 at 5:52pm, 1/13/26 2:29pm, and 1/15/26 at 11:50am. All four dates had yes answered to the question. Entries that documented he had received a bath on 1/17/26 and 1/20/26 were missing.Record review on 1/21/26 at 3:05pm of the 100 hall Shower Sheet binder, revealed there was one sheet for Resident #5 for January 2026. A paper Shower Sheet dated 1/8/26 revealed the resident had a bath on that day. There were no other Shower Sheets or refusals.Record review of Resident #5's paper Shower Sheets provided by the facility after exit, on 1/21/26 at 6:00pm, revealed the resident had a bed bath on 1/17/26 at 11:25am, and 1/21/26 at 4:32pm.In an interview on 1/21/26 at 1:35pm, the DON said showers/baths were documented in the EMR under the tasks section of the resident's chart. She said the only reason they used the paper Shower Sheet was for the CNA to mark if there was a skin issue, and then they gave it to the nurse.In an interview on 1/21/26 at 3:12pm, CNA A said she worked the front part of the 100 hall. She said on Mon/Wed/Fri the even numbered rooms received showers/baths, and on Tue/Thu/Sat the odd numbered rooms received showers/baths. CNA A said day shift gave showers/baths to A beds and residents in single rooms, and night shift gave showers/baths to B beds. She said she felt she had enough time to get all the baths/showers done, plus her other CNA duties. She said Resident #2 was a new resident from another hall and today (1/21/26) was her first day back since the previous week, so she did not remember bathing her. The CNA said she did not remember the last time she had bathed Resident #5, but she remembered that he got baths instead of showers because he could not walk. She said if a resident refused a bath/shower it would be documented on the paper Shower Sheet or on the Shower Sheet in the computer. CNA A said if residents did not get showers they could get infections and would smell bad. In an interview on 1/21/26 at 3:45pm, the DON said her expectation was that residents received a shower/bath 3 times a week and PRN. She said the shower/bath had to be done, no questions asked, and that she expected her staff to give them. She said there would be no adverse effects if the resident did not get a shower/bath because they had to get done, and her staff knew that. The DON said there were no residents that she knew of that had gone without a shower/bath long enough for it to cause any issues. She said even though there were not paper Shower Sheets or Shower Sheets in the computer proving the residents received showers/baths, she knew that they received them, and she would confirm it.Record review of the facility's policy and procedure on Activities of Daily Living (10/2025) read in part: Hygiene: Resident self-image is maintained.Showers and baths are scheduled and assistance is provided.Record review of the facility's policy and procedure on Resident Rights (revised January 2026) read in part: To ensure each resident is treated with dignity and respect. This includes providing activities and interactions from staff, temporary agency or volunteers that is focused on assisting in maintaining and enhancing self-esteem, self-worth, individualizing goals, preferences, and choices. Resident Rights: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Our facility environment encourages self-selection to individualize needs, care, and routines in a dignified and [NAME] way to respect preferences and full exercise of rights. Our residents have rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (CR #1) reviewed for pressure ulcer treatment.The facility failed to ensure CR#1 with a documented sacral pressure injury (sustained force applied to the sacrum, the triangular bone at the base of the spine) received necessary wound treatment and monitoring.This failure could place the residents at risk of worsening wounds, infection, and hospitalization.Record review of CR #1's face sheet, dated 11/30/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/16/2025. Record review of CR #1's admission MDS assessment, dated 09/22/2025, reflected diagnoses included of Sepsis unspecified organism (occurs when your immune system has a dangerous reaction to an infection) and Type 2 Diabetes (a lifelong disease that keeps your body from using insulin the way it should). CR #1's BIMS score was not reflected. The MDS revealed CR #1 had cognitive impairment. The MDS further revealed that Section M - Skin Conditions indicated CR #1 had pressure ulcers (injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), among other skin alterations; upon admission to the facility on [DATE]. Record review of CR #1's care plan, dated 09/23/2025, reflected: Focus Area: Unstageable (wound) to sacrum. Goal: The resident will have no complications related to documented skin impairment through the review date. Interventions /Tasks: Evaluate and treat per physician's orders; evaluate resident for signs and symptoms of possible infections; follow facility protocols for treatment of injury; low air loss mattress, ensure functioning properly; nurse to assess/record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements or declines to the MD; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations, by wound nurse or provider. Record review of CR#1's clinical record revealed nursing staff submitted a wound care consultation at admission on [DATE]. Record review of CR #1's progress noted dated 09/19/2025, completed by Wound Care NP, revealed initial visit with Wound Care NP on 09/19/2025, there was no record of CR #1's identified sacral pressure injury being treated or assessed by the Wound Care NP at initial encounter on 09/19/2025 through CR #1's discharge date of 11/18/2025. Record review of CR #1 nurse progress note date 11/18/2025, reveal resident was transferred to hospital due to facial swelling to right side of face in the cheek area and eye. Record review of CR #1's EMR clinical documentation (MAR, TAR, Progress Notes and Physician order summary for September, October, and November 2025) revealed from 09/16/2025 through 11/18/2025:No documentation of wound care treatment was provided to the sacral pressure injury.No documented evidence of dressing changes on the sacral pressure injury.No documented evidence of wound staging and updates on the sacral pressure injury.No documented evidence of wound assessments of the sacral pressure injury.No documented evidence of measurements of the wound on the sacral pressure injury.There was also no documented evidence that nursing staff:Followed up with the provider regarding missing orders.Notified the DON or Administrator that orders were not provided.Escalated concerns when the wound was not being treated. Initiated interim wound care consistent with standards when no orders were received. Record review of CR #1' s Hospital admission record dated 12/05/2025 revealed CR #1 was admitted to the hospital on [DATE] with chief compliant of recurrence of R parotitis (term for a swollen parotid gland. Your parotid glands are located on the side of your face, between your ear and your jaw). CR #1 was previously admitted for sepsis on 09/08/2025 - 09/16/2025, underwent 2 tooth extractions of right upper molars with parotid duct fluid samples growing MRSA; discharged to SNF on 10 days of Bactrim, minocycline, Flagyl. There was multiple chronic pressure identified on CR # 1's admission to the hospital on [DATE]. There was no specific sacral pressure injury documented on CR # 1's admission to the hospital on [DATE]. As of 12/05/2025, the hospital noted pending SNF reauthorization for CR #1's return to the facility. Interview on 11/30/2025 at 2:00 PM, the DON stated that according to CR#1 admission evaluation and assessment completed on 09/16/2025 identified that CR #1 was admitted with a sacral pressure injury and several other identified skin conditions and injuries. She stated the expectation was when skin breakdown was identified, a wound consultation was submitted, and resident was assessed and treated by the Wound Care NP. She stated the Wound Care NP was responsible for providing orders related to wound care treatment. She stated that the nurse staff were responsible for implementing orders provided. She stated once the order was provided it would appear in the clinical MAR or TAR as an order or task to be implemented. She stated once orders were entered there was EMR monitoring and notification system to alert staff when wound treatments were overdue or missing. She stated that if orders were not provided and treatment was not implemented, it could delay wound healing and increase the risk of infection. She stated that she was familiar with CR #1 and had assisted in providing wound care to CR #1. She stated she recalled several wounds being treated but did not recall if a sacral pressure injury was treated. She stated a wound audit was completed monthly which included wounds being treated. Skin assessment and NP wound rounds were completed weekly. She could not explain how the CR #1's sacral pressure injury was missing. She also stated it was possibly due to the change in wound care documenting system that took place in September/2025. She stated the facility transitioned from one system to the current system (Wound Rounds) September/2025. She stated a skin sweep was completed on 12/01/2025, and no current residents residing at the facility were noted with missing identified skin breakdown. She stated as of 11/30/2025, she implemented a tracking system to ensure wound consults resulted in provider orders and treatment and or were congruent with nursing evaluation and skin assessment. She stated that when applicable, a follow-up with the provider regarding any identified missing wound assessments, treatment and orders was now required weekly. She stated staff would be trained starting 12/01/2025. Interview attempt via telephone, with Nurse K (nurse of record who completed the admission assessment on 09/16/2025) on 11/30/2025 at 3:20PM and 12/09/2025 at 6:45PM was unsuccessful as Nurse K was no longer employed by the facility and the telephone number on file was disconnected. Interview on 12/01/2025 at 1:39 PM, the Wound Care NP revealed it was her responsibility to assess, provide treatment, and provide wound care orders when she received a wound care consultation. The Wound Care NP stated she was familiar with CR #1. She stated CR #1 was admitted to the facility with several chronic pressure injuries. She stated that she had several wound treatment encounters with CR #1. She stated CR #1 was usually seen weekly, on Friday during wound care rounds and treatment provided was documented and reflected in the EMR record. She stated she could not recall if she had provided treatment to CR #1's sacrum area. She confirmed that if CR #1 received treatment to a sacrum area wound, it was documented in the EMR progress note where orders and treatment plan are reflected. She stated a written record of treatment was also provided to the facility's Wound Care Nurse to reflect treatment implemented and updates related to all wounds treated and assessed. She stated both the EMR record, and written record were identical and should include wound care treatment implemented during wound care rounds, treatment orders such as dressing changes, wound staging, wound measurements, updates reflecting if wound was resolved, and any wound progression or deterioration. She stated if there was not a record documented then treatment was not provided. She stated CR #1 had several chronic pressure and skin injuries upon admission with delayed wound healing possibly related to the resident's was chronic infection history of an unknown source. She stated if the sacral pressure injury was not reflected in her treatment round notes and CR #1 had a sacral pressure injury documented in the initial skin assessment by the admitting nurse and wound care nurse the sacral pressure injury had been missed and left untreated and assessed in human error. She stated that when a wound consultation was received, she would review the residents' history and nursing evaluation provided by the facility's Wound Care Nurse to guide her in her initial assessment. She stated that she was uncertain how she missed the wound, if the sacral pressure injury was documented in the initial nursing evaluation. She stated that it was necessary to ensure all residents with skin breakdown received necessary treatment and services, consistent with professional standards of practice. She stated that if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. She denied having any knowledge CR #1 presented with a worsening infection or decline in overall wellbeing.Interview on 12/01/2025 at 3:00 PM, the Wound Care Nurse confirmed the sacral wound was identified on admission and that a wound care consult was submitted. She stated per her assessment documentation; the sacral wound was identified. She stated she never received wound treatment orders per her review of CR #1's order summary. The Wound Care Nurse stated she could not recall if CR #1's sacral pressure injury was treated. She acknowledged all wound care treatment and orders were reflected in PCC (EMR system used by facility). She stated that if care was not documented in PCC no wound treatments were performed, and no provider orders were received and entered. She knowledge that she was present during wound care rounds completed by the Wound Care NP on 09/19/2025. She was unable to explain why the lack of treatment orders was not escalated to the DON or Medical Director. She stated she had not previously experienced missing a wound and a wound going untreated. She stated it was possible that the sacral wound was treated but not documented due to CR #1 condition of multiple. She stated that if wound treatment was not received it placed the resident at risk for delayed wound healing, infection and quality of care. She denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing. She confirmed that facility training related to wound care management and prevention had been provided but did not verbalize when. Interview on 12/01/2025 at 3:00 PM with Nurse A and CNA M, who were assigned to CR #1 during 09/16/2025 through 11/18/2025 revealed they were familiar and had provided care for CR #1. Both stated they recalled several wounds being treated for CR #1 but did not recall if a sacral pressure injury was treated. Nurse A stated that skin observations were not completed each shift, but were completed on the residents' shower days, and weekly by the wound care nurse. She stated it was everyone's responsible to the resident to ensure that wound treatment was provided. She stated it was possible for a wound and treatment to be missed if skin assessments were not completed and wound care orders were not provided. She stated if she identified a wound that may have been missed by the Wound Care Nurse or NP, she would notify both to obtain an order and implement care as soon as possible. She stated that if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. She denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing. Nurse A and CNA M stated that wound care prevention and infection control, and repositioning training had been recently provided but could not recall date of recent training. Interview on 12/02/2025 at 9:18 AM, the Wound Care Doctor stated that he was not familiar with CR #1. He confirmed that he was the medical provider the wound care nurse reported to. He stated that a wound consultation was submitted, the resident was assessed, and treatment was guided by the Wound Care NP. He stated that the initial skin evaluation and consultation was completed by the facility's nursing staff. He stated the Wound Care NP was then responsible for assessment and treatment planning for the identified wound. He stated the Wound Care NP assessment should identify the wound location, wound staging, wound measurements, and wound identification/type. He stated the assessment detail then would indicate the treatment plan, orders provided, and treatment implemented. He stated the Wound Care NP was responsible for treatment of all identified pressure injuries identified by the facility. He stated that if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. He denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing related to lack of wound care provided. Interviews with staff (CNA D, Staff J, Nurse A, Nurse R) at varies times between 12N - 5PM on 11/30/2025 and 12/01/2025 revealed that staff had been trained on wound prevention, repositioning, infection control, and abuse and neglect. Record review and observations and conducted in the facility on 11/30/2025 and 12/01/2025, between 11AM - 3PM revealed pressure-relieving devices available for Residents (#1 and #2) with wounds. November MAR/TAR reveal treatment provided to Resident #1 and Resident #2. Progress notes and skin assessment for November 2025 reveal that documentation was congruent with Residents (1 and #2) wound present during surveyor's observation Staff observed repositioning residents. In-service and training documentation related to wound care order, prevention and management was requested on 11/30/2025, 12/01/2025, and 12/08/2025 and not provided by the facility. Review of the facility's current policy dated March 2020 titled, Treatment of Wounds: Dressing Changes-Performing reflected: The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus.Any Wounds assessed will be captured in the PCC nursing evaluation, in progress notes, or by completing in Wound Rounds via Quick Shot (within 2-6 hours of admission) .Orders are verified or obtained as needed.Assessments and interventions implemented are documented in the resident clinical record.

Based on observation, interviews and record review, the facility failed to ensure each resident had acceptable parameters of nutritional status such as usual body weight or desirable body weight range for 1 (Residents #2) of 5 residents reviewed for weights. -The facility failed to weigh Resident #2 on 10/4/2025 per physician orders. This failure has the potential to affect other residents requiring weight management, especially those who have weight loss and weight gain and who could be at risk of serious harm due to poor nutrition and weight loss.Record review of Resident #2's face sheet dated 11/12/2025, revealed he was a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including burn of second degree of male genital region, Chronic Obstructive Pulmonary Disorder (damage to the lungs causing swelling, irritation inside the airways, lead to narrowed airways and difficulty breathing), type 2 diabetes mellitus (high blood sugar), anemia (low red blood count), dependence on renal dialysis ((kidney treatment where someone's blood is cleaned and excess fluid is removed from the body when the kidneys are no longer able to perform its functions effectively), major depressive disorder (a mood disorder where someone has persistent feelings of sadness and loss of interest), and heart failure. He was discharged on 10/14/2025 to a private home. Record review of Resident #2's Comprehensive MDS dated [DATE], revealed he had a BIMS score of 15, indicating his cognition was intact. Resident #2 required total assistance/total dependence on staff for toileting, showering, dressing and footwear. He was totally dependent on staff with transferring in and out of bed and mobility in bed. Resident #2 had no or unknown amount of weight loss in the last 6 months.Record review of Resident #2's care plan dated 11/12/2025, revealed he was care-panned for ADL self-care performance deficits and limitations in physical mobility and had interventions such as substantial assistance with toilet transfer, moderate assistance with toileting. Resident #2 was also care-planned for having altered cardiovascular status r/t A-fib (atrial fibrillation meaning irregular heartbeat) and CHF with interventions including monitoring, documenting and reporting PRN any changes in lung sounds and evaluating chest pain and changes in pain level and requesting medication from the physician. Resident #2 was also care-planned for the potential for alterations in nutrition and hydration with interventions including monitor/record/report to MD PRN s/sx of malnutrition: emaciation (being unusually thin or weak), muscle wasting, or significant weight loss: 3lbs in 1 week, >5% in 1 month,>7.5% in 3 months, >10% in 6 months.Record review of Resident #2's physician orders, he had orders for weights with a start date of 09/30/2025 for 1 time a day for 3 days, then 1 time a week for 4 weeks and another order start date of 10/04/2025 for one time a day every 7 day(s) for 4 weeks.Record review of Resident #2's MAR and TAR for October 2025, his weight was not documented on 10/4/2025 . Record review of Resident #2's weights, he weighed the following:9/30/2025 at 5:29pm: 177 lbs.10/1/2025 at 2:06am: 177 lbs.10/13/2025 at 12:19pm: 161.3 lbs. (8.9% weight loss from 9/30/2025 during admission to 10/14/2025 discharge) During an interview with LVN B on 11/12/2025 at 12:00pm, she said aides did weights and then they would tell her, and she would input weights into a resident's medical record. LVN B said weights helped keep track of resident's nutrients and track their health. If weights were not documented as needed, vital labs would not be ordered. Interview with the Administrator and DON on 11/12/2025 at 3:29pm, the DON said that Resident #2 was a dialysis resident and the facility did not need to check their weights often because dialysis would monitor them. The DON said weights should have been documented for Resident #2 because weights documented their progress, and the Administrator said weights were documented to track residents' care at the facility. The DON said if weights were not done, staff would not know how they were progressing and if residents were improving at the facility or not. The DON said Resident #2 left the facility before she could re-measure his weights but that Resident #2's discharge weight of 161.8 and the 8.9% weight loss was incorrect. Going forward, the DON said she would educate staff on weighing residents with one method such as with a mechanical lift or standing scale throughout their time at the facility and she would continue to review weights to ensure this compliance. Record review of the facility's policy on Quality-of-Care last revised May 2025, it read in part, Key Principles .Person-Centered Care: This facility prioritizes individual preferences, choices, and unique needs, promoting a person-centered approach to care planning and care delivery . The facility's QAPI Committee through the facility's QAPI Plan will define and monitor key performance indicators related to quality of care including but not limited to .unintended weight loss .

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment such as services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 (Resident #5) of 5 residents reviewed for care plans.-Resident #5's care plan failed to include weights as part of their diagnosis of CHF and as a resident requiring dialysis.This failure could cause residents to not have their individualized needs met and lead to a decline in function that is not documented and treated. Record review of Resident #5's face sheet dated 11/12/2025, revealed she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted [DATE]. Her medical diagnoses included end stage renal disease (final stage of chronic kidney disease where the kidneys can no longer function adequately and require either dialysis or a kidney transplant for survival), kidney transplant status (when someone is waiting for a new kidney), immunodeficiency (when someone's immune system's ability to fight infectious diseases is compromised or entirely absent), muscle weakness (generalized), major depressive disorder (a mood disorder where someone has persistent feelings of sadness and loss of interest), heart failure and dependence on renal dialysis (kidney treatment where someone's blood is cleaned and excess fluid is removed from the body when the kidneys are no longer able to perform its functions effectively). Record review of Resident #5's Comprehensive MDS dated [DATE], revealed she had a BIMS score of 5, indicating severe cognitive impairment. Resident #5 required total assistance from staff for ADLs including toileting, showering, dressing and personal hygiene. Resident #5 required substantial to total assistance with transferring in and out of bed and mobility in bed such as rolling left and right and lying to sitting on side of the bed. Resident #5 had no or unknown amount of weight loss in the last 6 months.Record review of Resident #5's care plan dated 11/12/2025, revealed she had an altered cardiovascular status r/t Coronary artery disease, Hypertension with interventions including monitor vital signs as ordered and notify MD of significant abnormalities. She was also care-planned for having potential fluid volume overload r/t CHF with interventions including monitoring, documenting, and reporting any signs or symptoms of fluid overload such as sudden weight gain and to monitor vital signs/weights as ordered and record.Record review of Resident #5's physician orders dated 11/12/2025, revealed she had orders for weights on 10/16/2025 one time a day every 7 days for 4 weeks. Record review of Resident #5's MAR and TAR for October 2025, her weight was not documented on 10/27/2025.Record review of resident #5's progress notes for October 2025, there were no weights documented for 10/27/2025.Attempted interview with Resident #5's RP on 11/12/2025 at 12:38pm, no returned phone calls or messages.Attempted interview with RN A on 11/12/2025 at 3:17pm, because she was the nurse on duty on 10/27/2025 for Resident #5. There was no answer and no returned phone calls or messages.During an interview with LVN B on 11/12/2025 at 12:00pm, she said aides did weights and then they would tell her, and she would input weights into a resident's medical record. LVN B said weights helped keep track of resident's nutrients and track their health. If weights were not documented as needed, vital labs would not be ordered. Interview with the Administrator and DON on 11/12/2025 at 3:29pm, the DON said that Resident #5 was a dialysis resident and the facility did not need to check their weights often because dialysis would monitor them. When Resident #5's dialysis sheet was requested for 10/7/2025, the DON said it was difficult to get those records, and she had already called them twice on 11/12/2025 and would try again later. The DON said weights should have been documented for Resident #5 because weights documented their progress, and the Administrator said weights were documented to track residents' care at the facility. The DON said if weights were not done, staff would not know how they were progressing and if residents were improving at the facility or not. Going forward, the DON said she would educate staff on weighing residents with one method such as with a mechanical lift or standing scale throughout their time at the facility and she would continue to review weights to ensure this compliance. Record review of the facility's policy on Quality-of-Care last revised May 2025, it read in part, Key Principles .Person-Centered Care: This facility prioritizes individual preferences, choices, and unique needs, promoting a person-centered approach to care planning and care delivery . The facility's QAPI Committee through the facility's QAPI Plan will define and monitor key performance indicators related to quality of care including but not limited to .unintended weight loss .

Based on observation, interview, and record review the facility failed to ensure residents were free of significant medications errors for 1 resident (Resident #20) of 8 resident for medication errors in that: - The facility was unable to locate a current order for Resident #20 for the medication Brilinta (blood thinner/antiplatelet {medication that prevents blood clots}) 90mg oral 1 tablet in the morning and at bedtime. Resident #20 received the medication from 05/01/25 at 9:00PM to 05/07/25 at 9:00PM. This failure placed resident at risk for increase in bleeding and unwanted hospitalization . Findings included: Resident #20: Record review of Resident #20's face sheet dated 05/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: osteomyelitis (inflammation of the bone caused by infection) of right ankle and foot, type 2 diabetes mellitus (when the body does not produce enough insulin (a hormone that helps glucose enter the cells for energy) or does not use insulin properly, leading to high blood glucose (sugar), peripheral vascular disease (circulatory condition in which the blood vessels become narrowed reducing blood flow to an extremity) , acute kidney failure (when the kidneys suddenly cannot filter waste from the blood) , atherosclerotic heart disease (damage or disease in the heart's major blood vessels), and hyperlipidemia (high cholesterol). Record review of Resident #20's admission MDS dated [DATE] reflected a BIMS score of 15 indicating the resident's cognition was intact. Further review section O-Special Treatments, Procedures, and Programs reflected that resident was receiving anticoagulant medication. Record review of Resident #20's Comprehensive Care Plan dated 04/24/24 reflected that resident was care planned for receiving anticoagulant therapy with interventions that included the following: -Monitor/document/ report PRN adverse reactions of anticoagulant therapy: blood tinged or blood in urine, black tarry stools, blood in stools, bruising, sudden changes in mental status .or vital signs. Record review of Resident #20's Physician's Order Summary Report for the month of May 2025 reflected the following orders: -Dated 04/23/25 Aspirin 81mg give 1 tablet by mouth one time a day for blood thinner. -Dated 04-24-25 Plavix 75mg give 1 tablet by mouth in the AM for blood thinner. -Dated 04/24/25 Heparin injection (anticoagulant) 5000 units subq (fatty tissue below the skin for example outer upper arm, around the belly, upper thigs and buttocks) BID for blood thinner. -Dated 05/01/25 Brilinta 90mg 1 tablet by mouth every morning and bedtime for blood thinner. Further review revealed that RN Q transcribed this order. Record review of Resident #20's Pharmacy Note dated 05/01/25, Order Note reflected the following: Severity: Severe, Interaction: Brilinta oral tablet 90mg, Plavix oral tablet 75mg may enhanced the anticoagulant effect of heparin, and ASA blood thinner oral capsule 81mg. Record review of Resident #20's MAR/TAR for the month of May 2025 reflected the facility was following physician's orders for ASA, Plavix, and heparin and that resident was being monitored for abnormalities for receiving anticoagulants. Further review reflected the administrations of Brilinta 90mg 1 tablet orally was given in the morning and at bedtime as follows: -1st dose was initiated by the ADON-RN on 05/01/25 at 2100 (9:00PM). -the ADON administered Brilinta on 05/02/25 at 9:00AM. - On 05/02/25 RN N administered the 9:00pm dose on 05/02/25. -On 05/03/25 at 9:00AM RN O administered the medication Brilinta along with other blood thinners. -On 05/03/25, at 9:00PM nurse RN N administered the medication Brilinta. -On 05/04/25 at 9:00AM the ADON administered the morning medications along with Brilinta medication. -On 5/4/25 at 9:00PM RN N administered medications. -On 05/05/25 medications administered by the ADON at 9:00AM and at 9:00PM. -On 05/06/25 morning medications was administered by ADON. -On 05/06/25 at 9:00PM medication administered by RN O. -On 05/07/25 at 9:00AM medication was administered by RN M -On 05/07/25 RN N administered medications at 9:00PM. -On 05/08/25 the medication Brilinta was placed as pending , but did not specify who placed medication as pending. Record review of Resident #20's PT (blood test used to assess how quickly blood clots) and INR (a blood test that measures how long it takes for blood to clot, standardize way of reporting PT results and help to determine correct dosage for blood thinners) collected on 05/06/25. The lab results reflected the following: -PT 23.0 (H) reference range (9.9-11.0) -INR 2.4 (H) reference range (0.8-1.2) Record review of Resident #20's Nursing Progress notes reflected that RN P was the nurse that admitted the resident to the facility on [DATE] with no order for Brilinta 90mg oral 1 tablet in the morning and bedtime. Further review revealed there was no order for the medication Brilinta 90mg oral to be administered in the morning and at bedtime. Interview on 05/08/25 at 9:05AM with the Pharmacist via phone revealed she came to the facility on ce a month and was scheduled to come to the facility on [DATE]. The Pharmacist said she was not aware of how many blood thinners that Resident #20 was receiving at the facility. After the P harmacist reviewed Resident #20's medication profile while on the phone with the surveyor said the medication Plavix and Brilinta worked the same and would be considered a duplicate of each other and this would increase the resident's risk of bleeding. The Pharmacist said she would have to see who ordered the medication Brilinta. The Pharmacist said she would maybe recommend the following labs CBC (a common blood test that measures the number of different types of cells in the blood, including red blood cells, white blood cells, and platelets) and PT to be collected to see the resident's blood levels. Interview on 05/08/25 at 9:16AM the DON said she was not aware of Resident #20 being on 4 different types of blood thinners. The DON said she was responsible for reviewing the residents' orders and that Resident #20's medications were discussed in the morning meeting. The DON said she would have to look at her computer and to see what was documented and come back to speak with the surveyor. Observation on 05/08/25 at 9:20AM revealed Resident #20 awake, in bed watching TV ,alert and oriented to person, place, time, and happenings. Resident #20 said he was doing fine and had not experienced abnormal bleeding such as nose bleeding, blood in stool or urine, or bruising of the skin. Resident #20 denied any falls while residing at the facility. Resident #20 had a dressing to his right foot area that was dry and intact with no drainage observed. Interview on 05/08/25 at 9:28AM RN M said she worked at the facility on the morning shift full time 7AM-7PM. RN M said she did not administer the medication Brilinta to Resident #20 for the morning due to the medication being placed on pending but did administer Brilinta 90mg orally on 5/07/25 the morning dose along with resident's other ordered medications. Interview on 05/08/25 at 9:59AM the DON said the medication Brilinta had been placed on pending dated 05/08/25 and that she would have to check to see who placed the medication on pending. The DON began to review Resident #20's records and said it was Resident #20's Dr. at the nursing facility that ordered the medication Brilinta 90mg 1 tablet by mouth in the morning and at bedtime. The DON said when Resident #20 was admitted to the facility a morning meeting was conducted (could not say who all was a part of the meeting). The DON said in the meeting Resident #20's medication heparin was discussed regarding a stop date. The DON said the physician was called on 04/24/25 regarding stop dates on certain medications. The DON said she learned about the new medication Brilinta being added to the resident's medication profile on 05/02/25. The DON said she knew that Brilinta was a blood thinner but did not think anything about it because Resident #20 had a follow-up appointment with the surgical doctor on 05/12/25 due to CAD (coronary heart disease-blood vessel disorder affecting blood supply to the heart). The DON said when a resident was on blood thinners or anticoagulants, the nurse had to monitor for bleeding. The DON said it was RN Q that transcribed the order for Brilinta 90mg 1 tablet by mouth to be administered in the morning and at bedtime. Interview on 05/08/25 at 11:02AM with Resident #20's Primary Care Dr. at the facility said she was notified on 05/08/25 that Resident #20 was receiving the medication Brilinta 90mg 1 tablet by mouth in the morning and at bedtime. The doctor said she did not give the order to administer the medication Brilinta because it would have placed resident at risk for increase bleeding. The doctor said there were no routine lab tests required for medication Brilinta or Plavix. The doctor said she had spoken with the facility and there had not been any negative side effects reported such as abnormal bleeding or injuries. The doctor said if the resident was experiencing any bleeding, she would have stopped all resident blood thinners and continued to monitor Resident #20 for further bleeding and if so, she would have the facility to send resident to the hospital. The doctor said at this time there were no warrant for further concern and to just continue to monitor resident for signs and symptoms of bleeding. Interview on 05/08/25 at 11:16AM RN P said she worked the night shift 7PM-7AM and could not remember Resident #20. RN P said she was familiar with the medications Brilinta and Plavix. RN P said she believed the medications were administered for heart issues. Further interview with RN P revealed she would not administer the medications Plavix and Brilinta together because they were the same. Interview on 05/08/25 at 12:00PM RN Q said she had been working as a nurse since 2013. RN Q said she had been working at the facility since 04/24/25. RN Q said on 05/01/25, Resident #20 went to a doctor appointment and from the Summary Report that she review ed, she saw the medication Brilinta on the summary report from the doctor visit. RN Q said she noticed that Brilinta was not on resident medication profile and therefore added the medication Brilinta to the resident profile. RN Q did not answer if she saw an order to administer the medication Brilinta, was she familiar with the medication Brilinta, and did she call the doctor for clarification. RN Q said the protocol when a resident returned to the facility and there is a new medication or change in a resident plan of care she was supposed to call the attending physician at the facility to inform of any changes. RN Q said she did not do any of the above and did not answer why she did not take those steps. RN Q said she placed the resident records regarding Brilinta in a box at the nurses' station. Attempted interview via phone on 05/08/25 at 12:30PM with RN N, no answer, left a voicemail with a call back number. Interview on 05/08/15 at 12:58PM the ADON said she initiated the first dose of the medication Brilinta 90mg 1 tab by mouth at 9:00PM on 05/01/25. The ADON said the primary care nurse on duty was nurse RN Q. The ADON said RN Q said she needed some help, and she therefore administered the medication Brilinta to Resident #20. The ADON said she was aware the resident was receiving other blood thinners but never thought to question or clarified the order. The ADON said because she failed to do that, the resident could have bled out (significant and rapid loss of blood). Interview on 05/08/25 at 1:05PM RN M said she worked the morning shift from 7AM-7PM full time. RN M said she was familiar with blood thinner medications. RN M said she chose to administer Resident #20's medications which included Plavix, Heparin injection, Brilinta , and ASA because Resident #20 was not exhibiting any signs or symptoms of bleeding. RN M said she had received in-services on medication administration in regard to anticoagulants/blood thinners. RN M said because the conversation was being had regarding Resident #20's medications, maybe she could have read more about the added medication Brilinta . Interview on 05/08/25 at 1:40PM the [NAME] President of Clinical Operations said the facility was trying to call the doctor office on 05/08/25 regarding Resident #20's doctor visit on 05/01/25 with no reply. The VPCO said the facility had yet to locate an order or a Physician Summary Note for the medication Brilinta 90mg 1 tablet to be administered in the morning and at bedtime. The VPCO said the doctor had not responded to the facility request of medical records for the resident's doctor visits. The VPCO said the facility had in-serviced staff on medication administration regarding blood/thinners, the importance of following up with the physician after a doctor visit regarding any new order. Further interview, the VPCO said the facility had done a 100 % audit on all residents receiving blood thinners and anticoagulants and there had not been any adverse effects or concerns identified. Further interview on 05/08/25 at 2:17PM the DON said whenever a resident returned from a doctor visit the nurses were supposed to call the attending physician at the nursing facility to inform the doctor of the visit. The DON said RN Q should have called the attending physician at the facility about a new medication for Resident #20. The DON and the Administrator was asked for the facility policy on Medication Administration, Physician Orders, and Transcribing of Orders. Interview on 05/08/25 at 4:02PM via phone, RN O said if a resident was on several blood thinners or anticoagulants, she would review resident's orders and medical diagnoses and inform the physician. RN O said if a resident had a doctor appointment and returned to the facility with new orders, she was supposed to call the attending doctor at the facility to confirm before administering a new medication. Interview on 05/08/25 at 6:11PM the Director of Pharmacy Services said he was not the pharmacist that filled the order Brilinta 90mg 1 tablet orally in the morning and at bedtime for Resident #20. The Director of Pharmacy Services said normally he did not see the medications Plavix and Brilinta given together. The Director of Pharmacy Services said the pharmacy had access to Resident #20's medication profile. The Director of Pharmacy Services said he did not see any documentation of the pharmacist reaching out to the doctor to clarify the order for Brilinta. The Director of Pharmacy Services said the pharmacist that filled the order for Brilinta 90mg 1 tablet by mouth in the morning and at bedtime was not available. Record review of the facility quality assurance dated 05/08/25 revealed that the facility [NAME] President of Clinical Operations had done a 100 % audit on all residents receiving blood thinners/anticoagulants with no duplicate medications. The VPCO had in-serviced the DON and ADON on monitoring all new anticoagulant orders for proper utilization and notifying the MD for any clarification of usage and monitoring tool form. Further review revealed that in-services were conducted with licenses and registered nurses currently in the facility about the utilization of anticoagulants and notifying clinical managers and physician of any signs and symptoms of adverse reactions, order clarification with the facility continuing to Inservice. Further review revealed that the facility had assessed Resident [NAME] Ewing with no adverse reactions at the present time. Record review of staff training revealed that RN M, N, O, P, Q had completed their Nurse Competency Training that included Medication Administration/ 6 Rights of Medication Administration. Record review of the facility policy on Physician Orders revised May 2023 reflected in part: .All medications will be administered as ordered by a health care professional authorized by the state to order medications . Record review of the facility policy Administration of Medication revised April 2023 reflected in part: A physician or nurse practitioner is required for administration of all medications .check medication administration record prior to administering medication for the right medication, dose, route, patient, and time . Record review of the nursing facility policy on Pharmacy Services revised May 2024 reflected in part: .The provision of pharmaceutical services is an integral part of the care provided to nursing home residents. The management of complex medication regimens is challenging and requires diverse pharmaceutical services and formal mechanisms to safely handle and control medications, to maintain accurate and timely medication records, and to minimize medication related adverse consequences or events. The overall goal of the pharmaceutical service system within a facility is to ensure the safe effective use of medications .Responsible Party: Interdisciplinary Clinical Team .

Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of three medication carts and one of two medication room reviewed for drug for drug labeling and storage, in that: The 200 medication cart reviewed contained heparin 50,000 USP unit per 10 ml 1 vial open not dated (medication used to prevent blood clots). The medication room had 8 cartons of Nurten 2.0 (calorically dense complete nutrition unflavored) that were expired. These failures placed residents at risk for receiving biologicals and medications which were ineffective and/or not safe. Findings include: An observation on 05/07/25 at 3:09 PM of the medication cart checked on the 200 hall with RN A and the DON, revealed inside the medication cart was Heparin 50,000 USP unit per 10 ml 1 vial open and not dated. Observation of the medication room on the 100 hall with the DON on 5/7/25 at 4:00 PM revealed expired Nurten 2.0 (calorically dense complete nutrition unflavored ) High Quality casein -soy protein blend 50% fat 8.45 Fl.oz (250ml) X 8 cartons with an expiration date of April 02 2025. An interview with RN A on 05/07/25 at 3:09 PM revealed she was not aware of the open date not on the Heparin vial. RN A and DON said all open vials should always be dated to know the expired date. Interview with the DON on 5/7/25 4:05 PM, she said she checked the medication room that morning and forgot to check the expiration date and the med rooms were checked weekly for expired meds and Nutren was used for a supplement. The DON threw the Nutren 2.0 away in the trash The DON said using the expired medication/Nutren could place residents at risk for receiving biologicals and medications which were ineffective and/or not safe. During an interview with the DON on 05/07/25 at 10:30 AM , the DON was asked who checked the medication room for expired medications and Nutren supplements and how did they monitor medications. The DON said the night nurses checked the medication room for expired medications. The DON said she did check the medication room periodically and she did not have any daily log for checking medication room. The Pharmacist came once a month and documented the expired meds and discarded them. Record review of the facility policy /Title 5.3 Storage and Expiration of Medications, Biologicals, syringe and needles policy and procedure, dated 12/01/07: Application: LTC Facilities Receiving Pharmacy Products and Services From Pharmacy revealed [in part] . Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label ; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. 2. The facility failed to store personal food items outside of the kitchen area. 3. The facility failed to ensure food items were sealed and secure. These failures could place residents at risk of food borne illness and disease. Findings Included: In an observation on [DATE] at 08:16 a.m., of the 1 of 1 facility walk-in refrigerators revealed the following: 2-personal fruit trays containing black grapes, not labeled, or dated. 2-Hamburger buns in a bag, used and not labeled. English muffin packaged, half used, not labeled, or dated. 1-gal zip lock bag of croissants, not labeled or dated. 1-small glass bowl with lid, labeled room [ROOM NUMBER] not dated. 1-package of soft tortilla shells not sealed and exposed to air. 1-tray full of 2-ounce dipping sauces containers of hot sauce, not covered/exposed to air, and not labeled or dated. 1-zipped lock bag of kale that appeared to be welted, not labeled, or dated. 24-oz jar of piccata sauce, half used, not dated. 1-bag of cilantro opened, not sealed/exposed to air, and not labeled, or dated. The Dietary Manager was observed removing all listed items from the refrigerator. In an observation on [DATE] at 08:20 a.m., of the 1 of 1 facility walk-in freezers revealed the following: 1-large box of mixed vegetables not sealed/exposed to air. 1-square plastic measuring bowl of vanilla ice cream not covered/exposed to air, and not labeled, or dated. 2-[NAME] ice cream bars in a box not labeled or dated. 1-small blue bag of corn not labeled or dated. The Dietary Manager was observed removing all listed items from the freezer. In an interview on [DATE] at 8:25 a.m., Dietary Manager (DM) stated she had worked for the facility for 3-years. She stated that the cooks were responsible for ensuring that all staff properly stored, dated, and labeled foods. She stated that the 2-personal fruit trays containing blackberries were left in the refrigerator after a Cinco de Mayo event on [DATE] at the facility and should have been removed at the end of the shift. She stated that the small glass bowl with lid, labeled room [ROOM NUMBER] was her personal bowl from home. She stated she had made hot sauce for the event yesterday had planned to take the sauce home the night before and had forgotten. She stated that the zipped lock bag of kale was used to garnish serving trays on [DATE] and had been surprised to see that it had welted in such a short time, but should have been labeled, or dated. She stated that the tray full of 2-ounce dipping sauces containers of hot sauce were from the [DATE] party and should have been covered and dated. She stated the 24-oz jar of piccata sauce was brought from her home and used to make the hot sauce used on [DATE]. She stated it had been her intentions to take the sauce home after her shift on [DATE], but she had forgotten. She stated that the hamburger buns, English muffins, and croissants should have been labeled or dated. She stated that the package of soft tortilla shells and bag of cilantro that were opened should have been sealed, labeled, or dated and if found opened discharged . In an interview on [DATE] at 01:19 p.m., DM stated that 2-personal fruit trays containing black grapes should have been stored in the employee breakrooms refrigerator. She stated that the facility did not have a policy on how or where to store personal food items. She stated that that they were just not supposed to keep personal food in there the kitchen. She stated that leftover foods were to be discharged after 7-days if not used before. She stated after 7-days food items were considered expired and if used, could but residents at risk of food [NAME] illness. She stated that the hamburger buns, English muffins, and croissants, were removed from the refrigerator because it had no opened on and used by date and she was not aware how long those items had been in the refrigerator. She stated she removed the soft tortilla shells because they had not been sealed and had probably lost its flavoring and had become stale and hard. She stated foods uncovered and exposed could get stale, and hard, and if consumed, could make someone ill. She stated the small glass bowl was hers she had brought from home. She stated that she had prepared the hot taco sauce for breakfast for the staff. She stated she placed the leftover in the small bowl to take home, placed it in the refrigerator because she had not wanted it to spoil on [DATE], but had forgotten to take it home. She stated that staff were not allowed to store personal items in the kitchen's refrigerator. She stated that the small hot sauce dipping containers should have been thrown away after not being served on [DATE] because they had not place of serving them again. She stated the mix vegetables of peas carrots and corn mixed had been closed and not used. She believed that the box was cut opened, and the sealed bag must have gotten torn in the process. She stated that facility had a 5-gallon container of ice cream and instead of removing the 5-gallan container each time staff needed ice cream, they would scoop ice cream into the square plastic bowl while in the freezer. She stated the ice cream had been covered and dated, but somehow the plastic covering peeled back. She stated that the [NAME] ice cream bars belonged to the facility Activities director and was used as bingo prizes. She stated that she checked the food items for property labeling and storage every day. She stated that she had not had a chance to check on [DATE] before the initial tour of the kitchen began. She stated the provided the dietary staff with an labeling and storage in-service training on [DATE]. In an interview on [DATE] at 03:14 p.m., Administrator (ADM), stated that it had been her expectations that the dietary staff following all the rules for proper food storing and labeling to ensure that the food was safe to consume. She stated that the risk of not properly following food process could place residents at risk for gastrointestinal issues. She stated that the dietary manager was responsible for provide the dietary staff education and training on the dietary policies. She stated that the dietary staff received an in-service on proper food storage on [DATE]. She stated that the kitchen staff were provided an additional in-service training on [DATE]. Record Review of the Nursing Facility (NF)'s in-service record dated [DATE] reflected: Topic Standard Operating Procedure (mandatory). Provided by DM, Chef, signed and dated by dietary staff and the DM. Record Review of the NF's in-service training record dated [DATE] reflected: Provided by: Target Population: Topic: Labeling and Dating. Lecture. Signature is acknowledgement you have been presented with the information and were given the opportunity for questions and clarification, not with agreement to new procedure - dietary staff. Presented by / Signature & Title of in-service DM, Chef. Dated [DATE]. Record Review of the NF's Policy titled: FOOD & NUTRITION SERVICES SANITATION & FOOD SAFETY. LABELING AND DATING FOODS and dated 2021 reflected, Policy To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received the date opened and the date by which the item should be discarded. Policy and Procedure Manual. [DATE] at 09:35 a.m. Record Review of the NF's Policy titled: FOOD & NUTRITION SERVICES SANITATION & FOOD SAFETY. LABELING AND DATING FOODS Revised 2017 reflected, PROCEDURE: Refrigerated Food Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day I. For example, food prepared on [DATE]th will be marked to discard on or use by [DATE]th. Refrigerated Potentially Hazardous Food or Time/temperature Controlled for Safety foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by. Record Review of the NF's Policy titled: Policy Mandatory Dietary Standard Operating Procedure, undated, reflected, Objective: These standards of procedures aim to enhance food safety, prevent contamination, maintain hygiene standards, and ensure dietary operations align with regulations. All staff involved in dietary services, including Chefs, Sous Chefs, Cooks, Dietary Aides, and designated employees, are required to adhere to these protocols daily. 4. Labeling and Dating of Food Items Dry Goods: Include received and expiration dates manually, vendor labels are not acceptable. Dented cans should be rejected, labeled appropriately, and reported for credit. Cooler Goods: Items should display prep and use-by dates. Opened items must be labeled with opened and use-by dates. Store food according to the proper order to prevent cross-contamination: A: Ready-to-eat foods. B: Seafood. C: Whole cuts of beef/pork. D: Ground meat/fish. E: Poultry. Freezer Goods: Maintain airtight containers to prevent freezer burn. Clearly label boxes with received and expiration dates. Follow First in First Out practices and appropriate food storage charts. Record Review of the NF's Policy titled: Personal Food General Dated [DATE], revised ,d+[DATE] reflected, It is our practice to support food brought for residents from outside sources. Food provided for a resident by family and visitor will be stored separately from facility food under safe and sanitary conditions. If needed, facility employees will help the resident access food. Safe food handling procedures will be shared with family members to ensure safe and sanitary food storage, handling, and consumption. Responsible party: Guidelines: Purpose: It is our practice to support food brought for residents from outside sources. Food provided for a resident by family and visitors will be stored separately from facility food under safe and sanitary conditions. If needed, facility employees will help the resident access food. Safe food handling procedures will be shared with residents and family members to ensure safe and sanitary food storage, handling, and consumption. Responsible Party Dietary, Clinical. Guidelines: Securing Food Personal food and safe food handling procedures will be shared with the residents upon admission and as needed.1 Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include Product Name, received date, Used by date (no longer than 3-days), Resident names. Staff members will ensure food id labeled, dated, stored in proper temperature zones, and reheated according to any state or city requirements. Designated staff members will log refrigeration temperatures (2) times per day. Facility staff will be available to assist the resident with personal food access while adhering to safe food handling procedures during reheating or preparation activity in accordance with city or state requirements. Cooking and reheating temperature logs will be maintained and completed when assisting residents. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The facility had a medication error rate of 17% based on 6 errors for 34 opportunities. The errors effected2 resident (Resident #101,Resident #20) of 4 residents reviewed for medication administration. -Two medications, Ascorbic Acid tablet 250 mg (used to treat supporting tissue growth and repair, boosting immunity and acting as an antioxidant) and Doxycycline Hyclate oral tablet 100 mg (use to treat infections) for Resident #20 were not dispensed or administered. - Four medications: were not administered to Resident #101 - Jardiance oral tablet 10mg ( Empaglittozin)( medication use to treat diabetes mellitus) - Ascorbic Acid tablet 500 mg - Myfortic oral tablet delay release (mycophenolic Acid Dr).180 mg, 3 tablets a day to prevent organ rejection - Prograf oral capsule 0.5mg (Tacrolimus drug used to prevent organ rejection) The failures placed resident at risk for inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #20's Admission Record dated 05/07/25 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, acute osteomyelitis ( infection of a bone), right ankle and foot, anemia ( not having enough healthy red blood to carry oxygen to the body tissues) hyperlipidemia ( high level fat in the blood), atherosclerotic heart disease of native coronary artery ( chronic disease in which fatty deposits in arteries) , acute kidney failure, acute metabolic acidosis, severe protein-calorie malnutrition, type 2 diabetes mellitus with hyperglycemia , elevated white blood cell count, peripheral vascular disease, muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination. The MDS admitted d 4/26/25 indicated resident had moderate impaired cognition with a BIMS score of 15. Record review of the Physician Order dated 04/24/25 for Resident #20 read, in part, . Ascorbic Acid tablet 250 mg. Give 1 tablet by mouth one time a day for supplement and Doxycycline Hyclate oral tablet 100 mg- Give 1 tablet by mouth two times for infection. Observation and interview on 05/07/25 at 8:30 AM. revealed RN A at that medication cart outside of Resident #20's room. RN A looked at the May MAR and retrieved the following medications from the medication cart and dispensed them into a plastic medication cup: 1 Metoprolol Succ ER 25 mg 1 Po (use to high blood pressure) 1 Amox-Clav 875 -125mg 1 tab po ( antibiotic) 1 Aspirin 81 mg tab po ( used to treat blood clot) 1 Clopidogrel 75 mg 1 tab po ( used to treat blood clot) 1 Magnesium oxide 400 mg 1 po ( used to treat low magnesium) 1 Metformin Hcl ER 500mg 1tab ( used to treat high glucose in the blood ) 1 Heparin 5000 units/ml 10ml = 0.1ml right abdomen SQ( injection used to treat blood clot) Continued observation revealed RN A closed the medication cart and locked it. The Surveyor asked RN A to count the number of tablets/capsules/injection in the medication cup. RN A counted, then answered Seven. RN A entered the room and obtained Resident #20's blood pressure. RN A administered the 7 tablets/capsules/injection to Resident #20. RN A did not administered Ascorbic Acid tablet 250 mg and and Doxycycline Hyclate oral tablet 100 mg to Resident #20 Record review of the May 2025 MAR for Resident #20 revealed the Ascorbic Acid tablet 250 mg. Give 1 tablet by mouth one time a day for supplement and Doxycycline Hyclate oral tablet 100 mg- Give 1 tablet by mouth two times for infection was listed on the MAR as current. RN A had initialed MAR for Ascorbic Acid 250mg and Doxycycline 100mg as administered on 05/07/25 at 9:00 AM Record review of Resident #101's admission MDS assessment, dated 05/4/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Dementia ( the loss of cognitive functioning, thinking, remembering and reasoning that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance( when a person has trouble telling the difference between what's real and what's not, mood disturbance( less energy, trouble sleeping, trouble concentrating, changes in appetite and motivation, anxiety (feeling of worry, nervousness, or unease ,often about something that might happen in the future or current situation), atrial fibrillation (irregular, often rapid, heartbeat that occurs when the heart's upper chambers(atria) don't beat in sync with the lower chambers( ventricles). Hypertension (low blood pressure) , hyperlipidemia ( high lipid/fat in the blood), benign prostatic hyperplasia( a condition that occurs when the prostate gland enlarges blocking the urine stream) without lower urinary tract symptoms, type 2 diabetes mellitus with hyperglycemia ( high glucose level in the blood), immunodeficiency ( when the body's immune response is reduced or absent) due to drugs, kidney transplant, pneumonia, muscle weakness ( Generalized) , cognitive communication deficit. Review of the MDS admitted d 5/3/25 indicated Resident #101 had severe impaired cognition with a BIMS score of 03. Record review of the Physician's Order dated 04/24/25 for Resident #101 revealed: . Jardiance oral tablet 10mg ( Empaglittozin ) Give 1 tablet by po one time a day for DM. Ascorbic Acid tablet 500 mg Give 2 tablets by po one time a day for supplement. Myfortic oral tablet delay release (Mycophenolic Acid Dr).180 mg, Give 3 tablet by mouth two times a day for prevent organ rejection Prograf oral capsule (Tacrolimus), Give 0.5mg capsule by mouth two times a day for rejection prevention of organ. Observation and interview on 05/07/25 at 9:38 AM revealed RN A at that medication cart outside of Resident #101's room. Resident #101 was eating breakfast. RN A looked at the May MAR and retrieved the following medications from the medication cart and dispensed them into a plastic medication cup and administered to Resident #101 by mouth:. 2 Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs po 1 .Stool Softener 100mg1 tab po 1 .COQ10 100mg 1 tablet po 1 Daily Vitamin 1 tablet po 1 Amlodipine Besylate 10 mg 1 tablet po 1 Clopidogrel 75 mg 1tablet po 1 Eliquis 5 mg 1 tablet po 2 Metoprolol Succ ER 50 mg 2 tablet po 3 Mycophenolic Acid Dr.180 mg 3tabs (To prevent organ rejection (Box warning Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure). 1 Prednisone 5 mg tablet 1 po 1 Pantoprazole Sodium Dr 40 mg 1po 1 Tamsulosin Hcl 0.4mg 1 tab po 1 Vitamin D3 125 mcg(5000iu) 1 tab po 1 Vitamin B1 100 mg 1 tab po (Injection) Lantus ( insulin glardin injection ) 100 unit/mg 34 unit Continued observation revealed RN A closed the medication cart and lock it. The Surveyor asked RN A to count the number of tablets/capsules/injection in the medication cup. RN A counted, then answered Nineteen RN A entered the room and obtained Resident #101's blood pressure. RN A administered the 19 tablets/capsules/injection to Resident #101. RN A did not administer the following medications to Resident #101: -Jardiance oral tablet 10mg (Empaglittozin)( medication use to treat diabetes mellitus). - Ascorbic Acid tablet 500 mg. -Myfortic oral tablet delay release (mycophenolic Acid Dr).180 mg, 3 tablets a day to prevent organ rejection (Box warning -Prograf oral capsule 0.5mg (to prevent organ rejection). Record review of Resident #101's May 2025 MAR dated 5/7/2025 reflected the following: Jardiance oral tablet 10mg ( Empaglittozin ) Give 1 tablet by po one time a day for DM Ascorbic Acid tablet 500 mg Give 2 tablets by po one time a day for supplement Prograf oral capsule (Tacrolimus), Give 0.5mg capsule by mouth two times a day RN A initialed the above medications as administered on 5/7/2025 at 9:00 AM. Interview on 5/7/25 4:48PM with RN A, regarding not giving medication but initialed as given, RN A said that she went back to ER box to get Doxycycline 100 mg and she gave at a different time. When checked initial time on the computer it was for 9:00 AM. RN A said she was overwhelmed and said if a resident did not get medication as ordered, it could cause a delay in the resident getting well. The Surveyor checked the ER box with the DON at 5:30 PM and there were no Doxycycline in the ER box and there was no sign out sheet available for Doxycycline. In an interview on 05/07/25 at 5:40 PM the DON said the process for administering medications was to identify the resident, then make sure which medications were to be administered by looking at the MAR and pharmacy recommendation. She said the negative outcomes of not getting medications could cause health issues. She said, A lot could happen. The DON said medication given every day should be administered at 9:00 AM and medication given twice a day was at 9:00 AM and 5:00PM. The DON stated the facility had done an in-service on medication administration and the pharmacist on training dated 04/23/25 on medication administration was provided and RN A was in attendance. Interview with the Administrator and DON on 5/7/25 at 5:47PM revealed the Administrator said her expectation was for medication to be given as ordered by the physician and follow pharmacist recommendations. Record review of the facility training log for medication administration revealed in-service dated 04/22/25, RN A was in attendance. Record review of medication pass times, undated, reflected QD ( every day) was at 9:00AM and BID (twice a day) was at 9:00 AM and 5:00 PM. Record review of the facility policy Medication Administration and Management (revised 04/2024) revealed, in part, .Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: The Right Patient/Resident The Right Drug. The Right Dose. The Right Time. The Right Route. The Right Charting. The Right Results. The Right Reason.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 resident (Resident #101) reviewed for pharmaceutical services. The facility failed to ensure RN A followed the physician's orders for administering Mycophenolic Acid, which was used for preventing organ rejection, to Resident #101 on 05/07/25. This failure could put residents at risk of not receiving their medications as ordered. Findings included: Record review of Resident #101's admission MDS assessment, dated 05/4/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Dementia ( the loss of cognitive functioning, thinking, remembering and reasoning that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance( when a person has trouble telling the difference between what's real and what's not, mood disturbance( less energy, trouble sleeping, trouble concentrating, changes in appetite and motivation, anxiety (feeling of worry, nervousness, or unease, often about something that might happen in the future or current situation), atrial fibrillation (irregular, often rapid, heartbeat that occurs when the heart's upper chambers(atria) don't beat in sync with the lower chambers( ventricles). Hypertension (low blood pressure) , hyperlipidemia ( high lipid/fat in the blood), benign prostatic hyperplasia( a condition that occurs when the prostate gland enlarges blocking the urine stream) without lower urinary tract symptoms, type 2 diabetes mellitus with hyperglycemia ( high glucose level in the blood), immunodeficiency ( when the body's immune response is reduced or absent) due to drugs, kidney transplant, pneumonia, muscle weakness ( Generalized) , cognitive communication deficit. Review of the MDS for admitted d 4/26/25 indicated the resident had no impaired cognition with a BIMS score of 15. Record review of Resident #101's April 2025 Physician's Orders dated 4/30/2025 reflected the following: Myfortic oral tablet delay release (Mycophenolic Acid Dr) .180 mg, Give 3 tablet by mouth two times a day for prevent organ rejection. Record review of Resident #101's blister packet for Mycophenolic Acid Dr.180 mg had (Box warning that reflected: Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure). Record review of the facility for meal times, undated, revealed breakfast was 8:00 AM, lunch was at 12:30 PM and dinner was at 6:00PM. Observation on 05/07/25 at 9:38 AM, during medication administration revealed Resident#101 was sitting on w/chair in the eating breakfast in his room . RN A administered Mycophenolic Acid Dr 180 mg, Give 3 tablets from blister packet with ((Box warning that reflected: Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure) RN A administered antacid medication of Pantoprazole Sodium Dr 40 mg 1po, Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs and other medications to Resident #101 by mouth Interview with RN A on 05/07/25 at 9:47 AM regarding administering Resident #101's Mycophenolic Acid Dr 180 mg with Pantoprazole Sodium Dr, Sodium Bicarbonate antacid(both antacid) and other medications to Resident #101 by mouth, revealed she said she had medication training with the DON before she started working with the facility and she started working 2 weeks ago. RN A said she was taught to check the resident name, dosage, frequency, route, time, and expiration date. RN A said she did not look at the box warning on the blister packet. She said if the medication were not as ordered, it would affect the absorption of medications and effectiveness. RN A said she would be changing the time. Interview with the DON on 05/07/25 at 10:34 AM, after showing the DON the blister packet for Resident #101 Mycophenolic Acid Dr180 mg, Give 3 tablets not given in an empty stomach and giving Pantoprazole Sodium Dr 40 mg 1po, Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs (both antacid), the DON said she was going to change the time. She knew not giving Resident #101's medication as ordered by the doctor and following pharmacy recommendation would cause the medication to not to be effective. The DON stated facility had done an in-service on medication administration and the pharmacist on training dated 04/23/25 on medication administration was provided and RN A was in attendance. Interview with the Administrator and DON on 5/7/25 at 5:47PM, the Administrator said her expectation was for medications to be given as ordered by the physician and follow all warning on the blister packet to avoid drug -drug interaction. Record review of the facility trainings revealed an in-service dated 04/22/25 on medication administration and RN A was in attendance. Record review of the facility's current Pharmacy Services policy revision/Reviewed dated 05/2023 and 05/2024, reflected :- .Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 (Resident #1) reviewed for pain management. -The facility failed to ensure that as a resident with cancer of the esophagus Resident #1's pain medications (Lyrica 75mg and Tramadol HCl 50mg) were available at the facility after he was admitted from a cancer treatment hospital. Resident #1 missed 6 doses of Lyrica on 09/04/2024 at 10pm, 09/05/2024 at 6am, 2pm and 10pm, and 09/06/2024 at 6am and 2pm and said he was in pain at a level 10 from 0 to 10 on 09/06/2024 - The facility failed to provide Resident #1 with prescribed pain management per Physician Orders dated 09/04/2024 -The facility failed to assess Resident #1 for pain on 09/05/2024 and 09/06/2024 per Physician Orders for every shift. -The facility failed to ensure RN B and LVN B followed the proper facility protocols when Resident #1's pain medication was not delivered and administered. This failure could cause residents on pain medications to experience unnecessary pain and serious harm. Findings included: Record review of Resident #1's facesheet dated 09/06/2024 reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included: malignant neoplasm of esophagus, Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, Hypertension, Atherosclerotic Heart Disease, and Dysphagia. Record review of the Resident #1's care plan dated 09/04/2024 revealed Resident #1 has the potential for pain. Interventions included: anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/document for probable cause of each pain. Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score was not completed. Record review of Resident #1's progress notes dated 9/6/20024 at 2:09 pm read in part . his BIMS score was a 13, indicating cognitive intactness . There were no documentation of Resident #1 taking any pain medication in the record. Record review of Resident #1's Physician Orders for September 2024, he was receiving the following: -Pain-Evaluate Pain every shift for Pain Evaluation with a start date 09/04/2024. -Lyrica Oral Capsule 75MG (Pregabalin) Give 1 capsule via G-Tube three times a day for Pain, May open capsule and crush, mix with water with a start date 09/04/2024. -Tramadol HCL oral Tablet 50 MG Give 1 tablet via G-Tube every 6 hours as needed for pain. Record review of Resident #1's order audit report dated 09/06/2024 at 5:56pm, LVN A created an order for Lyrica Oral Capsule 75MG (Controlled Drug) on 09/04/2024 at 5:02pm. Further review of Resident #1's order audit report dated 09/06/2024 at 5:57pm, LVN A created an order for Tramadol Hcl (Controlled Drug) on 09/04/2024 at 4:34pm. Record review of Resident #1's September 2024 MAR dated 09/06/2024 at 7:41pm, the resident did not have pain evaluations for 09/05/2024 for the evening shift and 09/06/2024 for the day shift. Resident #1 did not have Lyrica for 09/04/2024 at 10pm, 09/05/2024 at 6am, 2pm, and 10pm, and 09/06/2024 at 6am, and was marked as administered at 2pm. Resident #1 had the following pain assessments completed: 09/04/2024 during admissions/evening shift with a pain level of 0, 09/05/2024 day shift with a pain level of 0, and on 09/06/2024 at 6:31pm with a pain level of 4 and received Tramadol HCl 50MG. Record review of Resident #1's hospital clinicals sent to the facility on [DATE] at 10:01am revealed he was taking Lyrica 75mg oral route scheduled every 12 hours and Tramadol 50mg every 6 hours as needed at the cancer treatment hospital. Interview with Resident #1 and FM W on 09/06/24 at 2:50 p.m., Resident #1 was attempted to talk but he lost his voice. FM W was in the room with Resident #1 and she said Resident #1 does lose his voice sometimes. FM W said Resident #1 had been in pain because he had not received his pain medication since being admitted to the facility. FM W said she had been asking the nurses when Resident #1 would get his pain medication. When Surveyor A was about to leave the room, Resident #1 was pointing to his throat and FM W said he was trying to say he was in pain. Observation of Resident #1's bolus feeding on 09/06/24 at 3:09 p.m., FM W asked RN A when she would administer pain medication to Resident #1 because he was in pain. RN A said she would check on the pain medication again when she finished administering the feeding. Interview with Resident #1 and FM W 09/06/24 at 4:00 p.m., Surveyor A assessed Resident #1's pain level on a scale of 1 to 10, and 1 being least and 10 being the most pain where you would rate your pain level. Resident #1 took some minutes strained with difficulty before he responded that his pain level was at 10. FM W said that the pharmacy had not delivered the medication. FM W said she had been asking the nurses and they kept telling her that they are working with the pharmacy. FM W said the nurse that worked yesterday told her most likely the medication would be sent today (09/06/24) by noon. FM W said she knew when Resident #1 was in pain because she had been with him for a long time. Interview with RN A on 09/06/24 at 4:22 p.m., RN A said Resident #1 had two pain medications. RN A said Lyrica was a scheduled medication and Tramadol was PRN and that Resident #1 had not received any of the pain medication. RN A said she called the pharmacy by 4:00 p.m. for both pain medications and the pharmacy said they did not have any order for those medications. RN A said she called the NP B at 4:08 p.m., and NP B told RN A to text the medications to her, which RN A did. RN A said she had not worked with Resident #1 since he was admitted since today was her first day and FM W had asked for Resident #1's earlier and she had not checked to see if the pain medication was in the building until now. RN A said if Resident #1 did not get his pain medication, then the physician order was not followed. Interview with the DON on 09/06/24 at 5:32 p.m., the DON said Resident #1 has two pain medications. The DON said Resident #1 was admitted on the 09/04/24 and that both medications were ordered on 09/04/24 which meant Resident #1 was admitted with the medication. The DON said when the nurse verified Resident #1's medications with the physician or NP, then the physician would call in the medication to the pharmacy and the pharmacy would give the nurse a code to get the medication form the emergency kit (e-kit). The DON said the Lyrica was a scheduled medication for every 8 hours and Tramadol was PRN every 6 hours for pain. The DON said the initial dose for Lyrica would have been given to Resident #1 at 10:00 p.m. on the day of admission. Interview with the VPCO on 09/06/24 at 5:40 p.m., the VPCO said if the medication was not available, the nurses should have called the physician and asked if there was an alternative medication and notify the physician Resident #1 medication script had not been faxed to the pharmacy. The VPCO said the nurses should have notified the DON that Resident #1 pain medication was not delivered, and the DON would have followed up with the physician and pharmacy too. Interview with the DON on 09/06/24 at 6:04 p.m., the DON said RN A did not notify her that Resident #1 had not received his pain medication from the pharmacy nor that the medication had not been administered to Resident #1. The DON said if Resident #1 did not receive his pain medication he would be in pain. The DON said the medication was given on 09/05/24 according to the MAR. Interview with the VPCO on 09/06/24 at 6:13 p.m., the VPCO said the system was broken down when the nurses did not follow the facility protocol by not notifying the physician and not asking for physician to send the script to the pharmacy and or to receive an alternate pain medication. The VPCO said Resident #1 would be in pain until the facility was able to address it (obtained Resident #1 medication and administered the medication). Interview with NP B on 09/06/24 at 7:26 p.m., NP B said she was the person who verified Resident #1's medication on admission. NP B said Resident #1 was either admitted in the evening or at night and she did not fax Resident #1's medication until the next day when she went to her office because she did not have access to her communication system in order to fax the medication after she verified the medications. NP B said the facility nurse told her Resident #1 was not in pain on admission. NP B said the nurses would have let her know that the medication was not in the building, and they would have had a three-way call to the pharmacy, and pharmacy would give the nurse a code for the pain medication which the nurses would use and get the pain medication from the e-kit. NP B said she did not remember if the nurses had called her before 09/06/24. NP B said RN A called her today (09/06/24) at 4:00 p.m. and told her that Resident #1's pain medications was not in the building, and she told her to call the pharmacy for the pain medications. NP B said RN A called her back and told NP B that the pharmacy said they have not received the pain medication prescription, that was when she said did a three way call around 4:30 p.m., and she told the pharmacy to give RN A the code to get the pain medication from the E-kit. Interview with RN A on 09/06/24 at 8:01 p.m., RN A said she made a mistake by signing off on the Lyrica. RN A said she gave the pain medication Tramadol at 6:31 p.m. after she had a three-way call with pharmacy and NP B. RN A said she did not get report from the previous nursing shift that the resident medication was not delivered. RNA said FM had been telling her Resident #1 was in pain during her shift. RN A said Resident #1 could not tell her because the resident had Aphasia (difficulty talking). RN A said she did not notify the DON because she was trying to find out how to get the pain medication. RN A said when the FM was asking for the pain medication, she thought FM was referring to other medications. Telephone interview with RN B on 09/06/24 at 8:29 p.m., RN B said the nurse she took over from told her that she called the doctor, and the doctor would call it in the pain medication to the pharmacy. RN B said when the pharmacy brought Resident #1 medication on 09/04/2024 Resident #1's pain medications were not among his medications. RN B said she called the pharmacy, and they told her they did not have the triplicate paperwork to be able to provide the pain medications. RN B said she did not call the doctor on 09/04/24. RN B said when she came back on 09/05/24, she called the pharmacy and reported to the person on-call that the facility had not received Resident #1's pain medications. The on-call person told RN B that said she would relate it to the pharmacy. RN B said she went about doing her work and she did not call the doctor or notified the DON or documented the calls she made to the pharmacy. RN B said FM was always in Resident #1's room and would ask for Resident #1's pain medication. RN B said she did not know what the facility protocol was if Resident #1's pain medications were not delivered. RN B said she told the morning nurse (RN A) on 09/06/24 that Resident #1 pain medication did not come. She said she did not know she did not document on the MAR about Resident #1 pain assessment. RN B said the DON monitors nurses during rounding. Telephone interview with LVN C on 09/07/24 at 9:33 a.m., LVN C said FM told her that Resident #1 was in pain, and she said told FM W about 4 or 5 times during her shift that the pharmacy had not brought the pain medications. LVN C said the pain medications did not come in before she left her shift and she had not returned to work since then. LVN C said she was a new staff, and she did not know the facility protocol if a resident missed medications or if the medication was not delivered. LVN C said she told the DON on 09/05/24 that Resident #1's pain medication was not delivered, and she could not remember what the DON said. Record review of the facility's Pharmacy Services policy last revised or reviewed in May 2024 reflected the facility's overall goal of the pharmaceutical services system is to ensure safe and effective use of medications by providing routine and emergency drugs and biologicals to our residents or obtain them through contractual arrangements .that ensure accurate acquiring, receiving, dispensing and administration of all drugs .to meet the needs of each resident. Record review of the facility's Pain Management policy last revised or reviewed May 2023 stated, Each and every resident has a right to the assessment and management of pain. The policy then goes on and discussed chronic pain, which included malignant, cancerous chronic pain, which may be due to tumor progression, invasive procedures infection, physical limitations, may be experienced by the resident as chronic and acute pain and that the facility should investigate immediately any new pain. It further stated that, if the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 (Resident #1) residents reviewed. -The facility failed to ensure that as a resident with cancer of the esophagus Resident #1's Lyrica and Tramadol were available for administration from 09/04/2024 at 10pm to 09/06/2024 at 2pm according to Physician Orders started on 09/04/2024 when Resident #1's nurses knew the pharmacy did not have the prescription for the pain medications but the nurses did not intervene even after Resident #1's representatives requested his pain medications This deficient practice could place residents at risk for adverse effects by not receiving the therapeutic effects of the medication. Findings included: Record review of Resident #1's face sheet dated 09/06/2024 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included: malignant neoplasm of esophagus, Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, Hypertension, Atherosclerotic Heart Disease, and Dysphagia. Record review of the Resident #1's care plan dated 09/04/2024 revealed Resident #1 has the potential for pain. Interventions included: anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/document for probable cause of each pain. Record review of Resident #1's progress notes dated 9/6/20024 at 2:09 pm read in part . his BIMS score was a 13, indicating cognitive intactness . There were no documentation of Resident #1 taking any pain medication in the record. Record review of Resident #1's Physician Orders for September 2024, he was receiving the following: -Pain-Evaluate Pain every shift for Pain Evaluation with a start date 09/04/2024 -Lyrica Oral Capsule 75MG (Pregabalin) Give 1 capsule via G-Tube three times a day for Pain, May open capsule and crush, mix with water with a start date 09/04/2024 -Tramadol Hcl oral Tablet 50 MG Give 1 tablet vi G-Tube every 6 hours as needed for pain Record review of Resident #1's order audit report dated 09/06/2024 at 5:56pm, LVN A created an order for Lyrica Oral Capsule 75MG (Controlled Drug) on 09/04/2024 at 5:02pm. Further review of Resident #1's order audit report dated 09/06/2024 at 5:57pm, LVN A created an order for Tramadol Hcl on 09/04/2024 at 4:34pm. Record review of Resident #1's MAR for September 2024 dated 09/06/2024 at 7:41pm, the resident did not have pain evaluations for 09/05/2024 for the evening shift and 09/06/2024 for the day shift. Resident #1 did not have Lyrica for 09/04/2024 at 10pm, 09/05/2024 at 6am, 2pm, and 10pm, and 09/06/2024 at 6am, and was marked as administered at 2pm. Resident #1 had the following pain assessments completed: 09/04/2024 during admissions/evening shift with a pain level of 0, 09/05/2024 day shift with a pain level of 0, and on 09/06/2024 at 6:31pm with a pain level of 4 and received Tramadol HCl 50MG. Record review of Resident #1's hospital clinicals sent to the facility on [DATE] at 10:01am reflected he was taking Lyrica 75mg oral route scheduled every 12 hours and Tramadol 50mg every 6 hours as needed at the cancer treatment hospital. Interview with Resident #1 and FM W on 09/06/24 at 2:50 p.m., Resident #1 was attempted to talk but he lost his voice. FM W was in the room with Resident #1 and she said Resident #1 does lose his voice sometimes. FM W said Resident #1 had been in pain because he had not received his pain medication since being admitted to the facility. FM W said she had been asking the nurses when Resident #1 would get his pain medication. When the surveyor was about to leave the room, Resident #1 was pointing to his throat and FM W said he was trying to say he was in pain. Observation of Resident #1's bolus feeding on 09/06/24 at 3:09 p.m., FM W asked RN A when she would administer pain medication to Resident #1 because he was in pain. RN A said she would check on the pain medication order after she finished administering the feeding. Interview with Resident #1 and FM W 09/06/24 at 4:00 p.m., Surveyor A assessed Resident #1's pain level on a scale of 1 to 10, and 1 being least and 10 being the most pain where you would rate your pain level. Resident #1 took some minutes strained with difficulty before he responded that his pain level was at 10. FM W said that the pharmacy had not delivered the medication. FM W said she had been asking the nurses and they kept telling her that they are working with the pharmacy. FM W said the nurse that worked yesterday told her must likely the medication would be sent today (09/06/24) by noon. FM W said she knew when Resident #1 was in pain because she had been with him for a long time. Interview with RN A on 09/06/24 at 4:22 p.m., RN A said Resident #1 had two pain medications. RN A said Lyrica was a scheduled medication and Tramadol was PRN and that Resident #1 had not received any of the pain medication. RN A said she called the pharmacy by 4:00 p.m. for both pain medications and the pharmacy said they did not have any order for those medications. RN A said she called the NP B at 4:08 p.m., and NP B told RN A to text the medications to her, which RN A did. RN A said she had not worked with Resident #1 since he was admitted since today was her first day and FM W had asked for Resident #1's earlier and she had not checked to see if the pain medication was in the building until now. RN A said if Resident #1 did not get his pain medication, then the physician order was not followed. Interview with the DON on 09/06/24 at 5:32 p.m., the DON said Resident #1 has two pain medications. The DON said Resident #1 was admitted on the 09/04/24 and that both medications were ordered on 09/04/24 which meant Resident #1 was admitted with the medication. The DON said when the nurse verified Resident #1's medications with the physician or NP, then the physician would call in the medication to the pharmacy and the pharmacy would give the nurse a code to get the medication form the emergency kit (e-kit). The DON said the Lyrica was a scheduled medication for every 8 hours and Tramadol was PRN every 6 hours for pain. The DON said the initial dose for Lyrica would have been given to Resident #1 at 10:00 p.m. on the day of admission. Interview with the VPCO on 09/06/24 at 5:40 p.m., the VPCO said if the medication was not available, the nurses should have called the physician and asked if there was an alternative medication and notify the physician Resident #1 medication script had not been faxed to the pharmacy. The VPCO said the nurses should have notified the DON that Resident #1 pain medication was not delivered, and the DON would have followed up with the physician and pharmacy too. Interview with the DON on 09/06/24 at 6:04 p.m., the DON said RN A did not notify her that Resident #1 had not received his pain medication from the pharmacy nor that the medication had not been administered to Resident #1. The DON said if Resident #1 did not receive his pain medication he would be in pain. The DON said the medication was given on 09/05/24 according to the MAR. Interview with the VPCO on 09/06/24 at 6:13 p.m., the VPCO said the system was broken down when the nurses did not follow the facility protocol by not notifying the physician and not asking for physician to send the script to the pharmacy and or to receive an alternate pain medication. The VPCO said Resident #1 would be in pain until the facility was able to address it (obtained Resident #1 medication and administered the medication). Interview with NP B on 09/06/24 at 7:26 p.m., NP B said she was the person who verified Resident #1's medication on admission. NP B said Resident #1 was either admitted in the evening or at night and she did not fax Resident #1's medication until the next day when she went to her office because she did not have access to her communication system in order to fax the medication after she verified the medications. NP B said the facility nurse told her Resident #1 was not in pain on admission. NP B said the nurses would have let her know that the medication was not in the building, and they would have had a three-way call to the pharmacy, and pharmacy would give the nurse a code for the pain medication which the nurses would use and get the pain medication from the e-kit. NP B said she did not remember if the nurses had called her before 09/06/24. NP B said RN A called her today (09/06/24) at 4:00 p.m. and told her that Resident #1's pain medications was not in the building, and she told her to call the pharmacy for the pain medications. NP B said RN A called her back and told NP B that the pharmacy said they have not received the pain medication prescription, that was when she said did a three way call around 4:30 p.m., and she told the pharmacy to give RN A the code to get the pain medication from the E kit. Interview with RN A on 09/06/24 at 8:01 p.m., RN A said she made a mistake by signing off on the Lyrica. RN A said she gave the pain medication Tramadol on 09/06/2024 at 6:31 p.m. after she had a three-way call with pharmacy and NP B. RN A said she did not get report from the previous nursing shift on 09/05/2024 from 7pm to 7am who would have been LVN C that the resident medication was not delivered. RNA said FM W had been telling her Resident #1 was in pain during her shift. RN A said Resident #1 could not tell her because the resident had Aphasia (difficulty talking). RN A said she did not notify the DON because she was trying to find out how to get the pain medication. RN A said when FM W was asking for the pain medication, she thought FM was referring to other medications. Telephone interview with RN B on 09/06/24 at 8:29 p.m., RN B said the nurse she took over from told her that she called the doctor, and the doctor would call in the pain medication to the pharmacy. RN B said when the pharmacy brought Resident #1 medication on 09/04/2024 Resident #1's pain medications were not among his medications. RN B said she called the pharmacy, and they told her they did not have the triplicate paperwork to be able to provide the pain medications. RN B said she did not call the doctor on 09/04/24. RN B said when she came back on 09/05/24, she called the pharmacy and reported to the person on-call that the facility had not received Resident #1's pain medications. The on-call person told RN B that said she would relate it to the pharmacy. RN B said she went about doing her work and she did not call the doctor or notified the DON or documented the calls she made to the pharmacy. RN B said FM W was always in Resident #1's room and would ask for Resident #1's pain medication. RN B said she did not know what the facility protocol was if Resident #1's pain medications were not delivered. RN B said she told the morning nurse (RN A) on 09/06/24 that Resident #1 pain medication did not come. RN B said she did not know she did not document on the MAR about Resident #1 pain assessment. RN B said the DON monitors nurses during rounding. Telephone interview with LVN C on 09/07/24 at 9:33 a.m., LVN C said FM told her that Resident #1 was in pain, and she said told FM W about 4 or 5 times during her shift that the pharmacy had not brought the pain medications. LVN C said the pain medications did not come in before she left her shift and she had not returned to work since then. LVN C said she was a new staff, and she did not know the facility protocol if a resident missed medications or if the medication was not delivered. LVN C said she told the DON on 09/05/24 that Resident #1's pain medication was not delivered, and she could not remember what the DON said. Record review of the facility's Pharmacy Services policy last revised or reviewed in May 2024 reflected the facility's overall goal of the pharmaceutical services system is to ensure safe and effective use of medications by providing routine and emergency drugs and biologicals to our residents or obtain them through contractual arrangements .that ensure accurate acquiring, receiving, dispensing and administration of all drugs .to meet the needs of each resident. Record review of the facility's Pain Management policy last revised or reviewed May 2023 stated, Each and every resident has a right to the assessment and management of pain. The policy then goes on and discussed chronic pain, which included malignant, cancerous chronic pain, which may be due to tumor progression, invasive procedures infection, physical limitations, may be experienced by the resident as chronic and acute pain and that the facility should investigate immediately any new pain. It further stated that, if the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident #1) reviewed for accidents and hazards, in that: Resident #1's fall intervention was not implemented when staff did not ensure bed was in its lowest position after therapy session . Resident #1 had an unwitnessed fall from his bed and sustained a fractured neck and vertebrae. This failure affected one resident and placed him at risk of pain , hospitalization and diminished quality of life . Findings included: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Fall Risk assessment dated [DATE] revealed he was a high fall risk. Record review of Resident #1's admission MDS dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 12 indicating moderate impaired cognition. Further review of the MDS revealed resident required total dependence on staff for ADL's. Pain assessment revealed resident had no pain. Further review of the MDS revealed Resident #1 had a fall within the last 2 - 6 months of his admission to the facility and he had a [DIAGNOSES REDACTED]. Record review of Resident #1's care plan initiated on 12/6/19 and last revised on 12/16/19 revealed he was at risk for falls due to his [MEDICAL CONDITION] and poor safety judgement secondary to his dementia. 12/14/19 - resident had a fall out of his bed onto his left side - swelling noted to left side of his head and skin tear to his left elbow. His interventions included, 12/14/19 - resident receiving part B therapy services and becoming stronger - resident was sent out to the ER for evaluation due to the swelling to left side of head - all staff will be in-serviced on bed in lowest position while resident is in it - and staff will place floor mats by his bed before he returns from the hospital - resident is able to utilize his call light - however his call light was not on when the nurse entered the room. Anticipate and meet the residents needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear daily. Follow facility fall protocol. The resident needs a safe environment with: even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night. Record review of Resident #1's progress notes dated 12/14/19 at 5:00PM by RN #1 revealed, Staff nurse was called by staff CNA ( CNA #2) to assess patient in his room. Patient observed lying on the floor on his left side next to his bed. Patient unable to give account of events leading to fall; oriented to self. Environment clean and clear of clutter. Head - to - toe assessment done. Patient observed with a swelling/hematoma to left frontal and occipital lobe (left side of head) and a skin tear to left elbow. Patient able to move all extremities without difficulty and appears within his neurological baseline. Neuro checks initiated. NP assessed patient; New order transfer patient to ER and to continue to monitor patient with neuro checks . Patient transferred to ER via 911 by stretcher accompanied by 2 EMS at approximately 5:25PM. Record review of Resident #1 facility incident report dated 12/14/19 at 5:00PM by RN #1 revealed Resident #1 was found on the floor on the left side of his bed by a CNA ( CNA #2) . Resident was assessed and found to have a hematoma to the left side of head and skin tear to left elbow. Resident complained of pain to his head. Resident level of pain was rated at a 4. Record review of Resident #1 hospital records dated 12/16/19 revealed in part, chief complaint: Transfer from[NAME]hospital status [REDACTED]. CT shows C2 - C3 fractures . Record review of RN #1 written statement dated 12/14/19 revealed at approximately 5PM , she was informed by a CNA ( CNA #2) to come and assess Resident #1 who was found on the floor on his left side. The bed was noted not to be in its lowest position. The NP was at the facility and assessed the resident and ordered to send him to the ER. The resident was transferred to the bed with his neck stabilized, he had complaints of pain to his head. The resident had a hematoma to the left side of his head and a skin tear on his elbow. Resident was transferred to the ER at approximately 5:25PM. A Phone interview was attempted with RN #1 on 12/17/19 at 1:57PM with no answer. Record review of LVN #1's written statement dated 12/14/19 revealed she was alerted by a CNA ( CNA #2) that Resident #1 was on the floor. She entered the room and observed Resident #1 on his left side on the floor. While RN #1 began assessing the resident she went to the nurse's station to alert the NP who was in the facility. The NP assessed the resident and ordered to transfer Resident #1 to the hospital. It was noted that Resident #1 bed was not in its lowest position at the time. Interview on 12/17/19 at 3:40PM, LVN #1 said she went into Resident #1's room after he was reported to be on the ground and she saw his bed was at a normal height, not low to the ground. She said Resident #1's was usually kept lower than how it was found when he fell . She said Resident #1 had little mobility and really could not move that much. Record review of RN #2's written statement dated 12/14/19 revealed she was alerted by a CNA around 5PM that Resident was laying on the floor by his bedside. The resident had swelling to his left frontal and occipital lobe. He was assessed by the NP and then transferred to his bed with 4 people with his neck stabilized. Resident was unable to state how he got on the floor. It was noted that the resident bed was not set to the lowest position at the time of the fall. Interview on 12/17/19 at 1:59PM, RN #2 said she did go into Resident #1's room after he was found on the floor and noticed his bed wasn't in lowest position. She said she did not really work with Resident #1 so she was not familiar with his interventions. She said she completed the in-services with the staff that day about lowering resident's bed and positioning them in bed. RN #2 said she heard an occupational therapist was the last person seen with Resident #2. Record review of CNA #1's written statement dated 12/14/19 revealed CNA #2 called her to Resident #1's room to help her assist him off the floor. It was noted Resident #1 was on his left side and the bed was not in the lowest position at the time. After the resident was assessed by nurses he was transferred by 4 people to his bed. Interview on 12/17/19 at 3:24PM, CNA #1 said CNA #2 came out of Resident #1's room and asked for the staff to come in and help. CNA #1 said Resident #1 was on the floor when she entered the room and it looked like he may have rolled out of bed because all of his covers and pillows were on the floor along with the feeding tube machine. She said the resident didn't say what happened or that he was in pain but just kept repeatedly saying, help me, help me. She said she saw there was a knot on his forehead and bleeding from his arm. She said she noticed the resident head of bed was all the way up and his bed was not lowered. She said she had worked with Resident #1 before and the staff knew to have his bed lowered. She said they were in-serviced on lowering the residents' bed when they leave the room and how to position them in bed. Interview on 12/17/19 at 2:58PM, CNA #2 said she worked a double on 12/14/19 and she was assigned to Resident #1. She said she last checked on Resident #1 after shift change (2 - 2:30PM). She said when she left the room the bed was low to the ground and had him positioned on his right side with pillows. CNA #2 said she went to check on Resident #1 again before dinner (around 4:30) and she found him on the ground on his left side. She said she noticed the resident's bed was not in low position like she left it and the resident Head of bed was lifted all the way up. She said the resident had a feeding tube, so the head of his bed was usually slightly elevated but never sitting all the way up. CNA said she'd never seen Resident #1 fall or try and move/get out of bed before, so she was not sure how he fell out of the bed. CNA #1 said the last person she saw go into Resident #1's room before he fell was OTA #1. Phone interview on 12/17/19 at 3:35PM, OTA #1 said she usually would see Resident #1 Monday - Friday but had missed a day so came in on Saturday to work with him. She said she did oral care and range of motion exercises with him in his bed. She said she usually worked with the resident in his wheel chair in the therapy gym but since it was Saturday there was not another therapist there to help her with having him up. She said it was around 3:30PM when she went in to work with Resident #1. She said the resident had verbal behaviors but did not know of him having any fall risk behaviors such as trying to get up or roll out of bed and said falls were not the normal for Resident #1. She said she left the bed positioned the same way she found. OTA #1 said she was short in height, so she wasn't sure if his bed would be considered low and could not say if the bed was in its normal position because she did not usually work with the resident in his bed. Interview on 12/17/19 at 4:15PM, the DON said Resident #1 was a fall risk because of his [DIAGNOSES REDACTED]. She said Resident #1's fall risk interventions were to keep him in the middle of the bed, lower his bed all the way down, and keep him near the nurse's station if in his wheel chair so he could be seen. The DON was asked staff would know what care the resident needed, she said the resident was on a falling star program which staff were made aware of. The DON also said the resident care plan reflected the need for his bed to be lowered . The DON said the resident was able to slightly move his hands . She said the resident bed was found a little higher above the normal lowered position after the fall. The DON said in response to the incident the staff were in-serviced on lowering the bed and how to position resident in bed. She said after the incident there was an audit done of resident beds being lowered and there was no one else found to not have their beds lowered. Observation on 12/18/19 at 10:21AM, Resident #1 was laying in hospital bed with a neck brace on and wrist restraints. Resident had discoloration and swelling to the top of his head on left side. Resident was able to speak but words didn't make sense. Resident repeatedly said, help me, help me but would not respond when asked what was wrong. Observation on 12/20/19 at 1:15AM, Resident #1 was back in facility in room directly across from the nurse's station. Resident #1's bed was observed to be lowered almost all the way to the ground with head of bed slightly elevated. Resident #1 was in and out of sleep and had his neck brace collar on. Resident had several pillows in the bed positioning him on his left side with falls on the floor on both sides of his bed. Interview on 12/20/19 at 2:57PM, an anonymous staff member said when Resident #1 fell out of his bed on 12/14/19, the bed was left in a high position. It was said that management asked staff members to just put in their statements and tell surveyor the bed wasn't in its lowest position and to not say, the bed was not lowered. It was said OTA #1 had went into Resident #1's room and did lower the bed back down when she left. Interview and observation on 12/20/19 at 4:13PM, CNA #2 was asked to demonstrate to surveyor how she left Resident #1's bed and then how she found it after the fall. Surveyor and CNA #2 entered Resident #1's room and she said she left the bed how the resident's bed was currently positioned (about 1 foot from the floor). CNA #2 then lifted the bed another 14 inches and then elevated the resident head of bed up to almost a 90-degree angle and said that was the bed position she found the bed in when Resident #1 was on the floor. CNA #2 said someone had to have moved the resident after she left him because she left the resident laying on his right side, but he was found on the left side of his bed. She Resident #1 was unable to rotate himself in bed. CNA #2 said she would consider the position the bed was found after the resident fell to be, not as low as it should have been. On 12/17/19 at 4:15PM, the DON said the facility did not have policy on accidents an supervision. Fall Management policy provided by facility did not address above concerns.

Based on observation, record review, and interview, the facility failed to ensure residents were free from neglect for one of ten residents (CR #1) reviewed for neglect. The facility failed to have system in place that ensured IV fluids were available in the facility emergency supply for immediate use. The facility failed to have system in place that ensured IV fluids were ordered and received within the two hour expected time frame. CR #1, who had physical signs of dehydration, was ordered to receive IV solution that was not provided by the facility. After 8 hours of no IV fluid , the resident was transferred to the hospital where she was diagnosed with [REDACTED]. CR #1 died the next day. An Immediate Threat (IT) was identified on [DATE] . While the IT was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one resident and delayed the resident from receiving ordered treatments which caused a decline in her medical condition. These failures placed all residents in the facility at risk of neglect and diminished quality of care. Findings include: Record review of CR #1's face-sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation of CR #1 on [DATE] at 4:15 p.m. revealed she was alert, oriented, and confined to a wheelchair. Record review of CR #1's record revealed CR #1 was sent out to a local hospital on [DATE], and she died on [DATE]. Record review of CR #1's MDS dated [DATE] revealed she had a BIMS score of 15 indicating her cognition was intact. Record review of CR #1's care plan, updated on [DATE] revealed on [DATE], CR #1 had critical labs which were reported to her physician. Record review of CR #1's physician progress notes [REDACTED].Family requested evaluation of continued abdominal discomfort and diarrhea overnight and acute change of increased weakness, patient notes she had 3 diarrhea stools on [DATE] and one this a.m. she reports her abdominal discomfort has decreased with initiation of [MEDICATION NAME] but now it has moved further down in her abdomen .-follow up evaluation required of the paraparesis ([DIAGNOSES REDACTED] of the lower limbs) , PT and OT note patient has increased weakness today and difficulty standing whereas normally he is able to stand on her own .Review of systems .Gastrointestinal: I hurt all over while rubbing her abdomen, diarrhea x3 on [DATE], diarrhea x1 on [DATE], decreased p.o. intake overnight and this a.m. I did not eat anything for breakfast .PHYSICAL EXAM; General: Frail and tired appearing elderly female with eyes sunken, dressed, lying in bed, alert, in no acute distress; HEENT: Normocephalic, PERRLA, sclera nonicteric, nasal mucosa pink, septum midline, no oral [MEDICAL CONDITION], oropharynx severely dry . Gastrointestinal: Round bowel sounds x4 quadrants, mild distention, diffuse mild tenderness to palpation, diarrheal stool today .ASSESSMENT & PLAN .Leukocytosis/dehydration - initiate IV, start Normal Saline 42 ml/hr for a total of 1 L, patient afebrile, decreased PO intake overnight and today, STAT CBC ordered. Abdominal pain and distention/chronic diarrhea - worsening, continue lactobacillus, [MEDICATION NAME] 40, STAT KUB, bladder scan, stool sample and C.diff, and BMP ordered .DISCUSSED PLAN OF CARE WITH: Patient, family, nursing and non licensed staff, PT, OT .ADDENDUM: Patient discharged to hospital per family request on [DATE] .Document e-signed by NP on [DATE] 3:03 p.m. Record review of CR#1's physician order [REDACTED]. In an interview with RN A on [DATE], at 12:49 p.m., she stated when she saw CR #1 on Wednesday, [DATE], she was surprised because she looked pale and the resident said she did not feel great. The resident's vitals were good and she observed her eating. At some point, NP #1 arrived and ordered stat labs, stat KUB, and IV of normal saline over 24 hours. When she went to gather supplies, there was no normal saline so she faxed an order to the pharmacy. Around 5 p.m. that day, one of the resident's family members asked about the lab results which had not yet come in. After that, the technician came to do the KUB and the verbal results came in for the critical labs. RN B took the call for the labs and reported them to her. The WBC were critical at 46.3. The value was reported to the NP and [MEDICATION NAME] was ordered for 14 days. The family member came back and asked RN B why the IV had not yet been started and RN B then asked her. The order popped up in the computer incorrectly as a saline flush and not an IV. RN A corrected the order in the computer. There was no normal saline in the building. When RN B had asked her at first, RN A had not yet corrected the order. She stated it was wrong. The order said normal saline flush but the description was correct. RN A said when RN B asked about it, she already knew there was no saline in the building. She had already checked the emergency supply in the Omnicell. As the interview continued RN A said she received the critical lab value, and notified the NP. She only gave the NP the critical lab value. She stated she did not send the resident out to the hospital because she was not a doctor. Sending residents out depends on the physicians' orders. She stated in her nursing judgement, the critical labs would have warranted a trip to the emergency room . That night, she left the facility at 8:30 p.m. The resident was still in the building and did not have an IV. The usual turn-around time for the pharmacy to return IV fluids was maybe two hours. The family member who was in the building stated she was contacting another family member who was a nurse, so RN A said she knew the other family member would want to send the resident out. The next shift nurse had already taken over. RN B asked the family if they wanted to send CR #1 out but they wanted to wait and see if they could get a direct admit. Record review of CR #1's Lab Results Report, dated, [DATE] at 4:39 p.m. revealed the following values: WBC (white blood cells): 46.3 (Critical) Reference Range: 3.8 - 10.1 BUN: 45 (High) Reference Range: 7 - 22 Creatinine: 2.0 (High) Reference Range: 0.6 - 1.2 Record review of the facility pharmacy shipment details dated [DATE] revealed unknown medications were shipped by the pharmacy on [DATE] and were picked from the pharmacy by the delivery person at 7:05 p.m. The last status indicates it was delivered but it did not indicate what time or what was delivered. In a telephone interview with CR #1's family member on [DATE], at 10:30 a.m., she stated she arrived at the facility on [DATE] at 6:55 p.m. When she got there, the resident appeared to be having a [MEDICAL CONDITION]. Once she came out of it, CR #1 said she was ok. She asked RN B where CR #1's IV was and the nurse said there was no order for an IV. Around 9:00 p.m., RN B came and said there was an order for [REDACTED]. The family member stated nobody ever went back to check on the resident and nobody went to check her vital signs. The resident lay there suffering with infection for ,[DATE] days. The resident was not drinking because she was afraid no staff would come and change her if she wet herself. The resident did not leave the facility to go to the hospital until 9:45 p.m. after they could not get a direct admit from the doctor. She said once they were at the hospital, the doctor stated CR #1 had a really bad case of [MEDICAL CONDITION], was extremely dehydrated, had a UTI, and her kidneys were only working at 19%. CR #1 was doing well after receiving IV fluids but then suddenly had a drastic decline and died in the ICU of the hospital on [DATE]. In an interview with NP #1 on [DATE], at 11:30 a.m., she stated she had assessed CR #1 on Monday, [DATE] when she complained of lower abdominal pain and again on Tuesday, [DATE]. By Tuesday, the discomfort had improved but her diarrhea had picked up and she was getting dry orally. She threatened CR #1 with IV fluids in hoped she would increases oral fluids. By Wednesday, [DATE], there was an acute difference. The resident's eyes were sunken in and her mouth was dry. PT said she was severely weak. NP #1 ordered an IV, CBC, chest x-ray and KUB. This was around 12 p.m. or 1 p.m. because she called CR #1's family member on her phone at 12:43 p.m. The resident was very dehydrated. She said she knew the expectation for nursing facilities to carry out orders would be a couple of hours but she hoped it would be sooner than later. She did let the nurse know CR #1 needed IV fluids. At 4:30 p.m. that day, CR #1's lab results were communicated to her by her partner, NP #2. She relayed through NP #2 to start [MEDICATION NAME]. At 8:39 p.m., CR #1's family member text her to verify she had ordered IV fluids because the facility's staff claimed there was no order for IV fluids. NP #1 text back and indicated she had ordered the IV fluid. NP #1 contacted NP #2 to question why the IV had not been started. NP #2 said she called the facility to ask about the IV. NP #1 stated she nor NP #2 had been informed there was no normal saline available in the facility. Had the staff communicated that, she would have substituted the order for something the facility did have in stock. Neither she nor NP #2 were contacted when there was a delay in getting the normal saline. NP #1 said she expected them to start the IV within ,[DATE] hours but she hoped sooner. CR #1's critical lab (WBC count) was relayed to her but the other high labs, including BUN and Creatinine were not communicated to her. The WBC count was extremely high but did not necessarily mean she should have gone to the emergency room . She said they could have controlled it at the facility because the level may have been due to the dehydration, which could have made the number high. CR #1's blood pressure was also a little low but she expected the IV fluids to rebound that. NP #1 stated with all the comorbidities CR #1 had going on, had she known about the other high labs, she would have ordered the resident to be sent out to the emergency room immediately. The WBC level qualifies as septic and with her symptoms, she would have sent her out. NP #1 stated if CR #1 had the IV fluids earlier, it could have improved her situation. An attempt was made to contact NP #2 on [DATE], at 10:31 a.m. but the voicemail message was never returned. In a telephone interview with CR #1's family member on [DATE], at 11:51 a.m., he stated on [DATE], at 7:04 p.m., he received a call from another family member who had just arrived to the facility and observed CR #1 did not have an IV started. The other family member also stated CR #1 was not acting right, she was confused, and she was convulsing like she was having a [MEDICAL CONDITION]. The nurses at the facility said there was no order for IV fluids. The family member sent NP #1 a text at 8:39 p.m. asking about the order. The NP indicated the IV fluids was part of the written orders she gave before she left. The family member stated he asked the NP about a direct admit for CR #1 because they did not want to go through the emergency room based on the critical labs. The direct admit was not possible so they decided to call 911. The family member stated at the hospital, CR #1 was diagnosed with [REDACTED]. In an interview with the DON on [DATE], at 1:45 p.m., she stated she left the facility around 6:30 p.m. on [DATE] after dealing with another family. The normal turn-around time was two hours. She stated they had used the last normal saline bag from the emergency supply kit (Omnicell) that day on another resident. She stated they ran a lot of IV's. She stated the saline had been received in the building before the resident left for the hospital but the resident's family would not allow RN B to do the IV. At that time, the DON was asked for documentation of how many residents required IV fluids of normal saline on [DATE]. She provided the name of only one resident who was on normal saline during that time period but she could not provided documentation to show that any bags of normal saline had been taken from the emergency supply kit (Omnicell) that day or any day. The DON stated the number of bags of normal saline vary before being restocked. Normally, there were two bags of each concentration of saline. She said the bags were either pulled for use on another resident of because they were expired. She was unable to say which situation occurred. She said the Omnicell tracks the supply and automatically sends orders for restock. The DON could not say how many bags or pills had to be taken out of the machine before the pharmacy sent additional medication to restock. She stated the facility received automatic stocks for both Omnicell machines once every week. The DON said there were so many different concentrations of saline that they may or may not have had someone else using that particular concentration at the time. It may have been pulled for expiration date. The DON said there was no minimum amount since it was an emergency stock. The amount of IV bags varied before being re-stocked. She said normally, there were two on hand of each kind but they try to always have at least one in stock. The Omnicell tracked the bags being pulled, they did not. The Omnicell automatically re-stocked what was taken out but the DON could not say how many had to be pulled or left in stock before the Omnicell would automatically re-stock. In an interview with the DON on [DATE], at 4:30 p.m., she stated RN B should have and would normally have called the pharmacy about the delay in delivery of the IV fluids. She stated she could not say if NP #1 was notified about the saline. In a later interview with the DON on [DATE], at 10:15 a.m., she stated she had no poof that facility nurses contacted the NP when the particular concentration of saline was found in the building or that the NP was contacted when the saline was not delivered to the building within the normal 2 hour time frame or even 4 hours. She also stated CR #1's WBC, BUN, Creatinine, and ammonia levels were always high. The DON said the lab called in a verbal report on the critical labs. The other values were not received until the lab faxed over the paper report. I did not ask if the nurse should have called the NP with the other values but she said say the resident's BUN and Creatinine were always elevated, so there was nothing unusual about it. In an interview with RN B on [DATE], at 3:30 p.m., she stated she was the charge nurse. She said the lab called the facility around 6 p.m. on [DATE]. She told RN A about the critical lab right away. She called the NP and told the lab to fax the original lab report. After dinner, between 6 or 7, CR #1's family member came and asked how she was. The morning nurse, RN A was still there giving report. The family member asked about the IV and she told her she thought they were still waiting on the fluids from the pharmacy. RN B had to go look for the evening nurse and clarify the order for IV fluids. The morning nurse did have the paper lab results faxed from the lab. The family member stated another family member was reviewing the video camera footage from inside CR #1's room and he saw the resident reaching up and grabbing for things that were not there. They were still waiting on the delivery of the IV fluids. RN B stated she was going to go ahead and insert the IV in preparation to receive the fluids from the pharmacy. She asked the family member if they wanted to start the IV or send the resident out to the hospital and she said she would talk to the other family member about a direct admit. RN B called the DON, who told her to give the family 15 minutes to decide if they wanted the IV or to send resident out. The family member came back inside the building and said to call 911. RN B said they always get critical labs but they manage the residents there at the facility as oppose to sending them out. She said she never interacted with the resident. RN B said the particular saline NP #1 ordered was very common. NP's always order that one. The normal saline was delivered after the resident was already transferred to the hospital. Record review of CR #1's EMS report, dated, [DATE] revealed they were called for transport on [DATE], at 9:30 p.m. EMS arrived on the scene at 9:36 p.m. ( however, the facility record indicated the resident was sent to the hospital same day at 8:33pm) and arrived at a local hospital at 9:38 p.m. At 9:52 p.m., CR #1 was administered normal saline. Her skin was described as cold, cyanotic, diaphoresis, hot, jaundiced, lividity, mottled, and pale. Record review of CR #1's hospital records revealed she was triaged at a local hospital on [DATE], at 10:07 p.m. Record review of the facility's policy on Abuse, Neglect, and Exploitation revealed it was not dated. The document read in part, Policy: This policy establishes the commitment of the facility to ensure that residents are free from abuse, neglect, misappropriation of resident property and exploitation .Definitions: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The Administrator and DON were notified of Immediate Jeopardy (IJ) on [DATE] at 1:41 p.m. due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 1:19 p.m. after several revisions were made. IJ/IT/SQC - [DATE] Plan of Removal 1. Review/Audit of the facility's E-Kit. The DON/Designee will audit daily the medications pulled from the Omni cell on [DATE] If any medications are needing to be replenished or re-ordered, the DON and/or designee will notify the Pharmacy of medication(s) needing to be re-ordered and will follow-up with the pharmacy. The expected turnaround from the pharmacy is ,[DATE] hours. Stat is 4 hours. Checkoff sheet was developed to be used daily by the DON/Designee and will start using immediately. The DON and Designee was training on the ekit checkoff on [DATE]. The ekit checkoff was started on [DATE]. The checkoff sheet includes: date, Auditor, Medications pulled from the Omnicell so they can be audited; Pharmacy notification, Date and time of pharmacy notification; Medication arrival The Administrator will collect and review checkoff sheets and will follow-up with action items, as needed. This started on [DATE]. Administrator/DON will meet with pharmacy to review and adjust Omni cell par levels with pharmacy. The PAR levels are being reviewed by Pharmacy Consultant, Omnicare, on [DATE]. Consultant will be providing us feedback on PAR levels on [DATE]. I have contacted the Medical Director for any recommendation for the ekit from the physician's perspective. Have extra saline's bags added to the Omni cell on [DATE]. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. The Administrator is reviewing for: new orders; reviewing new admission orders [REDACTED]. This process has begun on [DATE]. Any Changes in Condition and/or new order recommendations will be reviewed with the Director of Nursing with appropriate action and notification to physician taken. 2. Critical Lab Values/Change of Condition. Physician/Nurse Practitioner and Responsible Party will be notified of any Change of Condition of a resident, to include Critical Lab Values. The DON and Licensed Nurses were educated on [DATE] and [DATE] to immediately notify the physician and responsible party of changes in condition, to include critical lab values. Monitoring the residents and documenting changes and vital signs in resident records was included in the training on [DATE] and [DATE]. Licensed nurses have been educated, starting [DATE], if receiving the information about a critical lab, to also ask if there are any other abnormalities that need to address. The DON will be notified of any Changes in Condition, to include Critical Lab Values, starting on [DATE]. The Licensed Nurses were trained on the processes on [DATE] and [DATE]. The DON received training on the process on [DATE] by the Corporate Clinical Director. Critical Lab Form has been developed for the Licensed Nurses to use. This will prompt the nurse to ask for any other abnormalities and to notify the physician of any changes. The Director of Nursing and/or the Administrator will monitor Changes of Condition/Critical Labs and make recommendations, as needed. This process started on [DATE] and is being monitored daily. The DON has been educated by the Corporate Clinical Director on [DATE], on resident assessment, Change in Condition, to include Critical Lab Values and protocols of when a resident needs to be transferred to a higher level of care, ex. Hospital. The facility ensures that the nursing staff are properly advised and monitored for proficiency and competency in nursing assessments skill at: Nursing Orientation; Competency Check-offs - annually and as needed. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 3. Medication Availability/Notification to Physician/Responsible Party. Licensed Nurses have been educated, starting on [DATE], to notify the Physician if a medication is not available and document the recommendation from the physician in Point Click Care. Licensed Nurses have been educated, starting on [DATE], to check the facility eKit for medications not delivered from the pharmacy. If a medication is not available in the facility eKit, the Licensed Nurse is to notify the physician immediately of medications not available and receive directives from the physician and notify the DON. Licensed Nurses have been educated, starting on [DATE], to document the directive from the Physician in the resident's chart in Point-Click-Care. 100% MAR indicated [REDACTED]. All medications in the facility were accounted for all orders complete. The audit was completed by the: Assistant Director of Nursing, Transitional Nurse, and the MDS Nurse. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 4. We anticipate the completion of this plan [DATE]. 5. Nursing staff, who have not been trained on the above processes, will not be allowed to work in the facility until the training as taken place. As of [DATE], all scheduled nurses have been trained on the processes. An active staff roster was utilized to verify staff have been trained. 6. All these process will be audited and reported to the QAPI committee and reviewed for trends and/or corrections. The Administrator will monitor this process and make recommendations. Monitoring Monitoring of the plan to remove the immediate jeopardy was conducted daily at various times from [DATE] until [DATE]. In an interview with LVN C on [DATE], at 6:00 p.m. she stated she had been in-serviced on the facility's new procedures and forms. If a resident's IV fluids were not available, they would immediately call the NP to inform them it was not available and let them know what was available. Other topics included critical labs, SBAR's, and notifications. The nurses know to contact the big three (the DON, the physician, and the family) for any changes of condition, critical labs, or other high lab values. In an interview with LVN D on [DATE], at 6:30 p.m., she stated she had recently been in-serviced on the Omnicell process, the new forms for the Omnicell and critical labs, notification, and other high lab values. In an interview with RN [NAME] on [DATE], at 6:45 p.m., she stated she was the charge nurse for weekends only. She stated all of the facility's nurses had been in-serviced on new processes related to changes of conditions, notification of the big three, pharmacy orders, Omnicell, monitoring vital signs of residents with changes, and critical labs and other high values. In an interview with RN F on [DATE], at 7:15 p.m., she stated all the nurses were in-services on the new facility procedures. None of the nurses could work on the floor unless they were in-serviced. In an interview with RN G on [DATE], at 7:00 p.m., she stated she was a charge nurse and was the oncoming nurse on [DATE]. She had been off for two days and when she returned to the facility, CR #1's family member was there calling 911. The staff was trying to get the resident ready, so no staff was available at the time to give her situation report . There was no time to assess CR #1 because it was so chaotic. The IV fluids had not yet arrived in the building. All of the nurses were in-serviced on critical labs, Ominicell process and documentation of medications taken from it, critical labs and other high lab values, and notification. Record review of facility documents revealed the nursing staff was in-serviced on [DATE], [DATE], and [DATE] on: Formulary of E-kit, Medication Availability, Notification to Physician, DON, and family, Critical Labs and forms, Changes of Condition, and Omnicell. Record review of facility documents revealed the nursing staff was in-serviced on [DATE], [DATE], and [DATE] on: Formulary of E-kit, Medication Availability, Notification to Physician, DON, and family, Critical Labs and forms, Changes of Condition, and Omnicell. The Administrator and the DON were informed on [DATE] at 7:39 pm that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not immediate jeopardy due to the facility continued to train their staff.

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of ten residents (CR#1) reviewed for quality of care . The facility failed to notify CR #1's physician of unavailability of ordered IV fluids and failed to notify physician that when requested pharmacy delivered of IV was delayed for more than seven hours with the resident's condition deteriorating. The facility failed to notify CR #1's physician about abnormal lab values resulting in an order for [REDACTED]. The facility failed to identify CR#1's increased symptoms of dehydration and confusion while waiting to receive supplies. These changes not communicated to the NP delayed the resident's transfer to the acute care facility where she was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on [DATE] . While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected CR #1 and have the potential to affect all residents in the facility who experience changes in condition placing them at risk of complication and decline in health. Findings include: Record review of CR #1's face-sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's record revealed CR #1 was sent out to a local hospital on [DATE] and she died on [DATE]. Observation of CR #1 on [DATE] at 4:15 p.m. revealed she was alert, oriented, and confined to a wheelchair. Record review of CR #1's MDS dated [DATE] revealed she had a BIMS score of 15 indicating her cognition was intact. The assessment also indicated the resident required extensive staff assistance with bed mobility, transferring, locomotion, dressing, bathing, and toilet use, she ambulated via wheelchair, and she occasionally complained of pain and was on scheduled pain and as-needed medication for pain. CR#1 was independent with eating. Record review of CR #1's care plan updated on [DATE] revealed CR #1 had critical labs which were reported to her physician. Record review of CR #1's physician progress notes [REDACTED].Family requested evaluation of continued abdominal discomfort and diarrhea overnight and acute change of increased weakness, patient notes she had 3 diarrhea stools on [DATE] and one this a.m. she reports her abdominal discomfort has decreased with initiation of [MEDICATION NAME] but now it has moved further down in her abdomen .-follow up evaluation required of the paraparesis ([DIAGNOSES REDACTED] of the lower limbs) , PT and OT note patient has increased weakness today and difficulty standing whereas normally she is able to stand on her own .REVIEW OF SYSTEMS .Gastrointestinal: I hurt all over while rubbing her abdomen, diarrhea x3 on [DATE], diarrhea x1 on [DATE], decreased p.o. intake overnight and this a.m. I did not eat anything for breakfast .PHYSICAL EXAM; General: Frail and tired appearing elderly female with eyes sunken, dressed, lying in bed, alert, in no acute distress; HEENT: Normocephalic, PERRLA, sclera nonicteric, nasal mucosa pink, septum midline, no oral [MEDICAL CONDITION], oropharynx severely dry . Gastrointestinal: Round bowel sounds x4 quadrants, mild distention, diffuse mild tenderness to palpation, diarrheal stool today .ASSESSMENT & PLAN .Leukocytosis/dehydration - initiate IV, start Normal Saline 42 mL/hr for a total of 1 L, patient afebrile, decreased PO intake overnight and today, STAT CBC ordered. Abdominal pain and distention/chronic diarrhea - worsening, continue lactobacillus, [MEDICATION NAME] 40, STAT KUB, bladder scan, stool sample and C.diff, and BMP ordered .DISCUSSED PLAN OF CARE WITH: Patient, family, nursing and non-licensed staff, PT, OT .ADDENDUM: Patient discharged to hospital per family request on [DATE] .Document e-signed by NP on [DATE] 3:03 p.m. Record review of progress notes, dated, [DATE], revealed at 1:04 p.m., RN A wrote, Late entry: Patient received in bed alert and oriented x4, in no acute distress but voiced not feeling great . Vital signs assessed Blood Pressure ,[DATE], Pulse 78, respirations 20, temperature 98.6 axilla, and O2 saturation 96% . This note was crossed out by RN A on [DATE] at 2:26 p.m. The note was re-written on [DATE] at 2:26 p.m and read Patient received in bed alert and oriented x4, in no acute distress but voiced not feeling great . Vital signs assessed Blood Pressure ,[DATE], Pulse 78, respirations 20, temperature 98.6 axilla, and O2 saturation 96% . (the following note was added) NP in to assess patient. New order received for Stat CBC, BMP, KUB, collect stool for [MEDICAL CONDITION]. and IV for 0.9% Normal saline x 1L over 24 hours . In an interview with RN A on [DATE], at 12:49 p.m., she stated she crossed out the note because there was a typo. Record review of CR#1's physician order [REDACTED]. Record review of CR #1's Lab Results Report dated [DATE] at 4:39 p.m. revealed the following values: WBC (white blood cells): 46.3 (Critical) Reference Range: 3.8 - 10.1 BUN: 45 (High) Reference Range: 7 - 22. Creatinine: 2.0 (High) Reference Range: 0.6 - 1.2 . further review of the lab result revealed BUN and Creatinine were sent to the facility by 4:21pm on [DATE]. Record review of CR#1's progress notes dated [DATE] revealed at 5:35 p.m., RN A wrote, Critical lab report received from lab notified NP, new order [MEDICATION NAME] 125mg by mouth .Will continue to monitor and assist as needed Record review of CR#1's SBAR Communication Form and progress note dated [DATE], revealed the resident was noted to have abnormal lab, Poor appetite, and IV solution was ordered due to poor hydration. Under Vital Signs, the note read, i. Most Recent Blood Pressure: ,[DATE] Date: [DATE] at 9:32am . j. Most recent Pulse: 78 Date: [DATE] at 9:32am . k. Most recent Respiration: 18 Date: [DATE] at 9:56 p.m. m. Most recent temperature: 97.8 date: [DATE] at 11:32 p.m. P. Most recent O2 saturation: 97% date: [DATE] at 12:14am . 1. Mental Status Changes 1b is checked, indicating Increased confusion .[NAME] ASSESSMENT (RN) or APPEARANCE LPN) What do you think is going on with the resident? RN. I think the problem may be increased white count- rule [MEDICAL CONDITION] R. REQUEST 1. I suggest or request (check all that apply) 1a. is checked, indicating: Monitor vital signs and 1f. is checked, indicating Transfer to the hospital send a copy of this form) 2. Nursing Notes (for additional information on the Change in Condition): MD and family are aware of the current condition. interventions in place for IV and more lab work .3b. Date and time: [DATE] at 4:45 p.m . Further record review of all documentation provided revealed CR #1's condition and vitals were not monitored after she experienced visible symptoms of dehydration and confusion. She was not assessed after the delay in ordered administering IV fluids. Interview on [DATE] at 1:45pm, the DON said the only vital signs taken and documented for CR #1 was done about 2:26pm on [DATE] by RN [NAME] Record review of CR #1's EMS report, dated, [DATE] revealed they were called for transport on [DATE], at 9:30 p.m. EMS arrived on the scene at 9:36 p.m. ( however, the facility record indicated the resident was sent to the hospital same day at 8:33pm) and arrived at a local hospital at 9:38 p.m. At 9:52 p.m., CR #1 was administered normal saline. Her skin was described as cold, cyanotic (bluish coloration of skin and mucous membrane) , diaphoresis (Sweating) , hot, jaundiced (Yellowing of skin or eyes) , lividity ( bluish color of skin) , mottled (patchy, irregular skin colors) , and pale. Record review of progress notes, dated [DATE], revealed at 8:33 p.m., RN B, Resident was sent out 911 to hospital due to generalized weakness and critical lab result . Record review of CR #1's MAR/TAR dated (MONTH) 2019 revealed no documentation indicating the ordered normal saline (IV fluid) was administered to CR#1. Further review of MAR indicated [REDACTED]. Record review of CR #1's hospital records revealed she was triaged at a local hospital on [DATE], at 10:07 p.m. In a telephone interview with CR #1's family member on [DATE], at 10:30 a.m., she stated she arrived at the facility on [DATE] at 6:55 p.m. When she got there, the resident appeared to be having a [MEDICAL CONDITION]. Once she came out of it, CR #1 said she was ok. She asked RN B where CR #1's IV was and the nurse said there was no order for an IV. Around 9:00 p.m., RN B came and said there was an order for [REDACTED]. It was around that same time the nurse handed her the lab report and said they were critical. The family member stated nobody ever went back to check on the resident and nobody went to check her vital signs. The resident did not leave the facility to go to the hospital until 9:45 p.m. after they could not get a direct admit from the doctor. She said 5 hours with the IV could have made a difference. Once they were at the hospital, the surgeon stated CR #1 had a really bad case of [MEDICAL CONDITION], was extremely dehydrated, had a UTI, and her kidneys were only working at 19%. CR #1 was doing well after receiving IV fluids but then suddenly had a drastic decline and died in the ICU of the hospital on [DATE]. The family requested an autopsy. The family member was later contacted by the hospital and informed CR #1's body was turned over to the county medical examiner for autopsy because the hospital labeled the resident's death as suspicious. In an interview with NP #1 on [DATE], at 11:30 a.m., she stated she had assessed CR #1 on Monday, [DATE] when she complained of lower abdominal pain and again on Tuesday, [DATE]. By Tuesday, the discomfort had improved but her diarrhea had picked up and she was getting dry orally. She threatened CR #1 with IV fluids in hoped she would increases oral fluids. By Wednesday, [DATE], there was an acute difference. The resident's eyes were sunken in and her mouth was dry. PT said she was severely weak. NP #1 ordered an IV, CBC, chest x-ray and KUB. This was around 12 p.m. or 1 p.m. because she called CR #1's family member on her phone at 12:43 p.m. The resident was very dehydrated. She said she knew the expectation for nursing facilities to carry out orders would be a couple of hours but she hoped it would be sooner than later. She did let the nurse know CR #1 needed IV fluids. At 4:30 p.m. that day, CR #1's lab results were communicated to her by her partner, NP #2. She relayed through NP #2 to start [MEDICATION NAME]. At 8:39 p.m., CR #1's family member text her to verify she had ordered IV fluids because the facility's staff claimed there was no order for IV fluids. NP #1 text back and indicated she had ordered the IV fluid. NP #1 contacted NP #2 to question why the IV had not been started. NP #2 said she called the facility to ask about the IV. NP #1 stated she nor NP #2 had been informed there was no normal saline available in the facility. Had the staff communicated that, she would have substituted the order for something the facility did have in stock. Neither she nor NP #2 were contacted when there was a delay in getting the normal saline. NP #1 said she expected them to start the IV within ,[DATE] hours but she hoped sooner. CR #1's critical lab (WBC count) was relayed to her but the other high labs, including BUN and Creatinine were not communicated to her. The WBC count was extremely high but did not necessarily mean she should have gone to the emergency room . She said they could have controlled it at the facility because the level may have been due to the dehydration, which could have made the number high. CR #1's blood pressure was also a little low but she expected the IV fluids to rebound that. NP #1 stated with all the comorbidities CR #1 had going on, had she known about the other high labs, she would have ordered the resident to be sent out to the emergency room immediately. The WBC level qualifies as septic and with her symptoms, she would have sent her out. NP #1 stated if CR #1 had the IV fluids earlier, it could have improved her situation. An attempt was made to contact NP #2 on [DATE], at 10:31 a.m. but the voicemail message was never returned. In a telephone interview with CR #1's family member on [DATE], at 11:51 a.m., he stated on [DATE], at 7:04 p.m., he received a call from another family member who had just arrived to the facility and observed CR #1 did not have an IV started. The other family member also stated CR #1 was not acting right, she was confused, and she was convulsing like she was having a [MEDICAL CONDITION]. The nurses at the facility said there was no order for IV fluids. The family member sent NP #1 a text at 8:39 p.m. asking about the order. The NP indicated the IV fluids was part of the written orders she gave before she left. The family member stated he asked the NP about a direct admit for CR #1 because they did not want to go through the emergency room based on the critical labs. The direct admit was not possible so they decided to call 911. The family member stated at the hospital, CR #1 was diagnosed with [REDACTED]. In an interview with RN A on [DATE], at 12:49 p.m., she stated when she saw CR #1 on Wednesday, [DATE], she was surprised because she looked pale and the resident said she did not feel great. The resident's vitals were good and she observed her eating. At some point, NP #1 arrived and ordered stat labs, stat KUB, and IV of normal saline over 24 hours. When she went to gather supplies, there was no normal saline so she faxed an order to the pharmacy. Around 5 p.m. that day, one of the resident's family members asked about the lab results which had not yet come in. After that, the technician came to do the KUB and the verbal results came in for the critical labs. RN B took the call for the labs and reported them to her. The WBC were critical at 46.3. The value was reported to the NP and [MEDICATION NAME] was ordered for 14 days. The family member came back and asked RN B why the IV had not yet been started and RN B then asked her. The order popped up in the computer incorrectly as a saline flush and not an IV. RN A corrected the order in the computer. There was no normal saline in the building. When RN B had asked her at first, RN A had not yet corrected the order. She stated it was in wrong. When asked if she reported this to the NP, she said no. The order said normal saline flush but the description was correct. RN A said when RN B asked about it, she already knew there was no saline in the building. She had already checked the emergency supply in the Omnicell. When she received the critical lab, she notified the NP. She stated she did not send the resident out because she was not a doctor. Sending residents out depends on the physicians' orders. She stated in her nursing judgement, the critical labs would have warranted a trip to the emergency room . That night, she left the facility at 8:30 p.m. The resident was still in the building and did not have an IV. The usual turn-around time for the pharmacy to return IV fluids was maybe two hours. The family member who was in the building stated she was contacting another family member who was a nurse, so RN A said she knew he would want to send the resident out. The next shift nurse had already taken over. RN B asked the family if they wanted to send CR #1 out but they wanted to wait and see if they could get a direct admit. In an interview with the DON on [DATE], at 1:45 p.m., she stated she left the facility around 6:30 p.m. on [DATE] after dealing with another family. The critical labs were received around 4:45 p.m. but CR #1 was not sent out because the NP did not order it. CR #1 was given an order for [REDACTED]. She stated CR #1 did not have any visible signs of dehydration. The resident was very weak but nothing triggered that day. She did not notice signs of dehydration because CR #1's electrolytes were chronically off. The DON said you do need good functioning kidneys for [MEDICATION NAME] but the resident had been on [MEDICATION NAME] several times prior to that. She stated RN B was ready to do the IV when CR #1's family member arrived and said to wait until they called to see if they could get a direct admit. The DON stated the NP put the actual order on the correct sheet at 1:53 p.m. and that is when the order would have been sent to the pharmacy. The normal turn-around time was two hours. She stated they had used the last normal saline bag from the emergency supply kit (Omnicell) that day on another resident. She stated they ran a lot of IV's. She stated the saline had been received in the building before the resident left for the hospital but the resident's family would not allow RN B to do the IV. At that time, the DON was asked for documentation of how many residents required IV fluids of normal saline on [DATE]. She provided the name of only one resident who was on normal saline during that time period but she could not provided documentation to show that any bags of normal saline had been taken from the emergency supply kit (Omnicell) that day or any day. The DON stated the number of bags of normal saline vary before being restocked. Normally, there were two bags of each concentration of saline but they try to always have at least one in stock. She said the bags were either pulled for use on another resident or because they were expired. She was unable to say which situation occurred. She said the Omnicell tracks the supply and automatically sends orders for restock. The facility staff did not keep track of what was pulled from the Omnicell. The DON could not say how many bags or pills had to be taken out of the machine before the pharmacy sent additional medication to restock. She stated the facility received automatic stocks for both Omnicell machines once every week. The DON said there were so many different concentrations of saline that they may or may not have had someone else using that particular concentration at the time. It may have been pulled for expiration date. In an interview with RN B on [DATE], at 3:30 p.m., she stated she was the charge nurse. She said the lab called the facility around 6 p.m. on [DATE]. She told RN A about the critical lab right away. She called the NP and told the lab to fax the original lab report. After dinner, between 6 or 7, CR #1's family member came and asked how she was. The morning nurse, RN A was still there giving report. The family member asked about the IV and she told her she thought they were still waiting on the fluids from the pharmacy. RN B had to go look for the evening nurse and clarify the order for IV fluids. The morning nurse did have the paper lab results faxed from the lab. The family member stated another family member was reviewing the video camera footage from inside CR #1's room and he saw the resident reaching up and grabbing for things that were not there. They were still waiting on the delivery of the IV fluids. RN B stated she was going to go ahead and insert the IV in preparation to receive the fluids from the pharmacy. She asked the family member if they wanted to start the IV or send the resident out to the hospital and she said she would talk to the other family member about a direct admit. RN B called the DON, who told her to give the family 15 minutes to decide if they wanted the IV or to send resident out. The family member came back inside the building and said to call 911. RN B said they always get critical labs, but they manage the residents there at the facility as oppose to sending them out. She said she never interacted with the resident. RN B said the particular saline NP #1 ordered was very common. NP's always order that one. The normal saline was delivered after the resident was already gone. In an interview with the DON on [DATE], at 4:30 p.m., she stated RN B should have and would normally have called the pharmacy about the delay in delivery of the IV fluids. She stated she could not say whether or not NP #1 was notified about the saline. In a later interview with the DON on [DATE], at 10:15 a.m., she stated she had no proof that facility nurses contacted the NP when the particular concentration of saline was not found in the building or that the NP was contacted when the saline was not delivered to the building within the normal 2 hour time frame or even 4 hours. She also stated CR #1's WBC, BUN, Creatinine, and ammonia levels were always high and so not considered abnormal despite the resident showing changes . Record review of the facility's policy on, Provision of Physician Ordered Services revealed it was not dated. The document read in part, .3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [REDACTED]. Record review of the facility's policy on, Receipt of Interim/Stat/Emergency Deliveries revealed it was revised on [DATE]. The document read in part, .Procedure: 1. Facility should immediately notify Pharmacy when Facility receives from a Physician/Prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, facility should arrange either: 2.1 With Pharmacy to include the interim/stat/emergency medication in an earlier scheduled delivery or a special delivery, as required, or, 2.2 For delivery by contract courier, or, 2.3 For the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt . Record review of the facility's policy on, Notification Of Changes revealed it was dated, [DATE]. Thee document read in part, .Policy: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment . The Administrator and DON were notified of Immediate Jeopardy (IJ) on [DATE], at 1:41 p.m. due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 1:19 p.m. after several revisions were made. IJ/IT/SQC - [DATE] Plan of Removal 1. Review/Audit of the facility's E-Kit. The DON/Designee will audit daily the medications pulled from the Omni cell on [DATE] If any medications are needing to be replenished or re-ordered, the DON and/or designee will notify the Pharmacy of medication(s) needing to be re-ordered and will follow-up with the pharmacy. The expected turnaround from the pharmacy is ,[DATE] hours. Stat is 4 hours. Checkoff sheet was developed to be used daily by the DON/Designee and will start using immediately. The DON and Designee was training on the ekit checkoff on [DATE]. The ekit checkoff was started on [DATE]. The checkoff sheet includes: date, Auditor, Medications pulled from the Omnicell so they can be audited; Pharmacy notification, Date and time of pharmacy notification; Medication arrival The Administrator will collect and review checkoff sheets and will follow-up with action items, as needed. This started on [DATE]. Administrator/DON will meet with pharmacy to review and adjust Omni cell par levels with pharmacy. The PAR levels are being reviewed by Pharmacy Consultant, Omnicare, on [DATE]. Consultant will be providing us feedback on PAR levels on [DATE]. I have contacted the Medical Director for any recommendation for the ekit from the physician's perspective. Have extra saline's bags added to the Omni cell on [DATE]. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. The Administrator is reviewing for: new orders; reviewing new admission orders [REDACTED]. This process has begun on [DATE]. Any Changes in Condition and/or new order recommendations will be reviewed with the Director of Nursing with appropriate action and notification to physician taken. 2. Critical Lab Values/Change of Condition. Physician/Nurse Practitioner and Responsible Party will be notified of any Change of Condition of a resident, to include Critical Lab Values. The DON and Licensed Nurses were educated on [DATE] and [DATE] to immediately notify the physician and responsible party of changes in condition, to include critical lab values. Monitoring the residents and documenting changes and vital signs in resident records was included in the training on [DATE] and [DATE]. Licensed nurses have been educated, starting [DATE], if receiving the information about a critical lab, to also ask if there are any other abnormalities that need to address. The DON will be notified of any Changes in Condition, to include Critical Lab Values, starting on [DATE]. The Licensed Nurses were trained on the processes on [DATE] and [DATE]. The DON received training on the process on [DATE] by the Corporate Clinical Director. Critical Lab Form has been developed for the Licensed Nurses to use. This will prompt the nurse to ask for any other abnormalities and to notify the physician of any changes. The Director of Nursing and/or the Administrator will monitor Changes of Condition/Critical Labs and make recommendations, as needed. This process started on [DATE] and is being monitored daily. The DON has been educated by the Corporate Clinical Director on [DATE], on resident assessment, Change in Condition, to include Critical Lab Values and protocols of when a resident needs to be transferred to a higher level of care, ex. Hospital. The facility ensures that the nursing staff are properly advised and monitored for proficiency and competency in nursing assessments skill at: Nursing Orientation; Competency Check-offs - annually and as needed. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 3. Medication Availability/Notification to Physician/Responsible Party. Licensed Nurses have been educated, starting on [DATE], to notify the Physician if a medication is not available and document the recommendation from the physician in Point Click Care. Licensed Nurses have been educated, starting on [DATE], to check the facility eKit for medications not delivered from the pharmacy. If a medication is not available in the facility eKit, the Licensed Nurse is to notify the physician immediately of medications not available and receive directives from the physician and notify the DON. Licensed Nurses have been educated, starting on [DATE], to document the directive from the Physician in the resident's chart in Point-Click-Care. 100% MAR indicated [REDACTED]. All medications in the facility were accounted for all orders complete. The audit was completed by the: Assistant Director of Nursing, Transitional Nurse, and the MDS Nurse. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 4. We anticipate the completion of this plan [DATE]. 5. Nursing staff, who have not been trained on the above processes, will not be allowed to work in the facility until the training as taken place. As of [DATE], all scheduled nurses have been trained on the processes. An active staff roster was utilized to verify staff have been trained. 6. All these process will be audited and reported to the QAPI committee and reviewed for trends and/or corrections. The Administrator will monitor this process and make recommendations. Monitoring Monitoring of the plan to remove the immediate jeopardy was conducted daily at various times from [DATE] until [DATE]. In an interview with LVN C on [DATE], at 6:00 p.m. she stated she had been in-serviced on the facility's new procedures and forms. If a resident's IV fluids were not available, they would immediately call the NP to inform them it was not available and let them know what was available. Other topics included critical labs, SBAR's, and notifications. The nurses know to contact the big three (the DON, the physician, and the family) for any changes of condition, critical labs, or other high lab values. In an interview with LVN D on [DATE], at 6:30 p.m., she stated she had recently been in-serviced on the Omnicell process, the new forms for the Omnicell and critical labs, notification, and other high lab values. In an interview with RN [NAME] on [DATE], at 6:45 p.m., she stated she was the charge nurse for weekends only. She stated all of the facility's nurses had been in-serviced on new processes related to changes of conditions, notification of the big three, pharmacy orders, Omnicell, monitoring vital signs of residents with changes, and critical labs and other high values. In an interview with RN F on [DATE], at 7:15 p.m., she stated all the nurses were in-services on the new facility procedures. None of the nurses could work on the floor unless they were in-services. In an interview with RN G on [DATE], at 7:00 p.m., she stated she was a charge nurse and was the oncoming nurse on [DATE]. She had been off for two days and when she returned to the facility, CR #1's family member was there calling 911. The staff was trying to get the resident ready, so no staff was available at the time to give her situation report . There was no time to assess CR #1 because it was so chaotic. The IV fluids had not yet arrived in the building. All of the nurses were in-serviced on critical labs, Ominicell process and documentation of medications taken from it, critical labs and other high lab values, and notification. Record review

Based on observation, record review and interviews, the facility failed to immediately consult the physician when there was a need to alter treatment for one of ten residents (CR #1) reviewed for physician consultation. The facility failed to notify the physician when the ordered IV solution was not available in the facility to be administered to CR #1 who was displaying symptoms of dehydration. Eight hours after the order was received but not initiated, CR #1 was transferred to the hospital where she was diagnosed with [REDACTED]. CR #1 died the next day in the ICU. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure affected one resident who died in the ICU . Findings include: Record review of CR #1's face-sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation of CR #1 on [DATE] at 4:15 p.m. revealed she was alert, oriented, and confined to a wheelchair. Record review of CR #1's record revealed CR #1 was sent out to a local hospital on [DATE], and she died on [DATE]. Record review of CR #1's MDS dated [DATE] revealed she had a BIMS score of 15 indicating her cognition was intact. The assessment also indicated the resident required extensive staff assistance with bed mobility, transferring, locomotion, dressing, bathing, and toilet use, she ambulated via wheelchair, and she occasionally complained of pain and was on scheduled pain and as-needed medication for pain. Record review of CR #1's physician progress notes [REDACTED].Family requested evaluation of continued abdominal discomfort and diarrhea overnight and acute change of increased weakness, patient notes she had 3 diarrhea stools on [DATE] and one this a.m. she reports her abdominal discomfort has decreased with initiation of [MEDICATION NAME] but now it has moved further down in her abdomen .-follow up evaluation required of the paraparesis ([DIAGNOSES REDACTED] of the lower limbs) , PT and OT note patient has increased weakness today and difficulty standing whereas normally she is able to stand on her own .REVIEW OF SYSTEMS .Gastrointestinal: I hurt all over while rubbing her abdomen, diarrhea x3 on [DATE], diarrhea x1 on [DATE], decreased p.o. intake overnight and this a.m. I did not eat anything for breakfast .PHYSICAL EXAM; General: Frail and tired appearing elderly female with eyes sunken, dressed, lying in bed, alert, in no acute distress; HEENT: Normocephalic, PERRLA, sclera nonicteric, nasal mucosa pink, septum midline, no oral [MEDICAL CONDITION], oropharynx severely dry . Gastrointestinal: Round bowel sounds x4 quadrants, mild distention, diffuse mild tenderness to palpation, diarrheal stool today .ASSESSMENT & PLAN .Leukocytosis/dehydration - initiate IV, start Normal Saline 42 mL/hr for a total of 1 L, patient afebrile, decreased PO intake overnight and today, STAT CBC ordered. Abdominal pain and distention/chronic diarrhea - worsening, continue lactobacillus, [MEDICATION NAME] 40, STAT KUB, bladder scan, stool sample and C.diff, and BMP ordered .DISCUSSED PLAN OF CARE WITH: Patient, family, nursing and non-licensed staff, PT, OT .ADDENDUM: Patient discharged to hospital per family request on [DATE] .Document e-signed by NP on [DATE] 3:03 p.m. Record review of CR#1's nurses progress notes dated, [DATE], revealed at 1:04 p.m., RN A wrote, Late entry: Patient received in bed alert and oriented x4, in no acute distress but voiced not feeling great . Vital signs assessed Blood Pressure ,[DATE], Pulse 78, respirations 20, temperature 98.6 axilla, and O2 saturation 96% . This note was crossed out by RN A on [DATE] at 2:26 p.m. The note was re-written on [DATE] at 2:26pm and read Patient received in bed alert and oriented x 4, in no acute distress but voiced not feeling great . Vital signs assessed Blood Pressure ,[DATE], Pulse 78, respirations 20, temperature 98.6 axilla, and O2 saturation 96% . (the following note was added) NP in to assess patient. New order received for Stat CBC, BMP, KUB, collect stool for [MEDICAL CONDITION]. and IV for 0.9% Normal saline x 1L over 24 hours . Record review of CR#1's progress notes dated [DATE] revealed at 5:35 p.m., RN A wrote, Critical lab report received from lab notified NP, new order [MEDICATION NAME] 125mg by mouth .Will continue to monitor and assist as needed Record review of CR #1's care plan, updated on [DATE] revealed on [DATE], CR #1 had critical labs which were reported to her physician. Record review of CR#1's SBAR Communication Form and progress note dated [DATE], revealed the resident was noted to have abnormal lab, Poor appetite, and IV solution was ordered due to poor hydration. Under Vital Signs, the note read, i. Most Recent Blood Pressure: ,[DATE] Date: [DATE] at 9:32am . j. Most recent Pulse: 78 Date: [DATE] at 9:32am . k. Most recent Respiration: 18 Date: [DATE] at 9:56 p.m. m. Most recent temperature: 97.8 date: [DATE] at 11:32 p.m. P. Most recent O2 saturation: 97% date: [DATE] at 12:14am . 1. Mental Status Changes 1b is checked, indicating Increased confusion .[NAME] ASSESSMENT (RN) or APPEARANCE LPN) What do you think is going on with the resident? RN. I think the problem may be increased white count- rule [MEDICAL CONDITION] R. REQUEST 1. I suggest or request (check all that apply) 1a. is checked, indicating: Monitor vital signs and 1f. is checked, indicating Transfer to the hospital send a copy of this form) 2. Nursing Notes (for additional information on the Change in Condition): MD and family are aware of the current condition. interventions in place for IV and more lab work .3b. Date and time: [DATE] at 4:45 p.m . In an interview with RN A on [DATE], at 12:49 p.m., she stated when she saw CR #1 on Wednesday, [DATE], she was surprised because she looked pale and the resident said she did not feel great. The resident's vitals were good and she observed her eating. At some point, NP #1 arrived and ordered stat labs, stat KUB, and IV of normal saline over 24 hours. When she went to gather supplies, there was no normal saline so she faxed an order to the pharmacy. Around 5 p.m. that day, one of the resident's family members asked about the lab results which had not yet come in. After that, the technician came to do the KUB and the verbal results came in for the critical labs. RN B took the call for the labs and reported them to her. The WBC were critical at 46.3. The value was reported to the NP and [MEDICATION NAME] was ordered for 14 days. The family member came back and asked RN B why the IV had not yet been started and RN B then asked her. The order popped up in the computer incorrectly as a saline flush and not an IV. RN A corrected the order in the computer. There was no normal saline in the building. When RN B had asked her at first, RN A had not yet corrected the order. She stated it was in wrong but it was not wrong. The order said normal saline flush but the description was correct. She crossed out the note because there was a typo. RN A said when RN B asked about it, she already knew there was no saline in the building. She had already checked the emergency supply in the Omnicell. When she received the critical lab, she notified the NP. She stated she did not send the resident out because she was not a doctor. Sending residents out depends on the physicians' orders. She stated in her nursing judgement, the critical labs would have warranted a trip to the emergency room . That night, she left the facility at 8:30 p.m. The resident was still in the building and did not have an IV. Thee usual turn-around time for the pharmacy to return IV fluids was maybe two hours. The family member who was in the building stated she was contacting another family member who was a nurse, so RN A said she knew he would want to send the resident out. The next shift nurse had already taken over. RN B asked the family if they wanted to send CR #1 out but they wanted to wait and see if they could get a direct admit. In a telephone interview with CR #1's family member on [DATE], at 10:30 a.m., she stated she arrived at the facility on [DATE] at 6:55 p.m. When she got there, the resident appeared to be having a [MEDICAL CONDITION]. Once she came out of it, CR #1 said she was ok. She asked RN B where CR #1's IV was and the nurse said there was no order for an IV. Around 9:00 p.m., RN B came and said there was an order for [REDACTED]. It was around that same time the nurse handed her the lab report and said they were critical. The family member stated nobody ever went back to check on the resident and nobody went to check her vital signs. The resident did not leave the facility to go to the hospital until 9:45 p.m. after they could not get a direct admit from the doctor. She said 5 hours with the IV could have made a difference. Once they were at the hospital, the surgeon stated CR #1 had a really bad case of [MEDICAL CONDITION], was extremely dehydrated, had a UTI, and her kidneys were only working at 19%. CR #1 was doing well after receiving IV fluids but then suddenly had a drastic decline and died in the ICU of the hospital on [DATE]. The family requested an autopsy. The family member was later contacted by the hospital and informed CR #1's body was turned over to the county medical examiner for autopsy because the hospital labeled the resident's death as suspicious. In an interview with NP #1 on [DATE], at 11:30 a.m., she stated she had assessed CR #1 on Monday, [DATE] when she complained of lower abdominal pain and again on Tuesday, [DATE]. By Tuesday, the discomfort had improved but her diarrhea had picked up and she was getting dry orally. She threatened CR #1 with IV fluids in hoped she would increase oral fluids. By Wednesday, [DATE], there was an acute difference. The resident's eyes were sunken in and her mouth was dry. PT said she was severely weak. NP #1 ordered an IV, CBC, chest x-ray and KUB. This was around 12 p.m. or 1 p.m. because she called CR #1's family member on her phone at 12:43 p.m. The resident was very dehydrated. She said she knew the expectation for nursing facilities to carry out orders would be a couple of hours but she hoped it would be sooner than later. She did let the nurse know CR #1 needed IV fluids. At 4:30 p.m. that day, CR #1's lab results were communicated to her by her partner, NP #2. She relayed through NP #2 to start [MEDICATION NAME]. At 8:39 p.m., CR #1's family member text her to verify she had ordered IV fluids because the facility's staff claimed there was no order for IV fluids. NP #1 text back and indicated she had ordered the IV fluid. NP #1 contacted NP #2 to question why the IV had not been started. NP #2 said she called the facility to ask about the IV. NP #1 stated she nor NP #2 had been informed there was no normal saline available in the facility. Had the staff communicated that, she would have substituted the order for something the facility did have in stock. Neither she nor NP #2 were contacted when there was a delay in getting the normal saline. NP #1 said she expected them to start the IV within ,[DATE] hours but she hoped sooner. CR #1's critical lab (WBC count) was relayed to her but the other high labs, including BUN and Creatinine were not communicated to her. The WBC count was extremely high but did not necessarily mean she should have gone to the emergency room . She said they could have controlled it at the facility because the level may have been due to the dehydration, which could have made the number high. CR #1's blood pressure was also a little low but she expected the IV fluids to rebound that. NP #1 stated with all the comorbidities CR #1 had going on, had she known about the other high labs, she would have ordered the resident to be sent out to the emergency room immediately. The WBC level qualifies as septic and with her symptoms, she would have sent her out. NP #1 stated if CR #1 had the IV fluids earlier, it could have improved her situation. An attempt was made to contact NP #2 on [DATE], at 10:31 a.m. but the voicemail message was never returned. In a telephone interview with CR #1's family member on [DATE], at 11:51 a.m., he stated on [DATE], at 7:04 p.m., he received a call from another family member who had just arrived to the facility and observed CR #1 did not have an IV started. The other family member also stated CR #1 was not acting right, she was confused, and she was convulsing like she was having a [MEDICAL CONDITION]. The nurses at the facility said there was no order for IV fluids. The family member sent NP #1 a text at 8:39 p.m. asking about the order. The NP indicated the IV fluids was part of the written orders she gave before she left. The family member stated he asked the NP about a direct admit for CR #1 because they did not want to go through the emergency room based on the critical labs. The direct admit was not possible so they decided to call 911. The family member stated at the hospital, CR #1 was diagnosed with [REDACTED]. In an interview with the DON on [DATE], at 1:45 p.m., she stated she left the facility around 6:30 p.m. on [DATE] after dealing with another family. She stated CR #1 did not have any visible signs of dehydration. The resident was very weak but nothing triggered that day. She did not notice signs of dehydration because CR #1's electrolytes were chronically off. She stated RN B was ready to do the IV when CR #1's family member arrived and said to wait until they called to see if they could get a direct admit. The DON stated the NP put the actual order on the correct sheet at 1:53 p.m. and that is when the order would have been sent to the pharmacy. The normal turn-around time was two hours. She stated they had used the last normal saline bag from the emergency supply kit (Omnicell) that day on another resident. She stated they ran a lot of IV's. She stated the saline had been received in the building before the resident left for the hospital but the resident's family would not allow RN B to do the IV. At that time, the DON was asked for documentation of how many residents required IV fluids of normal saline on [DATE]. She provided the name of only one resident who was on normal saline during that time period but she could not provided documentation to show that any bags of normal saline had been taken from the emergency supply kit (Omnicell) that day or any day. The DON stated the number of bags of normal saline vary before being restocked. Normally, there were two bags of each concentration of saline. She said the bags were either pulled for use on another resident of because they were expired. She was unable to say which situation occurred. She said the Omnicell tracks the supply and automatically sends orders for restock. The DON could not say how many bags or pills had to be taken out of the machine before the pharmacy sent additional medication to restock. She stated the facility received automatic stocks for both Omnicell machines once every week. The DON said there were so many different concentrations of saline that they may or may not have had someone else using that particular concentration at the time. It may have been pulled for expiration date. In an interview with RN B on [DATE], at 3:30 p.m., she stated she was the charge nurse. She said the lab called the facility around 6 p.m. on [DATE]. She told RN A about the critical lab right away. She called the NP and told the lab to fax the original lab report. After dinner, between 6 or 7, CR #1's family member came and asked how she was. The morning nurse, RN A was still there giving report. The family member asked about the IV and she told her she thought they were still waiting on the fluids from the pharmacy. RN B had to go look for the evening nurse and clarify the order for IV fluids. The morning nurse did have the paper lab results faxed from the lab. The family member stated another family member was reviewing the video camera footage from inside CR #1's room and he saw the resident reaching up and grabbing for things that were not there. They were still waiting on the delivery of the IV fluids. RN B stated she was going to go ahead and insert the IV in preparation to receive the fluids from the pharmacy. She asked the family member if they wanted to start the IV or send the resident out to the hospital and she said she would talk to the other family member about a direct admit. RN B called the DON, who told her to give the family 15 minutes to decide if they wanted the IV or to send resident out. The family member came back inside the building and said to call 911. RN B said they always get critical labs, but they manage the residents there at the facility as oppose to sending them out. She said she never interacted with the resident. RN B said the particular saline NP #1 ordered was very common. NP's always order that one. The normal saline was delivered after the resident was already gone. Record review of the facility pharmacy shipment details dated [DATE] revealed unknown medications were shipped by the pharmacy on [DATE] and were picked from the pharmacy by the delivery person at 7:05 p.m. The last status indicates it was delivered but it did not indicate what time or what was delivered. Record review of CR #1's EMS report, dated, [DATE] revealed they were called for transport on [DATE], at 9:30 p.m. EMS arrived on the scene at 9:36 p.m.( however, the facility record indicated the resident was sent to the hospital same day at 8:33pm) and arrived at a local hospital at 9:38 p.m. At 9:52 p.m., CR #1 was administered normal saline. Her skin was described as cold, cyanotic (bluish coloration of skin and mucous membrane) , diaphoresis (Sweating) , hot, jaundiced (Yellowing of skin or eyes) , lividity ( bluish color of skin) , mottled (patchy, irregular skin colors) , and pale. Record review of CR #1's hospital records revealed she was triaged at a local hospital on [DATE], at 10:07 p.m. In an interview with the DON on [DATE], at 4:30 p.m., she stated RN B should have and would normally have called the pharmacy about the delay in delivery of the IV fluids. She stated she could not say whether or not NP #1 was notified about the saline. In a later interview with the DON on [DATE], at 10:15 a.m., she stated she had no poof that facility nurses contacted the NP when the particular concentration of saline was found in the building or that the NP was contacted when the saline was not delivered to the building within the normal 2 hour time frame or even 4 hours. Record review of the facility's policy on, Provision of Physician Ordered Services revealed it was not dated. The document read in part, .3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [REDACTED]. Record review of the facility's policy on, Receipt of Interim/Stat/Emergency Deliveries revealed it was revised on [DATE]. The document read in part, .Procedure: 1. Facility should immediately notify Pharmacy when Facility receives from a Physician/Prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, facility should arrange either: 2.1 With Pharmacy to include the interim/stat/emergency medication in an earlier scheduled delivery or a special delivery, as required, or, 2.2 For delivery by contract courier, or, 2.3 For the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt . Record review of the facility's policy on, Notification Of Changes revealed it was dated, [DATE]. Thee document read in part, .Policy: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment . The Administrator and DON were notified of Immediate Jeopardy (IJ) on [DATE], at 1:41 p.m. due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 1:19 p.m. after several revisions were made. IJ/IT/SQC - [DATE] Plan of Removal 1. Review/Audit of the facility's E-Kit. The DON/Designee will audit daily the medications pulled from the Omni cell on [DATE] If any medications are needing to be replenished or re-ordered, the DON and/or designee will notify the Pharmacy of medication(s) needing to be re-ordered and will follow-up with the pharmacy. The expected turnaround from the pharmacy is ,[DATE] hours. Stat is 4 hours. Checkoff sheet was developed to be used daily by the DON/Designee and will start using immediately. The DON and Designee was training on the ekit checkoff on [DATE]. The ekit checkoff was started on [DATE]. The checkoff sheet includes: date, Auditor, Medications pulled from the Omnicell so they can be audited; Pharmacy notification, Date and time of pharmacy notification; Medication arrival The Administrator will collect and review checkoff sheets and will follow-up with action items, as needed. This started on [DATE]. Administrator/DON will meet with pharmacy to review and adjust Omni cell par levels with pharmacy. The PAR levels are being reviewed by Pharmacy Consultant, Omnicare, on [DATE]. Consultant will be providing us feedback on PAR levels on [DATE]. I have contacted the Medical Director for any recommendation for the ekit from the physician's perspective. Have extra saline's bags added to the Omni cell on [DATE]. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. The Administrator is reviewing for: new orders; reviewing new admission orders [REDACTED]. This process has begun on [DATE]. Any Changes in Condition and/or new order recommendations will be reviewed with the Director of Nursing with appropriate action and notification to physician taken. 2. Critical Lab Values/Change of Condition. Physician/Nurse Practitioner and Responsible Party will be notified of any Change of Condition of a resident, to include Critical Lab Values. The DON and Licensed Nurses were educated on [DATE] and [DATE] to immediately notify the physician and responsible party of changes in condition, to include critical lab values. Monitoring the residents and documenting changes and vital signs in resident records was included in the training on [DATE] and [DATE]. Licensed nurses have been educated, starting [DATE], if receiving the information about a critical lab, to also ask if there are any other abnormalities that need to address. The DON will be notified of any Changes in Condition, to include Critical Lab Values, starting on [DATE]. The Licensed Nurses were trained on the processes on [DATE] and [DATE]. The DON received training on the process on [DATE] by the Corporate Clinical Director. Critical Lab Form has been developed for the Licensed Nurses to use. This will prompt the nurse to ask for any other abnormalities and to notify the physician of any changes. The Director of Nursing and/or the Administrator will monitor Changes of Condition/Critical Labs and make recommendations, as needed. This process started on [DATE] and is being monitored daily. The DON has been educated by the Corporate Clinical Director on [DATE], on resident assessment, Change in Condition, to include Critical Lab Values and protocols of when a resident needs to be transferred to a higher level of care, ex. Hospital. The facility ensures that the nursing staff are properly advised and monitored for proficiency and competency in nursing assessments skill at: Nursing Orientation; Competency Check-offs - annually and as needed. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 3. Medication Availability/Notification to Physician/Responsible Party. Licensed Nurses have been educated, starting on [DATE], to notify the Physician if a medication is not available and document the recommendation from the physician in Point Click Care. Licensed Nurses have been educated, starting on [DATE], to check the facility eKit for medications not delivered from the pharmacy. If a medication is not available in the facility eKit, the Licensed Nurse is to notify the physician immediately of medications not available and receive directives from the physician and notify the DON. Licensed Nurses have been educated, starting on [DATE], to document the directive from the Physician in the resident's chart in Point-Click-Care. 100% MAR indicated [REDACTED]. All medications in the facility were accounted for all orders complete. The audit was completed by the: Assistant Director of Nursing, Transitional Nurse, and the MDS Nurse. The Administrator/Designee to review daily the facility 24/hr report and review with clinical leader in stand-up meeting. 4. We anticipate the completion of this plan [DATE]. 5. Nursing staff, who have not been trained on the above processes, will not be allowed to work in the facility until the training as taken place. As of [DATE], all scheduled nurses have been trained on the processes. An active staff roster was utilized to verify staff have been trained. 6. All these process will be audited and reported to the QAPI committee and reviewed for trends and/or corrections. The Administrator will monitor this process and make recommendations. Monitoring Monitoring of the plan to remove the immediate jeopardy was conducted daily at various times from [DATE] until [DATE]. In an interview with LVN C on [DATE], at 6:00 p.m. she stated she had been in-serviced on the facility's new procedures and forms. If a resident's IV fluids were not available, they would immediately call the NP to inform them it was not available and let them know what was available. Other topics included critical labs, SBAR's, and notifications. The nurses know to contact the big three (the DON, the physician, and the family) for any changes of condition, critical labs, or other high lab values. In an interview with LVN D on [DATE], at 6:30 p.m., she stated she had recently been in-serviced on the Omnicell process, the new forms for the Omnicell and critical labs, notification, and other high lab values. In an interview with RN [NAME] on [DATE], at 6:45 p.m., she stated she was the charge nurse for weekends only. She stated all of the facility's nurses had been in-serviced on new processes related to changes of conditions, notification of the big three, pharmacy orders, Omnicell, monitoring vital signs of residents with changes, and critical labs and other high values. In an interview with RN F on [DATE], at 7:15 p.m., she stated all the nurses were in-services on the new facility procedures. None of the nurses could work on the floor unless they were in-serviced. In an interview with RN G on [DATE], at 7:00 p.m., she stated she was a charge nurse and was the oncoming nurse on [DATE]. She had been off for two days and when she returned to the facility, CR #1's family member was there calling 911. The staff was trying to get the resident ready, so no staff was available at the time to give her situation report . There was no time to assess CR #1 because it was so chaotic. The IV fluids had not yet arrived in the building. All of the nurses were in-serviced on critical labs, Ominicell process and documentation of medications taken from it, critical labs and other high lab values, and notification. Record review of facility documents revealed the nursing staff was in-serviced on [DATE], [DATE], and [DATE] on: Formulary of E-kit, Medication Availability, Notification to Physician, DON, and family, Critical Labs and forms, Changes of Condition, and Omnicell. The Administrator and the DON were informed on [DATE] at 7:39 pm that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not immediate jeopardy due to the facility continued to train their staff.