Every finding on record at Lake Bennet Center for Rehabilitation & Healing

Based on observation, interview, and record review, the facility failed to ensure dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions. Findings: On 08/04/2025 at 9:57 AM, during kitchen tour observation, Dietary Aide J was observed putting a dish rack containing dishes into the dish machine while [NAME] L removed items from the dish machine area and placed them with other eating items in the kitchen. The temperature dial on the dish machine showed temperature to be 110 degrees Fahrenheit (F). On 8/04/2025 at 10:03 AM, the Certified Dietary Manager (CDM) stated the dish machine was a low temperature machine and should wash at 120 degrees F or higher. She verified the temperature gauge registered at 110 degrees F and not 120 degrees F as noted on the data plate on the machine. She stated a repairman had been there the previous Friday and machine read 120 degrees F at that time. The CDM ran a rack through the machine again and the temperature gauge did not move past 110 degrees F. Dietary Aide J stated she began washing dishes at 9:00 AM that morning. The CDM did not tell the staff to pull the dishes and did not tell them to rewash the dishes that had already gone through the machine. On 8/04/2025 at 11:25 AM, [NAME] L, Dietary Aide J and Dietary Aide K were observed on tray line. No dishes were observed in the wash area. The dish machine was not running. The temperature gauge on top of the machine showed a water temperature of 90 degrees F. The dietary staff began meal service and were observed preparing trays and placed them on a delivery cart. After four trays were placed on the racks, staff were asked where the prepared meal trays were going to be delivered. Dietary Aide J stated the meals on the cart were for restorative dining. Staff acknowledged the dishes that were removed from the dish machine earlier in the morning were now mixed in with the other dishes. On 8/04/2025 at 11:35 AM, the CDM came from the other side of the kitchen. She was unaware the previous dishes were mixed in with clean dishes and had not been pulled out of service and rewashed. The CDM instructed the staff to re-plate the meals and serve them on disposable dishware. She stated she spoke to the Maintenance Director once she was made aware of the low dish machine temperature. On 8/04/2025 at 11:35 AM, the Maintenance Director verified he spoke with the CDM earlier and checked the hot water supply. He reported one of the screens needed to be cleaned. He stated the water temperature came back up to the appropriate level once the screen was cleaned. The Food and Drug Administration 2022 Food Code notes in section 4-501.15A, that a ware washing machine and its auxiliary components should be operated in accordance with the machine's data plate and other manufacturer's instructions.

Based on interview, and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 39 residents, (#63).Findings:Review of the medical record revealed resident #63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, heart valve insufficiency, and hyperlipidemia. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/29/25 revealed resident 63 had an active diagnosis of hypertension. Review of the Order Summary Report for August 2025 revealed resident #63 had a physician order dated 7/21/25 for Metoprolol Tartrate 12.5 milligrams to be given two times a day for beta-blocker. The order included parameters to hold the medication if resident #63's heart rate was less than 55 beats per minute or her Systolic Blood Pressure (SBP) was less than 120. Metoprolol is a beta-blocker medication used to treat hypertension (high blood pressure). Metoprolol affects the heart and circulation (blood flow through arteries and veins) by relaxing the blood vessels which helps to lower blood pressure and may cause very slow heartbeats (retrieved on 8/08/25 from www.drugs.com). Review of the Medication Administration Record (MAR) for July 2025 and August 2025 revealed nine nurses administered Metoprolol Tartrate to resident #63 outside of specified parameter, 10 times over a 30-day period. Documentation showed resident #63 received this medication on nine days although her SBP was less than the 120 indicated in the order parameters. The medication was administered on 7/06/25 with an SBP of 114, on 7/07/25 with an SBP of 112, on 7/08/25 with an SBP of 118, twice on 7/25/25 with an SBP of 116, on 7/27/25 with an SBP of 115, on 8/01/25 with an SBP of 112, on 8/02/25 with an SBP of 110, on 8/04/25 with an SBP of 107 and on 8/05/25 with an SBP of 118. Review of Progress Notes for July 2025 and August 2025 revealed no associated documentation for the above dates to explain why the Metoprolol was given outside of the physician ordered parameter. On 8/06/25 at 2:38 PM, Licensed Practical Nurse (LPN) C reviewed resident #63's MAR and confirmed she administered Metoprolol on 7/08/25 when it should have been held due to a low SBP. She acknowledged the medication was used to treat high blood pressure and giving it out of parameters could cause the resident's blood pressure to drop too low. On 8/06/25 at 2:46 PM, Registered Nurse (RN) B verified she gave resident #63 Metoprolol on 7/07/25 when it should have been held. She stated the parameters were set because the medication lowers blood pressure but you would not want it to drop too much. She explained she administered the medication outside the order parameters in error. On 8/07/25 at 10:38 AM, LPN D reviewed resident #63's MAR and acknowledged she administer Metoprolol outside of parameters on 7/25/25 and 8/01/25. LPN D stated it was in error. She explained Metoprolol does not always have a parameter set. But if there is one, it should be followed as prescribed. On 8/06/25 at 2:53 PM, the Director of Nursing (DON) - [NAME], RN/DON - verified medication was a blood pressure/cardiac medication. Used to lower blood pressure. Sometimes has parameters, but not always. Should follow the physician order. Expectation is nurses should follow physician orders. Medications should be given reviewed resident #63's MAR and confirmed that doses of Metoprolol were not held according to parameters. She confirmed the medication should have been held as it could further lower blood pressure. The DON explained Metoprolol sometimes has parameters set by a physician but not always. She stated nurses were expected to follow physician orders and only administer medications as prescribed. The facility's policy and procedure for Administering Medication revised April 2019 indicated medications were to be administered in accordance with prescriber orders including any required time frame. The policy included guidelines to check/verify vital signs, if necessary, for each resident prior to administering medications.

Based on interview, and record review, the facility neglected to ensure nurses implemented physician's orders for diagnostic testing, failed to notify the physician of any changes of status including refusal of care, and neglected to ensure the resident received the provision of necessary care and services; additionally, the facility failed to complete a thorough investigation for possible neglect for 1 of 6 residents reviewed for neglect, of a total sample of 6 residents, (#1). On [DATE], resident #1 was admitted to the facility from the hospital. On [DATE], the resident was re-hospitalized and required mechanical ventilation (life support to breathe) in the Intensive Care Unit (ICU) due to critically low blood pressure and septic shock from a Urinary Tract Infection (UTI). Sepsis is when your body's immune system has a dangerous response to an infection. It is a medical emergency that can be caused by many different kinds of infections. The quicker you receive treatment, the better your outcome will be. Septic shock can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment. It's the most severe stage of sepsis, (retrieved on [DATE] from www.clevelandclinic.org). Resident #1 was hospitalized for more than two weeks and was discharged from the hospital to another long term care facility on [DATE] for continued recovery and therapy. On [DATE], facility licensed nurses did not implement the physician's orders for urine diagnostic testing that could have detected infection, prevented complications/ worsening of the condition, and mitigated the risk of serious injury/impairment/death. Nurses never notified the resident's physicians/providers the test was not performed as ordered. The resident's primary care providers did not recognize test results were missing; and did not request results or re-order testing. Six days later, on Wednesday, [DATE] at approximately 3:45 PM, the resident was found by his family cold, clammy, and unresponsive. Nurses assessed the resident with significantly lower blood pressure than his normal readings and contacted the Physician's Assistant (PA) who ordered STAT (without delay) laboratory testing, and Intravenous (IV) fluids. At the resident's family's insistence for emergency treatment, nurses again contacted the PA and obtained orders to transport the resident to the hospital via 911 Emergency Medical Services (EMS). The facility's failure to implement physician's orders for diagnostic testing, notify the physician, recognize diagnostic testing results were missing, and to provide necessary care and services contributed to the destabilization of resident #1's medical conditions and placed all residents at risk for neglect and serious injury/impairment/death. For two weeks, the facility was unaware resident #1's test results had not been completed until [DATE], when the resident's wife called to request them, after he was re-hospitalized . This failure resulted in Immediate Jeopardy which began on [DATE]. Findings: Cross reference F684 Review of the medical records revealed resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus with polyneuropathy (weakness/numbness/burning), hypertension (high blood pressure), right bundle branch (heart signal) block, dysphagia (difficulty swallowing), cognitive communication deficit, hearing loss, dysarthria and anarthria (slow/slurred speech). The Minimum Data Set (MDS) Comprehensive Admission Assessment with an Assessment Reference Date (ARD) of [DATE] noted during the look-back period, resident #1 scored 12 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being, he had upper and lower extremity (arms/legs) functional Range of Motion limitations, used a wheelchair, was dependent on staff for assistance to complete Activities of Daily Living and mobility, was always incontinent of bladder and bowel functioning, and difficulty swallowing. The MDS Unplanned Discharge Assessment with an ARD of [DATE] noted during the look-back period, resident #1 did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being. Resident #1 had care plans related to impaired functional abilities ([DATE], revised [DATE]); altered metabolism related to type 2 diabetes mellitus and medication use ([DATE]); risk for falls/requires staff assistance for transfers ([DATE], revised [DATE]); potential nutritional problems ([DATE]); and potential skin integrity alteration ([DATE], revised [DATE]). On [DATE], a care plan for alteration of urinary elimination as evidenced by incontinence was initiated. Interventions included for nurses to monitor and document signs and symptoms of UTI. The Comprehensive Care Plan did not detail behaviors including refusals of care/treatments, or non-compliance. A nurse's Progress Note dated [DATE] at 2:33 PM, revealed resident #1 had red-tinged urine during the previous night. A note dated [DATE] at 8:23 AM, indicated the resident rolled out of bed onto the floor and required two staff to be assisted off the floor and back to bed. The Order Summary Report for [DATE] included a physician's order dated [DATE] for Urinalysis/Urine Culture (UA/CS). The order was marked as completed on [DATE]. On [DATE] the physician ordered Tylenol 650 milligrams (MG) every six hours as needed for pain, and on [DATE] Tramadol 50 MG, an opiate pain medication, was added for pain every eight hours. On [DATE] Tylenol 650 MG was added for fever over 100.0 degrees Fahrenheit (F). A urine sample should be provided for both a urinalysis and culture test (UA/CS). Your physician might order the urinalysis initially to look for blood cells and bacteria in the urine that can indicate an infection. If it's positive your provider would order a urine culture to grow microorganisms and identify the specific bacteria or fungus causing the infection, (retrieved on [DATE] from www.clevelandclinic.org. Further review of the medical record revealed a physician's order on [DATE] to send resident #1 to the emergency room (ER) for evaluation and treatment for blood pressure of ,d+[DATE], diaphoresis (excessive sweating), and slow to respond to verbal commands per family request. On [DATE] at 10:23 AM, in a telephone interview, Licensed Practical Nurse (LPN) C explained a Certified Nursing Assistant (CNA) informed her blood tinged urine was observed in resident #1's incontinence brief, so she obtained physician orders for the UA/CS. LPN C said she entered the UA/CS orders in to the computer system on [DATE] during the 11:00 PM to 7:00 AM shift and later passed on the information to LPN D for the oncoming 7:00 AM to 3:00 PM shift. She said the normal process was that after orders were processed, a printed copy of the order was placed in a binder at the nurses' station for the specimen bag but could not recall if she had done that. Review of the Medication Administration Record (MAR) for [DATE] revealed a physician's order dated [DATE] for Urinalysis/Urine Culture was signed as completed by LPN A on [DATE] at 5:20 AM. A week later on [DATE] at 10:11 AM, LPN D documentation revealed resident #1 was administered Tylenol for a temperature of 100.2 F and at 1:43 PM, he was administered Tramadol for pain. On [DATE] at 3:11 PM, in a telephone interview, LPN A recalled on [DATE] during the 11:00 PM to 7:00 AM shift, resident #1 had an order pending completion for a UA/CS. The nurse remembered she attempted to collect a specimen in the early morning hours of [DATE] and was unable, so she re-attempted unsuccessfully later in the shift. She said she marked, refused on the MAR but did not complete a progress note nor contact the physician. She could not recall if she passed on the information to the oncoming 7:00 AM to 3:00 PM nurse. She explained in early April, she was informed by the Director of Nursing (DON) that the resident's wife had called for the UA/CS results and the facility found the test was marked in the MAR as completed but it was never done. The LPN said the facility's normal practice was for night shift to obtain labs, but it was difficult to get urine specimens overnight or in the early morning when residents were sleeping. She acknowledged she should have written a progress note to document the refusal and contacted the physician. LPN A confirmed when a resident refused a procedure she should promptly notify the DON and the physician. Review of resident #1's medical record revealed there were no nursing progress notes documented on [DATE] by LPN A regarding the physician's order for the UA/CS not being performed, nor that the physician or anyone else was notified the test was not done. On [DATE] at 10:31 AM, LPN D recalled she cared for resident #1 many times during his stay including on the 7:00 AM to 3:00 PM shift on [DATE]. The nurse explained earlier in the shift on [DATE], the resident had a fever, so she called the PA who gave her orders for routine labs and Tylenol. She said at approximately 2:00 PM, the resident complained of pain and was administered Tramadol, and approximately a half hour later when the family arrived to visit, she re-checked the resident, and he was, lethargic (fatigue/sluggishness). LPN D stated she called the PA again who gave orders for STAT labs and IV fluids, but the family did not want to wait and were adamant about the resident going to the hospital immediately. The PA was called again, and orders were given to send the resident out to the ER via 911/EMS. Review of nurse's Progress Notes completed by LPN D documented on [DATE] at 10:11 AM, resident #1 had a temperature of 100.2 F. The attending physician was notified, and orders were obtained for Tylenol 650 MG and routine orders were obtained from the PA for laboratory testing. Later at 1:45 PM, the resident complained of left hip pain and was administered the pain medication Tramadol 50 MG. A nurse's Progress Note documented by LPN D on [DATE] at 3:45 PM, noted resident #1's wife and daughter were at the facility visiting and the resident was observed as slow to respond to verbal and touch stimulation, had dilated pupils, and sweaty/clammy skin. The resident's vital signs were assessed and measured with a blood pressure of 85 systolic and 50 diastolic millimeters of mercury (mmHg), and heart rate of 90 beats per minute. The Unit Manager contacted the PA who ordered STAT laboratory tests and IV fluids. The resident's daughter requested the resident be sent to the emergency room and the PA was contacted for orders. LPN D's note dated [DATE] at 4:24 PM, documented resident #1 left the facility by stretcher at 4:25 PM, with EMS to go to the hospital. On [DATE] at 10:16 AM, the North Unit Manager (UM) recalled in [DATE], she was working when resident #1 received Tramadol in the afternoon and a short time later; LPN D informed her the resident seemed more lethargic and wasn't responding to his family who were very concerned with his change in condition. The nurse explained the PA was called and provided orders for STAT labs and IV fluids, but the family was not satisfied with that intervention and wanted him to go to the hospital immediately, so the PA was called back and approved the orders for transport to the hospital. She explained that sometime later, in early [DATE] she was informed by the DON that the resident's lab could not be found and had been signed off as completed by a nurse. She said resident #1 had at least one family member visit every day and nurses could have asked the family to assist in obtaining the urine if the resident was refusing. She said the Unit Managers were responsible for checking a binder kept at the nurse's station for collection tracking and the APRNs (Advanced Practice Registered Nurses) assisted to check for results. The Unit Manager did not explain how or why resident #1's lab result was not done. Review of a Situation Background Assessment Recommendations-SBAR progress note completed by the North UM on [DATE] at 4:53 PM, revealed, at 2 PM, nurse on unit administered Tramadol 50 MG po (by mouth) for pain x 1 dose. Resident eyes were dilated, slow to respond to verbal commands and diaphoretic at 1550 (3:50 PM). Temperature 100.2 this AM with complaints of sore throat. Throat was pink, and moist with no patchy areas noted. The North UM documented the resident 's vital signs were blood pressure of ,d+[DATE], heart rate of 90, respirations of 19, blood sugar of 159, and temporal temperature of 97.5 F. She noted resident #1 had excessive sweating on the trunk of his body. She said the PA ordered IV fluids, Normal Saline, get STAT labs for UA, C/S, a complete blood count with differential and a basic metabolic panel. The UM documented that the wife and daughter adamantly requested for him to go to hospital. In a telephone interview on [DATE] at 10:37 AM, the PA explained she regularly came to the facility to see residents and as part of her assessments, she reviewed orders, labs, medications, vital signs, imaging, etc. The PA said lab orders and results were reviewed with the UM and stated, if I couldn't find results, I will go back and look to see when it was ordered to be collected, and if more than a day or two after it was to be collected, I notify nursing to see if it was even collected. She recalled on [DATE], she received a call from the North UM that resident #1 wasn't looking good and thought he either had a UTI or sepsis, so she gave orders for STAT labs and more frequent vital sign monitoring, but a short time later was called again because the family wanted to send him to the ER, so she gave those orders. She said she expected UA/CS orders to be processed the same day and sent to the lab, and for nurses to notify the provider when a test wasn't completed. She could not recall the facility informing her resident #1's order for UA/CS from [DATE] was not ever done. The PA stated, they [residents] can become septic, and we don't know the source of the infection; we have to treat them emergently. Review of Progress Notes completed by the PA dated [DATE] and [DATE], after the physician's diagnostic testing was ordered included documentation the resident was seen at the request of staff for a follow-up visit. Both notes indicated, Patient's labs/diagnostics and care provider notes reviewed . In a telephone interview on [DATE] at 11:59 AM, resident #1's wife recalled on [DATE], the family received a voicemail from the resident who stated he wasn't feeling well. She explained she and her daughter came to the facility, they observed him and described his condition as, cold, sweaty, clammy, and non-responsive. She said her daughter was a paramedic and believed he was in distress, possibly septic shock. She said nurses called the physician who ordered labs, but the family was very concerned he needed emergent care and insisted he be sent to the ER immediately, so 911 was initiated. She said she believed her husband would have died had they not been there and insisted he go immediately. She said she later requested the UA results from the facility and learned they were never done. She recalled the experience was very stressful, her family was distraught during the crisis and thought they may lose their loved one. She said her husband required a breathing machine and ICU care at the hospital for over two weeks. Resident #1's wife said he had to go to another facility to recover with continued therapy and nursing care. The resident's wife stated, looking back, he had no energy and would fall back like a ragdoll; no wonder he had no energy; he wasn't like that before; even now, he has gone down a lot. In a joint interview with the DON and Nursing Home Administrator (NHA) on [DATE] at 1:05 PM, the DON recalled on [DATE], the facility received a call from resident #1's wife who requested the UA/CS results from during his stay at the facility. The DON said after checking the medical records, she found the test was never done and LPN A had documented on the MAR that it was completed on [DATE]. She explained the facility initiated a grievance and found through interview with LPN A she attempted to obtain a specimen twice on [DATE], and the resident refused but she did not inform the physician, nursing management, nor complete a progress note. The DON said resident #1 did not return to the facility after he was sent to the hospital on [DATE], so the facility did not further investigate the reason for re-hospitalization . On [DATE] at 11:15 AM, the DON explained she believed resident #1 was hospitalized for something infection based and stated, I do believe it was UTI for his admitting diagnosis into the hospital. The DON recalled she spoke with resident #1's daughter on approximately [DATE] and was informed the resident was not returning to the facility. The DON said the facility did not consider requesting the hospital records to see if the adverse incident may have contributed to resident #1's re-hospitalization . She explained the facility's investigation revealed when the nurse signed the order as completed it fell off the record and stated, It's the Unit Manager or designee's responsibility to follow up on ordered lab results. On [DATE] at 12:14 PM, the facility's Grievance Officer checked her records and recalled on [DATE], the NHA received a call from resident #1's wife and daughter concerning lab collection for a UA and customer service. She said an investigation was completed and the facility found LPN A documented the test was completed on [DATE] when in fact it was never done. She said the facility made the family aware of the investigation results and interventions. In a joint interview with the NHA, DON and Risk Manager, on [DATE] at 1:52 PM, the Risk Manager recalled the facility conducted an investigation that started [DATE], after resident #1's wife called for test results. She said the investigation revealed nurses had not implemented the physician's order nor notified the physician. When asked what the facility considered resident neglect to be, the Risk Manager stated, Neglect is not providing goods and services; goods and services did not occur because they did not provide the UA. The NHA, DON, and Risk Manager did not explain why the facility had not reported possible neglect to the State Agency (SA) when they realized the ordered lab was not done. On [DATE] at approximately 2:00 PM, the NHA said the facility had submitted a Facility Reported Incident regarding neglect to the SA after it was brought to their attention during the survey. On [DATE] at 10:11 AM, in a telephone interview, resident #1's attending physician recalled resident #1 after reviewing his notes. He remembered a UA/CS was ordered on [DATE] for blood in the urine. The physician said he expected his orders to be completed by nurses or to notify him if they were unable to fulfill the order so he could decide what should be done as a next step. He confirmed he was told recently as to what happened regarding resident #1 not getting the ordered urine testing and stated, undetected UTI can lead to sepsis; in this case that is what happened. In a telephone interview on [DATE] at 10:53 AM, the facility's Medical Director said he was aware of the incident concerning resident #1's hospitalization and he knew the provider was not notified the lab tests were not performed hence the missing test results. The physician explained that he expected nurses to notify providers when they were unable to collect specimens and stated, unidentified UTI can lead to sepsis. Review of resident #1's hospital records from [DATE] showed during transport to the hospital EMS personnel used a Bag-Valve Mask to manually maintain resident #1's breathing until they arrived at the ER at approximately 4:30 PM. After resident #1 arrived at the ER, life sustaining measures were immediately implemented including insertion of an endotracheal airway (breathing tube), respiratory ventilation (breathing by machine), insertion of vena cava (heart) infusion IV device, and irrigation (flushing) of the genitourinary tract (genital tract in/out of bladder) due to severe sepsis. The resident required IV medications to stabilize his blood pressure and IV antibiotics for UTI and septicemia (blood infection) and was transferred to the ICU. The ICU physician's note read, Upon my evaluation, this patient has high probability of imminent, life-threatening, or organ-threatening deterioration and I provided life/organ saving interventions as noted above. Resident #1 required continued acute care hospitalization for more than two weeks until he was discharged to another long term care facility on [DATE] for continued recovery. The resident's hospital diagnoses included: critical hypotension (low blood pressure), acute (sudden onset) toxic encephalopathy (brain dysfunction), acute hypoxemia (low blood oxygen) respiratory failure, acute tubular necrosis (severe kidney cell damage from oxygen loss), and septic shock from UTI. Bag-Valve-Mask (BVM) ventilation is a critical life-saving technique used to provide oxygen and ventilation to patients who are apneic (temporary breathing cessation) or experiencing severe ventilatory (provision of air to the lungs) failure, (retrieved on [DATE] from www.medscape.com). The facility's undated standards and guidelines titled Abuse, Neglect, Exploitation & Misappropriation noted the Risk Manager/designee conducted a thorough investigation and reported possible neglect to the State Agency as per regulatory guidelines. The document included the following definition of neglect, Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm. The facility's undated standards and guidelines titled Nursing-Change in Resident's Condition or Status noted the physician and representative were to be promptly notified of any changes in condition or status. The procedure included nurse notifications to the attending or on-call physician when there was a refusal of treatment. The Facility assessment dated [DATE] noted the facility provided care and services for management of medical conditions including, Early Identification of Problems, and provided Person-Centered Care that included, Abuse/Neglect Prevention, and disorders of the genitourinary system.

Based on interview, and record review, the facility failed to attain or maintain the resident's highest practicable physical well-being by failing to ensure nurses implemented physician's orders for diagnostic testing, notified the physician, and ensured provision of necessary care and services for 1 of 6 residents reviewed for Quality of Care, of a total sample of 6 residents, (#1). The facility failed to implement a physician's order for Urinalysis with Culture and Sensitivity (UA/CS) for resident #1, failed to notify the physician that the ordered diagnostic test was not completed, and failed to follow up on the missing laboratory result. Additionally, the physician/provider did not recognize or act upon the absence of the test result. Due to these combined failures in care coordination, resident #1's Urinary Tract Infection (UTI) went undiagnosed and untreated, leading to the development of septic shock, a life-threatening condition. This failure to provide necessary care and services placed the resident and other residents in Immediate Jeopardy that began on [DATE], when the facility failed to ensure timely diagnostic testing and appropriate medical intervention. On [DATE], resident #1 was admitted to the facility from the hospital. Thirteen days later on [DATE], the facility sent the resident back to the hospital where he required mechanical ventilation (life support for breathing) in the Intensive Care Unit (ICU) for septic shock from the UTI. Sepsis is when your body's immune system has a dangerous response to an infection. It is a medical emergency that can be caused by many different kinds of infections. The quicker you receive treatment, the better your outcome will be. Septic shock can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment. It's the most severe stage of sepsis, (retrieved on [DATE] from www.clevelandclinic.org). Findings: Cross reference F600 Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus with polyneuropathy (weakness/numbness/burning), hypertension (high blood pressure), right bundle branch (heart signal) block, dysphagia (difficulty swallowing), cognitive communication deficit, hearing loss, dysarthria and anarthria (slow/slurred speech). The Minimum Data Set (MDS) Comprehensive Admission Assessment with an Assessment Reference Date (ARD) of [DATE] noted during the look-back period, resident #1 scored 12 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being, he had upper and lower extremity (arms/legs) functional Range of Motion limitations, used a wheelchair, was dependent on staff for assistance to complete Activities of Daily Living and mobility, was always incontinent of bladder and bowel functioning, and difficulty swallowing. The MDS Unplanned Discharge Assessment with an ARD of [DATE] noted during the look-back period, resident #1 did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being. Resident #1 had care plans related to impaired functional abilities ([DATE], revised [DATE]); altered metabolism related to type 2 diabetes mellitus and medication use ([DATE]); risk for falls/requires staff assistance for transfers ([DATE], revised [DATE]); potential nutritional problems ([DATE]); and potential skin integrity alteration ([DATE], revised [DATE]). On [DATE], a care plan for alteration of urinary elimination as evidenced by incontinence was initiated. Interventions included for nurses to monitor and document signs and symptoms of UTI. The Comprehensive Care Plan did not detail behaviors including refusals of care/treatments, or non-compliance. There were no care plans for blood in urine or for an actual urinary infection. The Order Summary Report for [DATE] included a physician's order dated [DATE] for Urinalysis/Urine Culture (UA/CS). The order was marked as completed on [DATE]. On [DATE] the physician ordered Tylenol 650 milligrams (MG) every six hours as needed for pain, and on [DATE] Tramadol 50 MG, an opiate pain medication, was added for pain every eight hours. On [DATE] Tylenol 650 MG was added for fever over 100.0 degrees Fahrenheit (F). A urine sample should be provided for both a urinalysis and culture test (UA/CS). Your physician might order the urinalysis initially to look for blood cells and bacteria in the urine that can indicate an infection. If it's positive your provider would order a urine culture to grow microorganisms and identify the specific bacteria or fungus causing the infection, (retrieved on [DATE] from www.clevelandclinic.org. On [DATE] a physician order indicated staff to send resident #1 to the emergency room (ER) for evaluation and treatment for blood pressure of ,d+[DATE], diaphoresis (excessive sweating), and slow to respond to verbal commands per family request. A nurse's Progress Note dated [DATE] at 2:33 PM, revealed resident #1 had red-tinged urine during the previous night. A note dated [DATE] at 8:23 AM, indicated the resident rolled out of bed onto the floor and required two staff to be assisted off the floor and back to bed. On [DATE] at 10:23 AM, in a telephone interview, Licensed Practical Nurse (LPN) C explained she obtained and entered UA/CS orders into the computer on [DATE] during the 11:00 PM to 7:00 AM shift after a Certified Nursing Assistant (CNA) informed her blood tinged urine was observed in resident #1's incontinence brief. The nurse recalled she later passed on the information to LPN D for the oncoming 7:00 AM to 3:00 PM shift. She said the normal process was that after orders were processed, a printed copy was placed in a binder at the nurses station for the specimen bag, but she could not recall if she had done that, or if the next shift did it. Review of the Medication Administration Record (MAR) showed a physician's order dated [DATE] for Urinalysis/Urine Culture was signed as completed by Licensed Practical Nurse (LPN) A on [DATE] at 5:20 AM. On [DATE] at 10:11 AM, LPN D signed that resident #1 was administered Tylenol 650 MG for a temperature of 100.2 F and at 1:43 PM, the nurse administered Tramadol 50 MG for pain. On [DATE] at 3:11 PM in a telephone interview, LPN A recalled on [DATE] during the 11:00 PM to 7:00 AM shift, resident #1 had an order pending completion for a UA/CS. The nurse recalled she attempted to collect the urine specimen in the early morning hours of [DATE] but was unable, so she tried again, unsuccessfully, later in the shift. She said she thought she marked refused on the MAR, but confirmed she did not complete a progress note nor contact the physician, that the lab was not collected. She did not recall if she passed on the information to the oncoming 7:00 AM to 3:00 PM shift nurse. She explained in early April, she was informed by the Director of Nursing (DON) that the resident's wife had called for the results and the facility found the test was marked in the MAR as completed but it was never done. The LPN said the facility's normal practice was for night shift to obtain labs and it was difficult to get urine specimens overnight or early morning when residents were sleeping. She said she should have written a progress note and contacted the physician and stated, I learned my lesson that when I go do a procedure and they refuse, don't wait until the end of the shift; notify the DON and the doctor. Review of resident #1's medical record revealed there were no nursing Progress Notes on [DATE] completed by LPN A that documented the UA/CS physician's order was not implemented, nor that the physician was notified. On [DATE] at 3:50 PM, Registered Nurse (RN) B explained that nurses entered the order for the lab in the computer by going into the documentation program and selecting the tab for labs. They would select the test that was ordered by the physician and put in the diagnosis for the test. The nurse would notify the resident or the family if a urine sample was needed and would try to obtain the sample. The nurse would print the order, place a copy in the specimen bag and get a cup to collect the urine. This gets completed just prior to collection of the sample. She confirmed another nurse created the order for resident #1's UA/CS, but she was the one to revise it. RN B confirmed the order should not be clicked off until it was actually done and said you would make a note if it was refused or you were unable to collect it. RN B conveyed you would notify the provider so they could reorder it or decide if they wanted to do something else. She explained the Unit Managers (UM's) would check the lab book to check the labs to ensure they were collected by the nurses. RN B said it was important to collect the labs timely before symptoms worsened. On [DATE] at 10:31 AM, LPN D recalled she cared for resident #1 many times during his stay including on the 7:00 AM to 3:00 PM shift on [DATE]. The nurse explained earlier in the shift on [DATE], the resident had a fever, so she called the Physician's Assistant (PA) who gave her orders for routine labs and Tylenol. She said at approximately 2:00 PM, the resident complained of pain and was administered Tramadol, and approximately a half hour later when the family arrived to visit, she re-checked the resident, and he was, lethargic (fatigue/sluggishness). LPN D stated she called the PA again who gave orders for STAT labs and IV fluids, but the family did not want to wait and were adamant about the resident going to the hospital immediately. The PA was called again, and orders were given to send the resident out to the ER via 911/EMS. Review of nurse's Progress Notes completed by LPN D documented on [DATE] at 10:11 AM, resident #1 had a temperature of 100.2 F. The attending physician was notified, and orders were obtained for Tylenol 650 MG and routine orders were obtained from the PA for laboratory testing. Later at 1:45 PM, the resident complained of left hip pain and was administered the pain medication, Tramadol 50 MG. A Progress Note documented by LPN D later on [DATE] at 3:45 PM, noted resident #1's wife and daughter were at the facility visiting and the resident was observed as slow to respond to verbal and touch stimulation, had dilated pupils, and sweaty/clammy skin. LPN D described that the resident's vital signs were assessed as a blood pressure of 85 systolic and 50 diastolic millimeters of mercury (mmHg), and heart rate of 90 beats per minute. She documented that the UM contacted the PA who ordered STAT laboratory tests and IV fluids. LPN D's note continued, the resident's daughter requested the resident be sent to the emergency room and the PA was contacted for orders. LPN D's note dated [DATE] at 4:24 PM, documented resident #1 left the facility by stretcher at 4:25 PM, with EMS to go to the hospital. On [DATE] at 10:16 AM, the North UM recalled in [DATE], she was working when resident #1 received the pain medication, Tramadol in the afternoon and a short time later; LPN D informed her the resident seemed more lethargic and wasn't responding to his family who were very concerned with his change in condition. The nurse explained the PA was called and provided orders for STAT labs and IV fluids, but the family was not satisfied with that intervention and wanted him to go to the hospital immediately, so the PA was called back and approved the orders for transport to the hospital. The UM explained that sometime later, in early [DATE] she was informed by the DON that the resident's lab could not be found and had been signed off as completed by a nurse. She said resident #1 had at least one family member visit every day and nurses could have asked the family to assist in obtaining the urine if the resident was refusing. She said the Unit Managers were responsible for checking a binder kept at the nurse's station for collection tracking and the APRNs (Advanced Practice Registered Nurses) assisted to check for results. The UM did not explain how or why resident #1's lab result was not done. Review of a Situation Background Assessment Recommendations-SBAR progress note completed by the North UM on [DATE] at 4:53 PM, revealed, at 2 PM, nurse on unit administered Tramadol 50 MG po (by mouth) for pain x 1 dose. Resident eyes were dilated, slow to respond to verbal commands and diaphoretic at 1550 (3:50 PM). Temperature 100.2 this AM with complaints of sore throat. Throat was pink, and moist with no patchy areas noted. The North UM documented the resident 's vital signs were blood pressure of ,d+[DATE], heart rate of 90, respirations of 19, blood sugar of 159, and temporal temperature of 97.5 F. She noted resident #1 had excessive sweating on the trunk of his body. She said the PA ordered IV fluids, Normal Saline, get STAT labs for UA, C/S, a complete blood count with differential and a basic metabolic panel. The UM documented that the wife and daughter adamantly requested for him to go to hospital. In a telephone interview on [DATE] at 10:37 AM, the PA explained she regularly came to the facility to see residents and as part of her assessments, she reviewed orders, labs, medications, vital signs, imaging, etc. The PA said lab orders and results were reviewed with the UM and stated, if I couldn't find results, I will go back and look to see when it was ordered to be collected, and if more than a day or two after it was to be collected, I notify nursing to see if it was even collected. She recalled on [DATE], she received a call from the North Unit Manager that resident #1 wasn't looking good and thought he either had a UTI or sepsis, so she gave orders for STAT labs, including a UA and more frequent vital sign monitoring. Later they called back because the family wanted to send him to the ER immediately, so she gave those orders. She said she expected any UA/CS orders to be processed the same day and sent to the lab, and for nurses to notify the provider when a test wasn't completed. She could not recall the facility informing her resident #1's UA/CS from [DATE] wasn't done. The PA stated, they can become septic, and we don't know the source of the infection; we have to treat them emergently. Review of Progress Notes documented by the PA dated [DATE] and [DATE], after the physician's diagnostic testing was ordered included documentation the resident was seen at the request of staff for a follow-up visit. Both notes indicated, Patient's labs/diagnostics and care provider notes reviewed . In a telephone interview on [DATE] at 11:59 AM, resident #1's wife recalled on [DATE], the family received a voicemail from the resident who stated he wasn't feeling well. She explained she and her daughter came to the facility, they observed him and described his condition as, cold, sweaty, clammy, and non-responsive. She said her daughter was a paramedic and believed he was in distress, possibly septic shock. She said nurses called the physician who ordered labs, but the family was very concerned he needed emergent care and insisted he be sent to the ER immediately, so 911 was initiated. She said she believed her husband would have died had they not been there and insisted he go immediately. She said she later requested the UA results from the facility and learned they were never done. She recalled the experience was very stressful, her family was distraught during the crisis and thought they may lose their loved one. She said her husband required a breathing machine and ICU care at the hospital for over two weeks. Resident #1's wife said he had to go to another facility to recover with continued therapy and nursing care. She exclaimed her family suspected her husband had a UTI at that time and would ask facility nurses about their concerns, but they would say he's fine, and tell her he just needed to, sleep it off. His wife said, they never did a urinalysis, they just didn't do it. She continued, we came in and basically had to find him catatonic before they did something. The resident's wife stated, looking back, he had no energy and would fall back like a ragdoll; no wonder he had no energy; he wasn't like that before; even now, he has gone down a lot. In a joint interview with the DON and Nursing Home Administrator (NHA) on [DATE] at 1:05 PM, the DON conveyed if a lab was unable to be collected, nurses were expected to report to the oncoming nurse and notify the physician for further orders. She said the physician may say to recollect or could decide to do something else. She confirmed that the facility had a responsibility to follow up on any orders including the collection of labs such as urine. The DON recalled on [DATE], the facility received a call from resident #1's wife who requested the UA/CS results from during his stay at the facility. She explained after she checked resident #1's medical records, she found the urine test was never done but LPN A had signed the MAR that it was completed on [DATE]. The DON explained when they questioned her, LPN A stated she attempted to obtain a specimen twice on [DATE], but the resident refused. LPN A told them she did not inform the physician, nursing management, nor did she complete a progress note explaining what happened. The DON explained routine labs were collected by the 11:00 PM to 7:00 AM nurses, and any time a test was not done for any reason, nurses were expected to notify the physician. She said when the nurse signed the order as completed it fell off the record and stated, It's the Unit Manager or designee's responsibility to follow up on ordered lab results. On [DATE] at 10:11 AM, in a telephone interview, resident #1's attending physician explained he checked resident #1's medical record and recalled a UA/CS was ordered on [DATE] for blood in the urine. The physician said he expected his lab orders to be carried out and for nurses to let him know if they were unable to obtain them so he could decide what to do next. He stated, undetected UTI can lead to sepsis; in this case that is what happened. In a telephone interview on [DATE] at 10:53 AM, the facility's Medical Director said he was aware of resident #1's incident. The Medical Director related he knew the provider was not notified the urine sample was not collected and the test was never completed. The physician explained he expected nurses to notify providers when they were unable to collect specimens and stated, unidentified UTI can lead to sepsis. Review of resident #1's hospital records from [DATE] showed during transport to the hospital EMS personnel used a Bag-Valve Mask to manually maintain resident #1's breathing until they arrived at the ER at approximately 4:30 PM. After resident #1 arrived at the ER, life sustaining measures were immediately implemented including insertion of an endotracheal airway (breathing tube), respiratory ventilation (breathing by machine), insertion of vena cava (heart) infusion IV device, and irrigation (flushing) of the genitourinary tract (genital tract in/out of bladder) due to severe sepsis. The resident required IV medications to stabilize his blood pressure and IV antibiotics for UTI and septicemia (blood infection) and was transferred to the ICU. The ICU physician's note read, Upon my evaluation, this patient has high probability of imminent, life-threatening, or organ-threatening deterioration and I provided life/organ saving interventions as noted above. Resident #1 required continued acute care hospitalization for more than two weeks until he was discharged to another long term care facility on [DATE] for continued recovery. The resident's hospital diagnoses included: critical hypotension (low blood pressure), acute (sudden onset) toxic encephalopathy (brain dysfunction), acute hypoxemia (low blood oxygen) respiratory failure, acute tubular necrosis (severe kidney cell damage from oxygen loss), and septic shock from UTI. Bag-Valve-Mask (BVM) ventilation is a critical life-saving technique used to provide oxygen and ventilation to patients who are apneic (temporary breathing cessation) or experiencing severe ventilatory (provision of air to the lungs) failure, (retrieved on [DATE] from www.medscape.com). The facility's undated policy and procedure, Laboratory Tests/Diagnostic Procedures: Communicating the results, revealed the facility would track ordered labs and diagnostic procedures and promptly notify the medical provider, resident and/or the representative. The procedure section described a facility designated nurse would review lab log sheets daily to verify protocol was followed and follow up on any discrepancies noted. The facility's undated standards and guidelines titled Nursing-Change in Resident's Condition or Status noted the physician and representative were to be promptly notified of any changes in condition or status. The procedure included nurse notifications to the attending or on-call physician when there was a refusal of treatment. The Facility assessment dated [DATE] noted the facility provided care and services for management of medical conditions including, Early Identification of Problems, and provided Person-Centered Care that included, disorders of the genitourinary system.

Based on interview and record review, the facility failed to develop an individualized Comprehensive Care Plan to include an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheters, of a total sample of 6 residents, (#3). Findings: Review of the medical record revealed resident #3, an [AGE] year old female was admitted to the facility from an acute care hospital on 12/11/24. She had diagnoses that included wedge compression fracture of thoracic (mid-spine) and lumbar (lower spine) vertebrae, and Urinary Tract Infection (UTI). The Minimum Data Set (MDS) Comprehensive Admission 5-day Assessment with an Assessment Reference Date (ARD) of 12/13/24 noted during the look back periods, resident #3 scored 10 out of 15 on the Brief Interview for Mental Status that indicated she was moderately cognitively impaired. The resident required staff assistance to complete Activities of Daily Living (ADLs) and the use of an indwelling urinary catheter appliance. During the 7-day look back period, the resident required high-risk antibiotic medications. The Care Area Assessment (CAA) Triggers dated 12/24/24 and the Comprehensive Care Plan Decisions dated 12/25/24 included an indwelling urinary catheter. The Order Summary Report noted resident #3 had physician's medication orders for antibiotics to treat a UTI that included: From 12/30/24 to 12/31/24, Macrobid 100 milligrams (mg) every 12 hours, and from 12/31/24 to 1/08/25, Cipro 500 mg every 12 hours. Review of the Nurses Progress Notes showed on 12/12/24, resident #1 was unable to urinate and required insertion of an indwelling urinary catheter. Review of the Care Plan Report with care plans completed 12/25/24, and revised 1/03/25 did not include a Focus, Goal, or Interventions for an indwelling urinary catheter. In an interview on 5/15/25 at 11:37 AM, the MDS Coordinator explained Comprehensive Care Plans were completed with input from the Interdisciplinary Team, and the MDS department was responsible for coordination to ensure all individualized elements were included. She checked resident #1's medical record and said the MDS CAA was triggered for inclusion of an indwelling urinary catheter in the Comprehensive Care Plan and acknowledged it was omitted. The MDS Coordinator stated, it was overlooked and not placed in the care plan. Review of the facility's standards and guidelines dated September 2024 and titled, Resident Assessment Instrument Comprehensive Care Plan Policy noted the facility used the CAA to ensure all possible resident care needs and risks identified during the MDS process were considered.

Based on interview and record review the facility failed to ensure accuracy of documentation in the electronic health record for changing of the enteral tube tubing, water bag, and water bag tubing for 1 of 3 residents reviewed for documentation accuracy of tube feedings, out of a total sample of 39 residents (#107). Findings: Review of the medical record revealed Resident #107 was admitted to the facility on [DATE]. Her diagnoses included surgical aftercare digestive system, dysphagia oropharyngeal phase, attention to gastrostomy and anarthria. Further review of the medical record showed a Physician Order dated 9/14/23 for an Enteral Feed Order with every night shift to change enteral feeding syringe, storage container, and tubing daily. Review of the Medication Administration Record (MAR) dated 11/25/23 at 11:00 PM, showed documentation signature initials for Licensed Practical Nurse (LPN) T and on 11/26/23 at 11:00 PM, a documentation signature initials for LPN U as having changed Resident #107 enteral tubing, water bag, and water bag tubing. On 11/27/23 at 10:23 AM, observation revealed an enteral Jevity 1.5 calorie container dated 11/25/23 at 7:45 AM, with a bag of clear liquid connected to the feeding pump and an infusion rate of 55 milliliters per hour on the feeding pump. It was noted that neither the enteral container tubing, the bag of clear liquid, or the tubing for the bag of clear liquid was labeled or dated. Resident #107 was observed laying in her bed, with a tablet/notepad and pen on her bedside table. She is non-verbal and uses the tablet/notepad, and pen to communicate her needs in writing. On 11/27/23 at 10:34 AM, Registered Nurse (RN) S was asked to come to resident #107 room. Upon this surveyor pointing out Resident #107 enteral container bag tubing, clear bag, and the clear bag tubing were not labeled or dated. RN S confirmed the enteral container was dated for 11/25/23 at 7:45 AM, the clear bag had no label or date and neither the container bag tubing or clear bag tubing was dated or labeled. RN S stated the 11-7 shift changes the tubing for the feeding container which is connected to the clear bag, and it is to be changed every 24 hours. While Registered Nurse S was at the bedside of resident #107 explaining the above statement Resident #107 wrote with her pen on her tablet/notepad for Registered Nurse S, last changed 2-3 days ago. On 11/27/23 at 12:16 PM, The South Wing Unit Manager stated the enteral tube feeding tubing is to be changed, and labeled every 24 hours, by the 11-7 shift. She stated, no nurses should be signing that the tubing was changed, if they have not changed the tubing, water bag, or enteral feeding container. Review of the Medication Administration Record (MAR) revealed inaccuracies in the documentation for resident #107 enteral feed container, water bag, and tubing changes. On 11/28/23 at 11:53 AM, Director of Nursing (DON) stated the expectation is for nurses to document in the medical record at the time frame of what they are doing. On 11/29/23 at 11:24 AM, Licensed Practical Nurse (LPN) R stated Resident #107 is alert, oriented, and able to make her needs known. She stated she is non-verbal and uses a tablet and pen to communicate her needs. Review of the facility staffing assignment sheet revealed LPN T working 11-7 shift on 11/25/23 and LPN U working the 11-7 shift on 11/26/23 in Resident #107 section. Further review of Resident #107 MAR and the facility Medication Administration History report for Enteral Feed tubing change showed LPN T's and LPN U's signature initials for administration of changing the enteral feeding, container tubing, and clear bag tubing changes. On 11/30/23 at 12:52 PM, LPN T was interviewed by telephone, and she confirmed she worked the 11-7 shift on 11/25/23, and those would be her initials on the MAR. LPN T stated yes, she is aware tubing is supposed to be dated, and bags labeled and dated when changing enteral feeding, water bag, or tubing. She stated she believes she wrote the resident room number, last name, first initial, time the bag was hung, her shift, then her initials. It was explained that the water bag was not labeled, and neither was the water bag tubing or the enteral container tubing. On 11/30/23 at 1:39 PM, during a telephone interview LPN U stated, that she did sign that she changed the enteral tubing, water bag and water bag tubing on the 11-7 shift on 11/26/23 at 4:56 AM. She stated truthfully that she does not remember if, they were labeled or dated. She stated that she is not sure. She stated she is aware that everything should be dated, and labeled when changed. The medical record for resident #107 showed inaccuracies documented on 11/25/23 and 11/26/23 for the administration of changing the enteral feeding container tubing, the clear bag, and the clear bag tubing. Review of the facility clinical nursing documentation guidelines (no date) revealed all entries in the medical records should be accurate, dated and timed.

Based on record review and interview the facility failed to provide adequate supervision and assistance to prevent avoidable falls for 1 of 3 residents reviewed for falls out of a total sample of 39 residents, (#83). Findings: Review of medical record revealed resident #83 was admitted to the facility on [DATE] with diagnoses to include heart failure, difficulty walking, muscle weakness, osteoarthritis of the right knee, and venous insufficiency. Review of physician note dated 12/7/22 at 9:11 PM, showed resident #83 had a history of falls. Review of the physician orders from December 2022 to November of 2023 showed an order for a silent bed alarm and resident #83 received Apixaban 2.5 mg by mouth twice a day, a medication that decreases the body's ability to clot (2023, December 9), retrieved December 1, 2023, from https://www.webmd.com/dvt/anticoagulant. Review of the admission Minimum Data Set (MDS) assessment for resident #83, with an assessment reference date (ARD) of 5/11/23, revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, and frequently incontinent of bladder and occasionally incontinent of bowel, with a fall since admission. Review of the care plan initiated on 5/20/22 with a focus for risk for falls related to requiring assistance with transfers showed falls on 12/29/22, 1/22/23, 3/20/23, 10/15/23, and 11/26/23, with no prevention interventions of frequent monitoring, or adequate supervision noted to ensure safety. On 11/29/23 at 11:03 AM, Certified Nursing Assistant (CNA) - Q, stated resident #83 is confused at times, two persons assist is needed for transfers, is always incontinent of bladder and bowel, is a fall risk, and is shaky. On 11/29/23 at 2:00 PM, Director of Nursing (DON) stated resident #83's high risk for fall screening score on 12/1/22 was a 13. Residents with a score equal to or greater than 9 are high risk for falls. Review of facility's Incident log and nurse's notes for resident #83 revealed he had several falls and review of the falls revealed lack of documentation where facility had provided safety assistance and monitoring of supervision tasks for preventing or mitigating avoidable falls. A nurse's note dated 12/29/22 at 7:45 PM, showed resident #83 was observed sitting on the bathroom floor. He stated he fell down to the floor after using the toilet. On 11/29/23 at 3:52 PM, MDS Coordinator stated post fall care plan interventions were range of motion, head to toe check, vital signs stable, physician and family notified, and the resident was educated on using call light for assistance. A nursing note dated 11/22/23 at 10:25 PM, revealed he was observed sitting on the floor with his back against his bed, wheelchair near, and he only had on socks. Resident #83 stated he was trying to transfer from the wheelchair unassisted and slipped. On 11/29/23 at 3:52 PM, MDS Coordinator stated post fall care plan interventions were a head-to-toe body check, treatment ordered for a skin tear, and physician and family notified. A nursing note dated 3/20/23 at 3:30 PM, disclosed resident #83 was found in the bathroom on the floor after he attempted to self-transfer from the toilet to the wheelchair. On 11/29/23 at 2:55 PM, DON stated on 5/2/23 resident #83's high risk for fall score was now an 18. Review of the medical record showed this was an increase of 5 points from 12/1/22. On 11/29/23 at 3:53 PM, MDS Coordinator stated his interventions post fall were a head-to-toe body check, vital signs stable, and physician and family notified. A nursing note dated 10/15/23 at 8:15 PM, showed resident #83 was observed laying on left side, wedged between the wheelchair and the bathroom doorway. He stated he was trying to use the bathroom and lost his balance. The soiled brief was in his wheelchair and his pants were unbuttoned exposing his buttocks. Nursing staff attempted to transfer resident #83, when he complained of right hip pain, and was then transferred to the hospital. On 11/29/23 at 3:54 PM, MDS Coordinator stated resident #83 post fall care plan interventions and the care plan reflected head to toe body check, vital signs stable, range of motion was within normal limits, physician and family notified and transferred to hospital; no new orders. Nursing notes dated 11/26/23 at 4:18 PM and 6:04 PM, and 11/27/23 at 12:08 PM, consecutively, indicated that Resident #83 fell in the bathroom and was found on the floor. The resident stated he stood up, fell , and hit his head and back when he attempted to self-transfer from the wheelchair to the commode. Review of the care plan revealed he was transferred to hospital for evaluation. Interviews with the Risk Manager, clinical staff, MDS Coordinator, and DON as well as the investigation and the medical record revealed resident #83 with an increase in high risk for fall scores, an increase in severity of falls, a trend of 4 out of 5 falls occurring in the bathroom resulting in the last two falls requiring transfers to a higher level of care. The medical record showed the facility did not provide support for overseeing resident #83's safety. Further review of the medical record revealed no prevention for safety measures to provide supervision, or prevent avoidable accidents. On 11/30/23 at 12:12 PM, DON stated MDS is responsible for the oversite of care plans. She confirmed measures should minimize the severity of injury for residents that have subsequent falls. She stated the ultimate person responsible is the DON. Review of the MDS Coordinator job description signed and dated on 11/22/14 revealed the basic function is to coordinate all aspects of residents assessments and all areas of MDS Assessment and care planning. Review of the facility risk management fall reduction program policy with no date showed the facility strives to reduce the risk for resident falls while promoting and supporting resident's independence and mobility. Components of the fall risk reduction program include but are not limited to implementation of individualized interventions to minimize the risk factors for falls and injuries. Evaluating the effectiveness of the interventions in minimizing fall risk factors, providing assistance whenever the resident ambulates, providing a toileting schedule, and supervised activities when up out of bed.

Based on observation and interview, the facility failed to conduct a thorough investigation for a bruise of unknown origin for 1 of 6 residents reviewed for accidents, out of a total sample of 39 residents, (#50). Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, dementia, mixed anxiety disorders, long-term use of anticoagulants and cognitive communication deficit. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 10/12/23 revealed resident #50 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated she had severe cognitive impairment. Resident required assistance with activities of daily living and used a wheelchair for mobility. A weekly skin assessment dated [DATE] indicated resident #50 had a discoloration on her left wrist. Review of resident #50's electronic medical record revealed a nursing progress note dated 12/30/22 which indicated resident #50 had a discolored area to her left wrist. The area was approximately 6 centimeters by 4 centimeters with no swelling. Resident #50 was noted to be alert and oriented to self with increased confusion and agitation. The note was entered by the Risk Manager. On 11/30/23 at 2:13 PM, the Risk Manager verified she was responsible for reviewing incidents and accidents. She explained she reviewed documentation and conducted interviews to determine the cause or possible cause for any incident or accident. The Risk Manager recalled she was informed resident #50 had a bruise and went to assess. She stated she observed a discolored area to resident #50's left wrist. She explained the resident did not say what happened. The Risk Manager stated from interviews and her own observation, resident #50 had increased confusion and agitation days before due to an infection and was on antibiotic therapy. She explained resident #50 took an anticoagulant and had anemia. She stated the cause of the bruise was determined to be from resident #50 being agitated and hitting on top of her overbed table which was witnessed by other staff members and herself. The Risk Manager reviewed resident #50's Electronic Medical Record (EMR) and verified there was no documentation in the record regarding resident #50's behaviors other than her own note from the investigation. The Risk Manager acknowledged she did not have any witness statements from staff contained in her investigation. She confirmed obtaining witness statements was part of the investigation process and could not explain why she did her own documentation and did not obtain any statements from staff. On 11/30/23 at 3:00 PM, the Administrator stated she had participated in the investigation but did not document any statements. She could not recall who was interviewed and could not state why no witness statements were in the investigation. The administrator acknowledged that interviews were part of an investigation and should be documented.

Based on interview and record review, the facility failed to review and/or revise the comprehensive fall care plan to reflect accurate, appropriate, and individualized interventions related to falls for 1 of 3 residents reviewed for falls of a total sample of 39 residents (#37). Findings: Resident #37 was admitted to the facility on [DATE] with diagnoses to include dementia, depression, anxiety, and long-term use of anticoagulants (blood thinner). The Minimum Data Set (MDS) significant change assessment, with an assessment reference date of 10/27/23 revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 01/15 which indicated she had severe cognitive impairment, she was dependent on staff for her daily care, and she used a wheelchair for mobility. On 11/30/23 at 10:42 AM, resident #37's falls were reviewed with the Risk Manager (RM) and revealed the following information: On 1/16/23 at 2:40 PM, resident#37 was found on the floor in her room. The resident complained of pain in ribs and hips. New orders were received for x-rays and labs. The fall was unwitnessed. On 2/11/23 at 2:20 PM, the resident was sitting in her wheelchair in the hallway and got out of the wheelchair and sat on the floor. This was witnessed by a nurse. On 2/22/23 at 12:40 AM, the resident was observed sitting on the floor in her room with the call light in one hand and roommate's phone in the other hand. The resident stated she was going to take the notebook off the table. On 3/22/23 at 6:40 AM, resident#37 was observed sitting on the floor in her room. She stated she was trying to go to the bathroom. No documentation of last time resident was toileted. Neuro checks completed x1. On 3/29/23 at 6:30 PM, resident#37 was observed sitting on the floor next to her wheelchair in the hallway. She yelled for help from the floor. The Risk Manager stated she was closely monitored through the night but could provide no documentation of the monitoring. On 6/19/23 at 6:45 PM, resident #37 was observed sitting on the floor in front of her wheelchair in her room. The resident was unable to verbalize what happened. She was observed by the Certified Nursing Assistant (CNA) at 6:30 PM with the call bell in reach. On 8/01/23 at 4:47 PM, resident #37 was observed on the floor on the 500 hallway and could not say what happened. She had an abrasion to her left forehead and right wrist. Resident #37 was sent to the emergency room because she had an abrasion to her head and she was receiving blood thinning medication (Eliquis). Radiology reports completed at the hospital were negative for injury. On 8/16/23 3:15 PM, resident was found sitting on floor in front of her room, unwitnessed incident, with a right hand skin tear, able to move extremities and family and physician notified. Interventions noted as redirect when noted to be walking, activities, but resident did not want to stay, and reorientation. The RM stated she has been educating the nurses regarding fall documentation and has been doing a lot of investigation regarding the root cause of the falls. She acknowledged the Fall Care plan did not have appropriate interventions following falls. The RM also acknowledged it was important for each care plan to reflect the unique needs of each resident. On 11/30/23 at 05:37 PM, the Director of Nursing (DON) stated that fall interventions need to be timely, patient specific, and have measurable goals. The interventions need to be meaningful to the fall to prevent it from happening again and interventions need to be appropriate for the person involved. Review of resident #37's Fall Care Plan with the DON confirmed the interventions should have been more appropriate and specific to the resident. The DON stated the facility does not necessarily do a fall evaluation after each fall, stating it is not part of the practice because the resident was already at high risk for falls. The DON said neuro checks are done after a head injury is confirmed and is circumstance based after that. Review of the comprehensive fall care plan dated 5/20/22, with a revision date of 11/15/23 did not include interventions that were specific to the falls and/or the resident. Review of the Risk Management-Fall Risk Reduction Program policy, no date, indicated the following steps should be taken after a fall . Update the residents care plan. Review of the facilities Person-Centered Care Planning document, revised 12/2016 revealed . An individualized comprehensive care plan will be person centered and must include measurable objectives and timetables that meet the resident's medical, nursing, mental, and psychosocial needs . Care plans are to be revised as changes in the resident's condition warrant or when there is a change in resident preference or choice of treatment.

Based on observation, interview, and record review the facility failed to provide adequate and appropriate care and services by not following the physician order for a resident who received gastric tube (GT) feedings for 1 of 3 resident reviewed out of a total of 39 sample residents, (#107). Findings: Review of Resident #107's medical record revealed she was admitted to the facility on [DATE] with diagnoses to include gastrostomy, severe protein calorie malnutrition, surgical aftercare of the digestive system, and dysphagia oropharyngeal phase. The resident's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/18/23 noted the resident has a Brief Interview for Mental Status (BIMS) score of 10 which is moderately impaired. She requires dependent to maximal care of staff for activities of daily living and requires a tube feeding to meet her nutritional needs due to loss of liquids when eating, coughing, choking during meals, pain, and difficulty with swallowing. Review of the care plan dated 9/14/23 revealed a history of feeding tube placement and interventions to check for placement, monitor for pain, provide feeding and flushes as ordered by the physician. Review of the most recent Physician Orders dated 11/24/23 revealed an order for Enteral Feed every shift for Jevity 1.5 continuous at 55 milliliters per hour for 16 hours. Off at 10:00 AM, and on at 6:00 PM. With an order dated 9/14/23 for Enteral Feed every night shift, and to change enteral feeding syringe, storage container, and tubing daily. On 11/27/23 at 10:23 AM, observation revealed an enteral Jevity 1.5 calorie container dated 11/25/23 at 7:45 AM, with no label or date on the tubing, a bag of clear liquid connected to the feeding pump that also showed no date or label and the tubing for the clear bag of liquid with no date or label. It was unknown when the feeding tubing or clear bag and tubing was last changed. On 11/27/23 at 10:34 AM, Registered Nurse (RN) S was asked to come to resident #107's room. Upon surveyor pointing out Resident #107's enteral container clear bag, and tubing's, RN S validated the enteral Jevity container had not been changed since 11/25/23 at 7:45 AM, and there was no indication of when the clear bag, or tubing was last changed as none were dated or labeled. She stated that the 3-11 shift starts the feeding container, and the 11-7 shift changes the tubing every 24 hours for the feeding container, and the clear bag. While Registered Nurse S was at the bedside of resident #107 explaining the above statement, Resident #107 wrote with her pen on her tablet/notepad for RN S, last changed 2-3 days ago. While reviewing resident #107 physician orders with RN S she acknowledged that the physician orders were not followed, and nursing did not adhere to accepted professional standards of practice. On 11/28/23 at 11:53 AM, The Director of Nursing (DON) stated the physician order was written for Resident #107 tubing, water and feeding bag to be changed daily. She stated the expectation is for nurses to follow the physician orders. Review of Skilled Nursing Policy showed guidelines for safe administration of tube feeding, administration bag, and tubing must be marked with the date and changed following manufactures recommendations. Review of manufacturers recommendations for enteral feeding pumps guidelines revealed feeding sets should be changed in 24 hours. The 24 hours is based on the feeding hang time, if the set is used for up to 48 hours, the accuracy of the feeding system may be affected.

Based on observation, interview and record review, the facility failed to follow plan of care for splint application for 2 of 5 residents reviewed for mobility of a total sample of 44 residents, (#104, #11). Findings: 1. Resident #104 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with reference date 01/10/22 revealed resident #104 had moderately impaired cognition and required extensive assistance of 1 person for bed mobility, dressing, personal hygiene and bathing. She was totally dependent on 1 staff for toilet use. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor for pain, discomfort, hand hygiene, splint hygiene, nail care and skin integrity every shift. A care plan initiated on 10/02/20, and revised on 12/24/21 noted resident #104 had self-care performance deficit which required assistance with bed mobility, toileting and Activities of Daily Living (ADL) care. She also had limited range of motion (ROM) to bilateral hands (contractures) and bilateral feet (foot drop). On 02/14/22 at 12:30 PM, resident #104 was in bed, and had limited responses to simple questions. Her right hand was on top of her chest area observed to be contracted without any splint or cushion. On 02/15/22 at 5:24 PM, the resident was alert, able to answer simple questions by nodding her head upwards or sideways. Her right hand did not have any splint or any kind of support while resting on her upper chest. On 02/16/22 at 10:35 AM, the resident was resting in bed and her right hand did not have any splint. On 02/17/22 at 10:32 AM, the resident was alert, able to whisper single word responses to questions. Her right hand was placed on top of her upper chest without splint/cushion. When asked if her right hand had been contracted, she whispered yes. When asked if she ever had a splint on her right hand, she whispered yes, but long time ago. When asked if the staff had been applying splint to her right hand, she replied no. On 02/17/22 at 10:48 AM, Certified Nursing Assistant (CNA) E explained the resident required extensive assistance of 1 staff for most of her ADLs. She added the resident never refused care during her shift. She recalled she had never seen the resident with a right hand splint ever since she started working with her around August of 2021. On 02/17/22 at 11:00 AM, Registered Nurse, (RN) F said she had never been informed of the resident refusing care. RN F explained the resident could not move her arms and hands at all and acknowledged there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN F said there were times the splint was there and other times it was gone. She stated it was difficult to monitor and ensure splints were being applied due to workload. She did not explain why the splint was not applied. A review of the progress notes reviewed from 02/01/22 to 02/16/22 did not show any documentation that resident #104 refused to wear the right hand splint. On 02/17/22 at 5:05 PM, the Director of Nursing (DON) explained when a resident was discharged from restorative nursing program, the restorative staff would relay the splinting plan to the nurse. The nurse then would notify the assigned CNA of the splint to be applied. She stated nurses were supposed to have a list of residents with splints. She did not explain why the splint was not applied for resident #104. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly MDS assessment with Assessment Reference Date of 10/29/21 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10/15. The resident required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene. Section G0400 Functional Limitation in Range of Motion revealed the resident had impairment of both sides of her upper extremities. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for ADL (Activities of Daily Living) care. Monitor for placement, pain/discomfort, hand hygiene, splint hygiene, nail care, and skin integrity every shift. This order was not transferred to the current electronic medical record (EMR) until 2/15/22 On 2/14/22 at 4:38 PM, resident #11 was lying on her back in bed. The third, fourth, and fifth fingers of her left hand were contracted and there was redness, and a creamy substance to her left palm. The resident's right hand/ fingers were also contracted. There were no splint devices noted to the resident's hands. No splint device was observed. On 2/16/22 at 4:09 PM, CNA H stated resident #11 wore a splint on her left hand, which was placed by Restorative CNA, or the resident's CNA. The CNA stated the splint goes on during the day and was off in the evening. Observation of the resident's hands with CNA H showed no splint in place at this time. On 2/16/22 at 4:13 PM, the resident was lying in bed on her back. Both hands/fingers were contracted, and the resident did not have any splints in place. There was no rolled washcloth, or carrot in her hands. On 2/16/22 at 4:17 PM, the resident's primary nurse Licensed Practical Nurse (LPN) G, stated resident #11 had contracture of bilateral hands, but she was not aware if the resident had splints. On 2/17/22 at 10:16 AM, resident #11 was observed in bed and her hands were covered with a blanket. The resident stated she had a splint on her right hand, but none on the left hand. On 2/17/22 at 10:19 AM, CNA I stated resident #11 required total assistance with two persons assist for ADL care. She stated the resident had contracted hands and had a splint to her right hand. Observation of the resident's hands with CNA I revealed a splint to the resident's right hand, but no splint/carrot to her left hand. This was verified by CNA I. On 2/17/22 at 10:28 AM, the Director of Rehabilitation stated resident #11 was not currently on therapy caseload. He stated she was last seen by Occupational Therapy for the certification period May-July 2021 and was discharged to Restorative Nursing Program (RNP). The Director of Rehabilitation stated the resident was provided with hand roll with finger separator for both hands. He explained that when a resident was discharged from therapy with any splint device the Restorative CNA would be trained to don/doff the device. He noted that Restorative CNA would manage the resident for 4 weeks, then train and transition care to the assigned CNAs, to continue therapy. On 2/17/22 at 1:28 PM, the DON stated resident #11 was discharged from therapy in July 2021 and was recommended to RNP for bilateral roll with finger separator application 3 times weekly for 12 weeks. She verbalized RNP transitioned to the floor staff in October 2021. The DON said the resident had contractures of bilateral hands and bilateral roll with finger separator should have been applied by the floor staff. She recalled the resident had refused splints in the past but the DON acknowledged no documentation could be identified regarding the placement or refusal of the splints. On 2/17/22 at 1:45 PM, the resident's EMR was reviewed with the South Wing Unit Manager (UM). She verified orders for hand rolls with finger separators were active in the previous EMR and were not transcribed to the new EMR until 2/15/22. Review of the clinical records revealed no documentation to address any attempt to apply the hand rolls with finger separator, or any refusal of the application by resident #11. The UM stated the resident's CNA or nurse would apply the splint, and it was the responsibility of the resident's nurse to ensure the splints were in place as ordered, along with documentation of the resident's tolerance to the device, skin assessment prior to donning and after doffing, and any refusal. The UM verbalized she could not identify any documentation in the resident's clinical records to address the hand rolls. Review of the resident's care plan self-care deficit requires assistance with bed mobility and ADL care .have limited ROM to bilateral hands edited on 11/09/21, revealed a handwritten date of 1/25/22 advising to continue with plan of care. Approaches included, hand rolls with finger separators or carrot to left and right hands all times as tolerated, Monitor for pain/discomfort, hand hygiene, splint hygiene, nail care and skin integrity every shift. Documentation indicated the task was changed from Restorative to nursing on 10/14/21. Review of the resident's clinical record revealed no documentation regarding application of the resident's hand roll with finger separator. There was no documentation regarding skin integrity, until a progress note dated 2/16/22 which read, left palm of hand and in between fingers reddened with white creamy build up in the palm of hand. Foul smelling odor noted .ARNP (Advance Registered Nurse Practitioner) new orders for [MEDICATION(S)] 200 mg(milligram) po (by mouth) daily x 10 days .

Based on observation, interview, and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #90 was admitted to the facility on [DATE] with his most recent readmission on 1/07/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's clinical records showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medicare 5-day Minimum Data Set (MDS) assessment with assessment reference date of 1/02/22 indicated the resident was rarely/never understood and required extensive assistance for most ADLs including eating, and personal hygiene, and was totally dependent on staff for transfers, and bathing. Resident #90 was assessed as having a feeding tube. On 2/14/22 at 10:06 AM, and on 2/15/22 at 1:15 PM, resident #90's TF formula was in a bag hanging from the feeding pump. The bag was labeled with the name of the formula, flow rate and was dated 2/13/22. The label did not have the time the formula was hung and was not initialed. On 2/15/22 at 11:08 AM, the TF formula bag was dated 2/13/22, no time or initial was documented on the label. There was 400 milliliters (ml) of formula in the bag, and the water flush bag was also dated 2/13/22 with 300 ml remaining in the bag. The system was hanging from the feeding pump, not connected to the resident. A large syringe was in a plastic bag on the resident's over bed table and was not dated. On 2/15/22 at 1:31 PM, the North Wing UM stated resident #90 was on tube feeding daily, and the system/ TF formula/flush bag was to be changed on the 11 PM-7 AM shift and should be checked by the resident's nurse every shift. Observation of the resident's TF was conducted with the UM. She verbalized date on the bag containing the TF formula, and the water flush bag were 2/13/22. On 2/15/22 at 1:38 PM, Licensed Practical Nurse (LPN) K stated the resident was on TF at 75 ml/hours, to be off at 10 AM and on at 2 PM. LPN K stated she disconnected the TF from the resident at 10 AM, but did not check the date on the TF formula bag. She stated she assumed the system was changed as required on the 11 PM-7 AM shift. In an interview with the Director of Nursing (DON) on 2/16/22 at 9:32 AM, she stated the system should be changed on the 11 PM-7 AM shift daily. The DON verbalized that nurses were educated to change the system once the bag was completed, and were educated to label, date, time and initial the formula prior to administration. Review of the feeding tube care plan noted that the resident was at risk for altered hydration related to receiving 100% of nutrition via feeding tube. An approach read, Feeding and flush as ordered. The facility's policy Enteral Tube Feeding via Continuous Pump read, Check the enteral nutrition label against the order before administration On the formula label document initials, date and time formula was hung/administered, and initial that the label was checked against the order.

Based on observation, interview and record review, the facility failed to ensure medication was not left at the bedside unattended for 1 of 17 residents on the 200 unit, out of a total sample of 44 residents, (#124). Findings: Resident #124 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] and cognitive communication deficit. Review of the medical record revealed a Brief Interview for Mental Status assessment dated [DATE] which indicated the resident was cognitively intact with a score of 15/15. Review of the physician orders for February 2022 revealed resident #124 had an order for [MEDICATION(S)] ([MEDICATION(S)]) Tablet 1 gram (gm) to be given three times a day for stomach acid. [MEDICATION(S)] is a prescription medication used to treat ulcers by sticking to the ulcer sites and protecting them from acids, enzymes and bile salts (retrieved on 2/18/22 from www.drugs.com). On 2/16/22 at 9:28 AM, resident #124 was observed sitting on the edge of her bed with her overbed table in front of her. An oval white tablet was observed in a disposable medicine cup on the overbed table. Resident #124 stated it was Tylenol and she was going to take it later. On 2/16/22 at 9:32 AM, Licensed Practical Nurse (LPN) B confirmed there was an oval white tablet in a medicine cup on resident #124's overbed table. LPN B stated the tablet was not Tylenol but could not identify the tablet. On 2/16/22 at 9:35 AM, resident #124 stated she thought the tablet was Tylenol but wasn't sure. The resident stated dietary brought the tablet to her and then stated the night nurse dropped it off. On 2/16/22 at 9:37 AM, LPN B removed the medicine cup with the oval white tablet from the resident's room and took it to the medication cart. Observation of the tablet revealed it was an oval white tablet imprinted with the letters TEVA on one side and 22/10 on the opposite side. LPN B compared the tablet to resident #124's medication cards and identified the tablet as [MEDICATION(S)] 1 gram. LPN B stated she administered [MEDICATION(S)] to resident #124 earlier in the morning. LPN B confirmed the nurse should ensure the resident took the medication and no medications should be left at bedside. She explained, if left unattended, another resident could ingest it, choke on it or have an adverse reaction to the medication. Review of resident #124's medical record on 2/16/22 revealed no physician order and no care plan for self-administration of medication. On 2/16/22 at 1:17 PM, the North Wing Unit Manager (UM) validated the medication observed in resident #124's room was identified as [MEDICATION(S)]. She explained the process for medication administration was to administer the medications and to observe the resident took all of their medications. She said, Medications should never be left unattended at a resident's bedside. On 2/16/22 at 4:03 PM, the Director of Nursing (DON) stated the standard of practice for medication administration was for the nurse to ensure the resident took the medication prior to leaving the bedside. She clarified if medications were left at bedside, there was a risk of another resident taking the medication. The DON acknowledged the nurse should not have left the medication at the resident's bedside on the overbed table. Review of the facility's Policy and Procedure for 6.0 General Dose Preparation and Medication Administration dated 12/01/17 included procedures to observe the resident's consumption of the medication(s).

Based on interview and record review, the facility failed to ensure a physician order was obtained for advanced directive/code status for 1 of 2 residents reviewed for advanced directives of a total sample of 44 residents, (#363). Findings: Review of resident #363's medical record documented she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/15/22 at 11:24 AM, a review of the resident's medical record did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 02/15/22 at 1:33 PM, a review the Advance Directives book for the 100 hall revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) from the hospital documented the resident's wishes for full code status. Review of the Social Service note dated 02/10/22 at 3:06 PM, noted the resident wishes for full code. On 02/16/22 at 9:30 AM, the North Wing Unit Manager (UM) stated the process for new admission was to review all hospital paperwork and advanced directives. She said, we then call the resident's physician to verify the orders and then enter those orders into the electronic medical record. A copy of the resident's code status order is placed in the advanced directive book on each wing. The UM confirmed resident #363 did not have a physician's order for full code status and the advanced directive book contained no order for the resident's code status. On 02/16/22 at 10:01 AM, Licensed Practical Nurse (LPN) B explained if a resident did not have a pulse or was not breathing, she would immediately look in the electronic medical record to check for code status. She added, every resident has a copy of their code status order in the Advanced Directives book but I don't know who is responsible for putting the form in book. On 02/16/22 at 11:35 AM, the Director of Nursing (DON) explained resident #363's physician orders for advance directive/full code was not entered in the medical record until 02/16/21. The DON noted the resident was admitted to the facility on [DATE] and the admitting nurse had not obtained a physician's order for code status at admission. Not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported the admitting nurse was required to call the physician for advance directive order which was part of the admission process. She said if a resident had a medical emergency, the nurse would check the physician orders for the resident's code status. She added that all nursing units also had an advanced directive book which contained a copy of each resident's code status order. On 02/17/22 at 4:57 PM, LPN N acknowledged she had admitted resident #363 on 02/09/22. She said she made an error in entering the resident's physician orders into the electronic medical record and as a result, the code status did not show up. I recall she was a full code. I put the order into a cue but did not activate the order so it did not show up. On 02/18/22 at 9:13 AM, the Administrator and DON confirmed that a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Nursing - Admitting/Readmitting a Resident Policy, not dated, read, Policy . admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: The Admission/Readmission Procedure is initiated upon the residents arrival to the facility. The nursing department, at minimum will complete the following: . 2. Physician orders, 3008 form . Code status/Advance Directives . 6. Obtain additional physician orders as indicated and verify the following: . Code Status/Advanced Directives. 7. Accurately and completely transcribe verified physician orders onto the physician order sheet (POS) .

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) therapy was administered per the physician's order for 1 of 3 residents (#51) and failed to obtain physician orders for O2 therapy for 1 of 3 residents reviewed for oxygen therapy, (#90) of a total sample of 44 residents. Findings: 1. Resident #51 was admitted to the facility on [DATE] with a recent readmission of 2/12/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician orders dated 2/13/22 noted oxygen at 2 Liters via nasal cannula (N/C) continuously. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 12/20/21 revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15/15, and indicated the resident used O2. Observations on 2/14/22 at 1:10 PM, and 2/15/22 at 10:49 AM showed resident # 51 received O2 via N/C at 3 Liter/Minute (L/M). On 2/15/22 at 5:20 PM, Licensed Practical Nurses (LPN) M stated after report from off going nurse, she performed a head-to-toe assessment of the resident, and usually checked on the resident's O2 setting. LPN M stated the resident had physician orders for O2 at 2 L/M. An observation of the resident's O2 was conducted with LPN M and she verbalized the O2 setting was on 3 L/M. The physician's orders were reviewed with LPN M, and she acknowledged the order was for 2 L/M. On 2/16/22 at 9:32 AM, the Director of Nursing (DON) stated O2 administration was by physician orders, and O2 therapy should have been administered as ordered for resident #51. The resident's care plan for Risk for ineffective tissue perfusion related to acute/chronic [CONDITION(S)] with [CONDITION(S)] created on 12/20/21 and revised on 2/12/22 included, Oxygen per order. 2. Resident #90 was admitted to the facility on [DATE] with his most recent readmission on 1/07/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 2/14/22 at 10:06 AM, 2/15/22 at 4:46 PM showed resident # 90 received O2 via N/C at 2 L/M, and 2.5 L/M. Review of the resident's physician orders revealed no order for O2 therapy. A nursing progress note dated 2/01/22, read, .O2 sats (saturation) 89% on RA (room air), 2 L of O2 applied with improvement of O2 sats 95% . On 2/15/22 at 4:49 PM, LPN K stated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's O2 settings were observed with LPN K She verbalized the O2 was infusing at 2.5 L/M. The resident's clinical records were reviewed with the LPN and showed no order for O2. LPN K stated the facility just switched to a new electronic medical record (EMR) system. A review of the prior EMR was also conducted and LPN K acknowledged she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN K confirmed that a physician's order could not be identified for O2 therapy for resident #90. On 2/15/22 at 4:56 PM, the North Wing UM stated resident #90 was on O2, but she was not sure of the settings. Observation of the resident's O2 settings was conducted with the UM and she verbalized the O2 was infusing via n/c at 2.5 L/M. The UM stated the resident had orders for 2 L/M, however, a review of the resident's clinical records did not show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/16/22 at 9:32 AM, the DON stated O2 administration was by physician orders. She stated administration of O2 could be a nursing judgement in an emergency, but nurses should follow up and obtain a physician's order for continued therapy. The DON verbalized O2 order should have been in place for resident #90 and should have been administered as ordered for resident #51. She verbalized the expectation was that nurses should ensure an order was in place, if not they were to follow-up with the physician, and obtain an order. On 2/16/22 at 11:29 AM, LPN L stated it could be a nursing judgement to initiate O2 in an emergency, but nurses needed to follow up and obtain a physician's order for continued therapy. LPN L stated resident #90 should have had an order in place for O2 therapy. The facility's policy Oxygen Administration revised 1/18/2018 read, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .start the flow of oxygen at ordered rate.

Based on observation, interview and record review, the facility failed to identify multiple bruises on a resident's neck/chest for 1 of 3 residents reviewed for non-pressure skin conditions out of a total sample of 44 residents, (#65). Findings: Review of resident #65's medical record documented she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations conducted on 02/14/22 at 2:30 PM, 02/15/22 at 5:22 PM, 02/16/22 at 9:50 AM, 1:35 PM, and 5:27 PM and on 02/17/22 at 10:12 AM, noted the resident had multiple (7) circular purple/red bruises on her right upper chest/neck area. The resident was not able to verbalize how she got the bruises but indicated she did not have any pain at the site. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had severe cognitive impairment, required extensive assistance with Activities of Daily Living, (ADL) limited assistance with personal hygiene and was always incontinent of bowel and bladder. Review of the plan of care dated 07/09/21 noted the resident was at risk for complications related to use of anticoagulant therapy. Approaches included to monitor for abnormal bleeding and to monitor for abnormal bruising. Resident #65's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weekly Skin Observation form competed by a licensed nurse on 01/14/22, 01/17/22, and 01/28/22 documented a check in the yes box for bruises and discolorations but failed to document the location of the bruises/discolorations. Review of the Certified Nursing Assistant (CNA) Skin Sheets dated 02/07/22 and 02/14/22 documented open area to the right ankle and open blister to right and left lower thigh, lateral knee, discoloration to both heels but there was no documentation of the bruises on the resident's right upper chest/neck area. Review of the Nurses Progress Notes dated 02/02/22-02/15/22 revealed no documentation of the bruises/discoloration on the resident's right upper chest/neck. On 02/17/22 at 3:54 PM, the Risk Manager stated if a resident had injuries of unknown origin, a report was completed and reviewed for Abuse/Neglect. All incidents of this nature are required to be reported to the Risk Manager within 2 hours and an investigation will be initiated which will include staff statements on all shifts. The Risk Manager confirmed the bruises on resident #65's right upper chest/neck area and stated, these bruises should have been reported to me immediately and they were not. I wish I had know about this sooner. Review of the Skin Care and Wound Management Policy, not dated. read, Policy: The overall goal of the Skin Care and Wound Management program will be to: identify residents at risk for skin impairment, provide care and services to attain or maintain intact skin, prevent complications and involve resident in self management . Procedure . c) Inspect resident skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted . Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policy, not dated, read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source . are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing . 7. A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate procedures for conducting the investigation .

Based on observation, interview, and policy review, the facility failed to remove expired thickened liquids stored in the nourishment room cabinet in 1 of 2 nourishment rooms which could affect 3 of 3 residents on nectar thickened liquids on North Wing (resident # 304, #306, and #450). Findings: On [DATE] at 11:27 AM, a 46 fluid ounce thickened apple juice from concentrate nectar consistency was noted in the North Hall nourishment room's cupboard. The thickened juice was unopened with use by date [DATE]. Next to it was a box of 46 fluid ounce nectar thickened consistency lemon flavored water with a use by date of [DATE]. On [DATE] at 11:35 AM, Staff F said dietary stocked the thickened liquids in the nourishment rooms and residents #304, #306 and #450 received thickened liquids. On [DATE] at 11:39 AM, the Dietary Manager said that dietary staff stocked the thickened liquids in the nourishment rooms daily. The manager explained that dietary staff write a use by date on the bottom of the boxes then they check the use by date on the top. She said, no, those are expired and should not be on the shelf or used. The facility's policy for non-perishable foods dated [DATE] read 8. Canned goods shall be stored for a period not to exceed one year and/or use by/expiration date whichever comes first.

Based on observation, interview and record review, the facility failed to provide nail care for 1 out of 3 dependent residents out of a total of 40 residents, (#93). Findings: Resident #93 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] showed resident #93's Brief Interview for Mental Status (BIMS) was 12/15 which indicated moderately impaired cognition. He required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was totally dependent for transfers and bathing. The resident's care plan dated 04/02/19 indicated Self-care deficit: requires extensive assistance with bed mobility and activities of daily living (ADL) care. Interventions included left arm comfy splint on during wake hours and off during sleeping hours, hand hygiene, splint hygiene, nail care and skin integrity every shift. A review of the nursing progress notes did not reveal any refusals of care by the resident. On 10/05/20 at 12:08 PM, resident #93 was observed resting in bed and was alert. His right hand was noted to have untrimmed, jagged, with black debris under the nails. His left hand was observed rolled over a comfy splint. On 10/06/20 at 12:37 PM, resident #93 was observed holding his water cup using his right hand during lunch time. He used his right hand while eating. His nails remained untrimmed, jagged with black debris under the nails. On 10/07/20 at 11:00 AM, resident #93 was seated in a wheelchair in his room waiting for his Certified Nursing Assistant (CNA) to transfer him to bed. When asked if he preferred to have his nails cleaned and trimmed, he replied yes while nodding his head. On 10/07/20 at 11:48 AM, CNA D stated that she had never given a shower or bed bath to resident #93 as she normally worked Friday, Saturday, Sunday and Monday on 7 AM to 3 PM shift. His shower schedule was Tuesdays and Fridays on the 3 PM to 11 PM shift. She explained that CNAs were expected to provide nail care to the residents when needed. She said if she could not trim the nails, she would just file them. She did not provide an answer when asked if she provided nail care for the resident. On 10/07/20 at 1:42 PM, the South Wing Unit Manager (UM) was requested to look at resident #93's nails on his right hand. She stated, Oh yeah, it needs cleaning, they are dirty. She added that CNAs were expected to trim and clean residents' nails when they gave shower. Resident #93 did not want to show his left hand during this time as it was painful. The Skin Monitoring: Comprehensive CNA Shower Review form revealed that resident #93 received shower on 10/02/20 and a bed bath on 10/06/20. On the question Are residents fingernails clean, trimmed and without rough edges?, neither yes or no was circled on both days. Policy and procedures on Care of Fingernails dated 01/17/18, revised 01/07/20, read General Guidelines: 1. Nail care includes daily cleaning and regular trimming .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interview, and record review, the facility failed to follow infection prevention practices and failed to follow physician orders [REDACTED].#61). Findings: Resident #61 was originally admitted to the facility on [DATE] with readmissions on 6/8/20 and 8/24/20. Her [DIAGNOSES REDACTED]. Resident #61's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a stage IV pressure ulcer. The assessment noted the resident was always incontinent of bowel and bladder. She required extensive assistance of two persons for toileting and bed mobility. The results of a Brief Interview for Mental Status (BIMS) score 10 out of 15, indicated moderately impaired cognition. (A stage IV Pressure Ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI (pressure injury). - CMS) Resident #61 received weekly wound care physician visits for the sacral PU that started June 15, 2020. At that time the PU measured 6 centimeters (cm) in length x 3 cm in width x not measurable depth. The most recent wound care physician's evaluation dated 10/05/20, included the following assessment findings: a stage IV sacrum pressure ulcer, 5.9 cm in length x 5 cm in width x 1.2 cm in depth, moderate serous exudate, 20% slough, 50% granulation tissue, other visible tissues, 15% dermis and fascia. Resident #61's sacral pressure ulcer treatment orders were as follows: Santyl ([MEDICATION NAME] ,[MEDICAL CONDITION]. histo. (histolyticum)) ointment; 250 unit/gram; amt (amount): nickel thick layer; topical. Cleanse sacrum area with normal saline solution (NSS), pat dry, apply Santyl, apply calcium alginate (dressing), cover with Allevyn dressing, change daily once a day; 07:00 AM - 03:00 PM (shift)., dated 8/25/2020. [MEDICATION NAME] cream; 100,000 unit/gram; amt: thin layer; topical. Apply to fungal rash peri-sacral wound every day (QD) with dressing changes and PRN if soiled or dislodged. Once a day: 07:00 AM - 03:00 PM (shift)., dated 8/31/2020. On 10/06/20 at 5:46 PM, observation of resident #61's sacral pressure treatment and dressing change was observed with Licensed Practical Nurse (LPN) B, and the Wound Care Nurse who assisted with positioning the resident. LPN B gathered the treatment supplies needed from the treatment cart. She placed Santyl 250 unit/gram into a small cup, took gauze, normal saline solution (NSS) and an Allevyn dressing from the cart. After gathering the items, she proceeded to the resident's room, performed hand hygiene, and donned gloves. The soiled sacral ulcer wound dressing was removed, rolled into a ball, and placed on the edge of the open incontinence brief that the resident was wearing. The dressing removed was covered with yellowish drainage. The wound bed was observed to have whitish yellow slough, with exposed fatty tissue and muscle. LPN B cleansed the pressure ulcer with normal saline soaked gauze. At this time, between dirty and clean procedures, LPN B did not remove her gloves and perform hand hygiene prior to application of the Santyl ointment into the wound bed. LPN B used her dirty gloved finger to apply the Santyl ointment directly into the wound bed. She then obtained more Santyl from the small cup with her dirty gloved hand, and applied Santyl ointment in circular motions onto the healthy peri-wound skin. LPN B covered the pressure ulcer with an Allevyn occlusive dressing and prepared to clean up her treatment items from the over-bed table. At this time, the dressing's bottom edge was observed not intact which could potentially allow bowel movement to enter underneath the dressing and into the wound bed. The Santyl ointment applied to the peri-wound area prevented the dressing's adherence. LPN B and the Wound Care Nurse secured the resident's brief and repositioned the resident onto her back without correcting the non-intact dressing. LPN B then removed her dirty gloves and performed hand hygiene. On 10/06/20 at 6:09 PM, resident #61's sacral pressure ulcer treatment orders were reviewed with LPN B and the Wound Care Nurse. They stated that the treatment orders were not done as ordered. The Calcium Alginate dressing was not applied over the wound bed prior to applying the occlusive Allevyn dressing. The [MEDICATION NAME] cream was not applied to the sacral area's fungal rash during treatment and dressing changes as ordered. LPN B and the Wound Care Nurse said that the order for the application of the Santyl ointment, a chemical [MEDICATION NAME] agent, did not include the Santyl ointment to be applied to the intact, healthy skin of peri-wound area. LPN B said she had provided resident #61's pressure ulcer treatments in the past. She did not offer an explanation as to why she had not followed the physician's orders [REDACTED]. Resident 61's pressure ulcer care plan initiated 5/28/2020 with goal target date of 11/25/2020 included approaches and treatments for the stage IV sacral wound that included the application of [MEDICATION NAME], Santyl, and Calcium Alginate. On 10/06/20 at 6:20 PM, the Director of Nursing (DON) explained that the facility expected nurses to follow physician's orders [REDACTED]. The DON added that nurses must perform hand hygiene as indicated in the facility's policies and procedures, after removing and discarding a soiled dressing and before cleaning the wound. Review of the facility's policy and procedure for Pressure Injury Treatment (23.7), revised on 01/07/20, included the following infection control practices: Stage IV Protocol .Steps in the Procedure .Position resident and adjust clothing .Wash and dry your hands thoroughly. Put on clean gloves. Loosen tape and remove soiled dressing. Discard soiled dressing into plastic or biohazard bag. Wash and dry your hands thoroughly. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior .Place on clean field .Using clean technique, open other products .Wash and dry your hands thoroughly. Put on clean gloves. Assess the wound and surrounding skin .Cleanse the wound with ordered cleanser .Apply the ordered dressing and secure with tape or bordered dressing per order .Discard disposable gloves and discard into designated container .Wash and dry your hands thoroughly

Based on observation, interview, and record review the facility failed to identify, document, and report bruised/discolored areas, for 1 of 2 residents reviewed for non-pressure related skin conditions, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set (MDS) assessment dated [DATE] showed resident #47's brief interview for mental status (BIMS) was not completed as she was rarely/never understood. The resident required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The care plan dated 12/23/18 for Anticoagulant therapy with risk of complications, related to [MEDICATION NAME] use status [REDACTED]. A physician order [REDACTED]. The weekly skin assessment for resident #47 completed on 12/28/18 and 1/4/18 showed the resident had no new areas of skin irregularities on her upper extremities. The nursing re-admission assessment dated [DATE] regarding skin revealed that she had 3 incisions on her right hip/thigh and redness with purple discoloration/blister to the sacral area. There was no documentation regarding bruised/discoloration areas to the upper extremities from 12/23/18 to 1/8/19. On 1/7/19 at 12:00 PM, resident #47 was observed lying in bed with her eyes closed. She did open her eyes when spoken to. She was not able to answer interview screening questions. She had visible bruised areas on her left wrist with purplish/yellow area approximately the size of plum and left elbow with purple colored area the size of a prune. The assigned licensed practical (LPN) C entered the room with the certified nursing assistant (CNA) and indicated that they were going to give the resident care at this time. On 1/8/19 at 4:52 PM an observation was conducted of resident #47 while CNA B was in the room who indicated she was getting ready to give care. The resident was observed lying in bed, confused and trying to remove her gown. She had the same bruised areas present on the left wrist and elbow as yesterday, however since her gown was off, another bruised area was visible on the left upper arm pale purplish in color, the size of a plum. The CNA B indicated that she was not the usual caregiver assigned to this resident and did not know if the bruised areas on the left arm were new or old. On 1/9/19 at 8:46 AM another observation was conducted of resident #47 lying in bed wearing a hospital gown. Her eyes were closed and she appeared asleep. The gown was covering her left arm, however she still had the same visible bruised are on the left wrist as prior observations. On her right forearm/wrist area she had a reddish round area approximately 1 centimeter (cm.) in size that was covered with a clear dressing. On 1/9/19 at 2:30 PM, an interview was conducted post wound care with LPN C. She verified that she was resident #47's assigned nurse since 1/7/19. The resident was lying in bed post wound care procedure. The LPN C was asked about the clear dressing on the resident's right wrist area. She confirmed that this area had been present since her last re-admission and that the bruising on her left arm was also present all this week while she had been caring for the resident. On 1/9/19 at 4:10 PM, an observation was conducted of resident #47's skin with the director of nursing (DON). The DON verified the bruised/discolored areas on the resident's right wrist and left upper extremity. She stated that the nursing staff were responsible for documenting changes in skin or new areas of concern. She said that the physician/family should be notified of any skin changes. The DON verified that there was no documentation in the medical record on re-admission 12/23/18 regarding clear dressing to the area on the resident's right wrist or any documentation regarding the multiple bruised areas on her left upper extremity. Review of the facility's incident log and medical record showed no entries for resident #47 regarding bruises until it was brought to the facility's attention on 1/9/19 by the surveyor. Review of the facility guidelines for Incident Report & Investigation, revised 11/1/18 read, An incident report and investigation should be completed for all incidents, on the shift that the incident occurred .and is to be reviewed at the Quality Assessment and Assurance (QAA) .

Based on observation, record review and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to provide residents safe medication practices necessary to avoid physical harm, to report and investigate incidents of unsafe medication practices for the 30 residents under the care of Nurse A on 9/11-12/12. The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure; the resident took [MEDICATION NAME] 500 milligrams (mg), an antidiabetic, [MEDICATION NAME] 20 mg, an antihypertensive, [MEDICATION NAME] 10 mg, an antidiabetic, and Simvastin 10 mg. an antilipemic, Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings are: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. a nurse (A) prepared medications belonging to her and her roommate; the nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and then left the room. She stated she came out of the bathroom, saw the cup of medications on the table between the 2 beds and took them assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and she is feeling better today. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready; " they know I take it. " The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m.; she stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress. " The note stated the physician's answering service was called and currently awaiting return call and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written 9/12/12 at 8:55 a.m. by Nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky; resident stated she was feeling fine and just wanted to rest. The next nurse's notes written 9/12/12 at 2:49 p.m. by Nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written 9/13/12 at 12:05 a.m. by Nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given; her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written 9/14/12 at 8:40 a.m. by Nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by Nurse B showed the resident was resting comfortably in in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, and [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. 3. During an interview with the Assistant Director of Nursing (ADON) on 9/17/12 at about 8:15 a.m. she stated the facility had had an incident with a medication error and presented a packet of information showing the investigation of the event; this information included the following: the Federal Immediate Report for neglect (completed 9/13/12 at 11:30 a.m.), the State Adverse Incident Report for transfer to a higher level of care (completed 9/13/12), the Fax form to Florida Department of Children and Families for neglect (completed 9/13/12), a signed letter from the nurse who committed the mediation error dated 9/12/12 with the pharmacy policy and procedure for " General Dose Preparation and Medication Administration attached, a time line of the event from 9/11/12 at 5:00 p.m. to 9/12/12 at 5:30 p.m., a note showing discussion with the nurse consultant on 9/13/12 at 9:00 a.m., a signed note dated 9/13/12 (no time) showing that the ADON and unit manager (UM) " approached resident and roommate to explain our nurse ' s policy that only one roommate should receive medication at one time and if they should ever experience that please notify one of us " , resident #1's face sheet, history and physical, physician's order form for September 2012, resident #12's physician's order form for September 2012, and a Medication Error Report dated 9/12/12 (no time or signature for Part 1). The Medication Error Report indicated the error occurred on 9/11/12 at 5:00 p.m., the DON was notified on 9/12/12 at 10:50 a.m., the physician was notified at 11:00 a.m., and the resident was given [MEDICATION NAME] 500 milligrams (mg), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and Simvastin 10 mg. During an interview on 9/17/12 at 10:45 a.m. with the Director of Nursing (DON), ADON, and Administrator, the DON stated they found out about the event late in the day on 9/12/12 and talked to the nurse involved. During the discussion with the nurse on 9/12/12 at 5:30 p.m. she admitted to the medication error and stated she "normally puts resident's medications on her table next to her window. So why she assumed they were her medications is very unfortunate." She stated did not report it because the resident did get her regular medication and seemed fine; the DON told her she would have to report the event to the state and the Nursing Board. The DON did not remove the nurse from direct resident care " because the medication pass was already done. " She stated she did provide the nurse with education concerning correct medication administration using the pharmacy policy and procedure for " General Dose Preparation and Medication Administration. " She and the administrator felt all residents were protected from harm since the nurse had received a thorough education concerning accurate medication administration and the investigation was competed at that time. The nurse was allowed to finish her shift; she continued to administer medications at 8:30 p.m. and checked a blood sugar at 10:14 p.m. and her last documentation was 9/13/12 at 12:05 a.m. The DON stated she discussed the event with the nurse consultant during a routine visit on 9/13/12 at 9:00 a.m. when she was told to suspend the nurse until the investigation could be completed. The DON stated the nurse was suspended on 9/13/12 at 2:00 p.m. and would be terminated 9/18/12. Nurse A was unavailable for interview during the survey. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and did not mention to him about getting the wrong medications the night before. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic but she did state she thought she got the wrong medications the night before but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars; the physician told her to just monitor the resident; no documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error; she also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator and the DON on 9/17/12 at about 4:15 p.m. they stated the facility had not had any medication errors for the last year so had not felt the need to complete a Quality Assurance plan on the issue. The nurse from the consultant pharmacy had done medication pass reviews with the nurses in July 2012 and had not identified any issues. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it; she stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse " concerning review of medication regimen " as stated in the facility's policy and procedure for Abuse Protection and Response. During an interview with the pharmacy consultant on 9/18/12 at 11:44 a.m. he stated he reviews the residents' medications monthly and has seen no issues with medication administration. He stated that of all the medications administered in error on 9/11/12, the [MEDICATION NAME] 10 mg was the one medication which could have had the most serious effect on the resident and as a result her blood sugar dropped to a low level of 41. Normal fasting blood sugar levels are 80-100. As listed on www.emedicine.health.com Common symptoms of low blood sugar ([DIAGNOSES REDACTED]) are: trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability. When the brain remains deprived of glucose symptoms are: difficulty in thinking, confusion, headache, [MEDICAL CONDITION], coma, and death. Resident #1 has [DIAGNOSES REDACTED]. She had already received the medication at 9:00 a.m. that morning on 9/11/12. During an interview with the Medical Director on 9/18/12 at 12:01 p.m. he stated he had only been informed of the medication error and the negative outcome for resident #1 that morning. He stated he was not her attending physician but felt he should have been notified of the medication error when it was identified in his role as the medical director. He stated he would contact her attending physician to ensure the issue was resolved for there resident. He also stated he was coming to a quality assurance meeting at the facility on 9/19/12 to address the issue.

Based on observations, interviews, and record review the facility failed to ensure the 30 residents on the North Wing under the care of Nurse A were free from neglect relative to medication administration for 1 of 12 sampled residents. (#1) The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took [MEDICATION NAME] 500 milligrams (mg) an antidiabetic medication, [MEDICATION NAME] 20 mg- antihypertensive, [MEDICATION NAME] 10 mg-antidiabetic, and [MEDICATION NAME] 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings include: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. by nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by Nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, and [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. 3. During an interview with the Assistant Director of Nursing (ADON) on 9/17/12 at about 8:15 a.m. she stated the facility had an incident with a medication error and presented a packet of information showing the investigation of the event. This information included the following: the Federal Immediate Report for neglect, completed 9/13/12 at 11:30 a.m., the State Adverse Incident Report for transfer to a higher level of care, completed 9/13/12, the Fax form to Florida Department of Children and Families for neglect, completed 9/13/12, a signed letter from the nurse who committed the mediation error dated 9/12/12 with the pharmacy policy and procedure for "General Dose Preparation and Medication Administration" attached, a time line of the event from 9/11/12 at 5:00 p.m. to 9/12/12 at 5:30 p.m., a note showing discussion with the nurse consultant on 9/13/12 at 9:00 a.m., a signed note dated 9/13/12 (no time) showing that the ADON and unit manager (UM) "approached resident and roommate to explain our nurse's policy that only one roommate should receive medication at one time and if they should ever experience that please notify one of us," resident #1's face sheet, history and physical, physician's order form for September 2012, resident #12's physician's order form for September 2012, and a Medication Error Report dated 9/12/12 (no time or signature for Part 1). The Medication Error Report indicated the error occurred on 9/11/12 at 5:00 p.m., the director of nursing (DON) was notified on 9/12/12 at 10:50 a.m., the physician was notified at 11:00 a.m., and that the resident was given [MEDICATION NAME] 500 milligrams (mg), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. During an interview on 9/17/12 at 10:45 a.m. with the DON, ADON, and Administrator, the DON stated they found out about the event late in the day on 9/12/12 and talked to the nurse involved. During their discussion with the nurse on 9/12/12 at 5:30 p.m., nurse A admitted to the medication error and stated she "normally puts resident's medications on her table next to her window. So why she assumed they were her medications is very unfortunate." She stated did not report it because the resident did get her regular medication and seemed fine. The DON told her she would have to report the event to the state and the Nursing Board. The DON did not remove the nurse from direct resident care " because the medication pass was already done." She stated she did provide the nurse with education concerning correct medication administration using the pharmacy policy and procedure for "General Dose Preparation and Medication Administration." She and the administrator felt all residents were protected from harm since the nurse had received a thorough education concerning accurate medication administration and the investigation was completed at that time. The nurse was allowed to finish her shift. She continued to give medications at 8:30 p.m., checked a blood sugar at 10:14 p.m., and her last documentation was 9/13/12 at 12:05 a.m. The DON stated she discussed the event with the nurse consultant during a routine visit on 9/13/12 at 9:00 a.m. when she was told to suspend the nurse until the investigation could be completed. The DON stated the nurse was suspended on 9/13/12 at 2:00 p.m. and would be terminated 9/18/12. Nurse A was unavailable for interview during the survey. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and she did not mention to him about getting the wrong medications the night before. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic. She did state she thought she got the wrong medications the night before, but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars. The physician told her to just monitor the resident. No documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error. She also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator and the DON on 9/17/12 at about 4:15 p.m. they stated the facility had not had any medication errors for the last year so had not felt the need to complete a Quality Assurance plan on the issue. The nurse from the consultant pharmacy had done medication pass reviews with the nurses in July 2012 and had not identified any issues. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. Both the Administrator and the DON continued to state the incident was only a "medication error" and the DON stated she should not have to suspend or terminate every nurse who makes a medication error. During an interview with the pharmacy consultant on 9/18/12 at 11:44 a.m. he stated he reviews the residents' medications monthly and has seen no issues with medication administration. He stated that of all the medications administered in error on 9/11/12, the [MEDICATION NAME] 10 mg was the one medication which could have had the most serious effect on the resident and as a result her blood sugar dropped to a low level of 41. Normal fasting blood sugar levels are 80-100. As listed on www.emedicine.health.com Common symptoms of low blood sugar ([DIAGNOSES REDACTED]) are: trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability. When the brain remains deprived of glucose symptoms are: difficulty in thinking, confusion, headache, [MEDICAL CONDITION], coma, and death. During an interview with the Medical Director on 9/18/12 at 12:01 p.m. he stated he had only been informed of the medication error and the negative outcome for resident #1 that morning. He stated he was not her attending physician but felt he should have been notified of the medication error when it was identified in his role as the medical director. He stated he would contact her attending physician to ensure the issue was resolved for the resident. He also stated he was coming to a quality assurance meeting at the facility on 9/19/12 to address the issue. The NWUM was aware of this significant medication error on 9/12/12 at 10:30 a.m. and the DON was aware at 10:50 a.m., but nurse A was not suspended until 9/13/12 at 2:00 p.m. This act allowed a total of 30 residents under her care to be at risk for neglect related to significant medication errors. The residents in nurse A's care were at risk for unsafe medication administration for a total of 27.5 hours before she was suspended.

Based on observations, interviews, and record review, the facility failed to operationalize policies and procedures for the protection of the 30 residents on the North Wing under the care of Nurse A and for thorough investigation and reporting of neglect relative to medication administration for 1 of 12 sampled residents. (#1) The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took [MEDICATION NAME] 500 milligrams (mg) an antidiabetic medication, [MEDICATION NAME] 20 mg- antihypertensive, [MEDICATION NAME] 10 mg-antidiabetic, and [MEDICATION NAME] 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings include: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by Nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by Nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by Nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by Nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, and [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. 3. During an interview with the Assistant Director of Nursing (ADON) on 9/17/12 at about 8:15 a.m. she stated the facility had an incident with a medication error and presented a packet of information showing the investigation of the event. This information included the following: the Federal Immediate Report for neglect, completed 9/13/12 at 11:30 a.m., the State Adverse Incident Report for transfer to a higher level of care, completed 9/13/12, the Fax form to Florida Department of Children and Families for neglect, completed 9/13/12, a signed letter from the nurse who committed the mediation error dated 9/12/12 with the pharmacy policy and procedure for "General Dose Preparation and Medication Administration" attached, a time line of the event from 9/11/12 at 5:00 p.m. to 9/12/12 at 5:30 p.m., a note showing discussion with the nurse consultant on 9/13/12 at 9:00 a.m., a signed note dated 9/13/12 (no time) showing that the ADON and unit manager (UM) "approached resident and roommate to explain our nurse's policy that only one roommate should receive medication at one time and if they should ever experience that please notify one of us," resident #1's face sheet, history and physical, physician's order form for September 2012, resident #12's physician's order form for September 2012, and a Medication Error Report dated 9/12/12 (no time or signature for Part 1). The Medication Error Report indicated the error occurred on 9/11/12 at 5:00 p.m., the director of nursing (DON) was notified on 9/12/12 at 10:50 a.m., the physician was notified at 11:00 a.m., and that the resident was given [MEDICATION NAME] 500 milligrams (mg), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. During an interview on 9/17/12 at 10:45 a.m. with the DON, ADON, and Administrator, the DON stated they found out about the event late in the day on 9/12/12 and talked to the nurse involved. During their discussion with the nurse on 9/12/12 at 5:30 p.m., nurse A admitted to the medication error and stated she "normally puts resident's medications on her table next to her window. So why she assumed they were her medications is very unfortunate." She stated did not report it because the resident did get her regular medication and seemed fine. The DON told her she would have to report the event to the state and the Nursing Board. The DON did not remove the nurse from direct resident care " because the medication pass was already done." She stated she did provide the nurse with education concerning correct medication administration using the pharmacy policy and procedure for "General Dose Preparation and Medication Administration." She and the administrator felt all residents were protected from harm since the nurse had received a thorough education concerning accurate medication administration and the investigation was completed at that time. The nurse was allowed to finish her shift. She continued to give medications at 8:30 p.m., checked a blood sugar at 10:14 p.m., and her last documentation was 9/13/12 at 12:05 a.m. The DON stated she discussed the event with the nurse consultant during a routine visit on 9/13/12 at 9:00 a.m. when she was told to suspend the nurse until the investigation could be completed. The DON stated the nurse was suspended on 9/13/12 at 2:00 p.m. and would be terminated 9/18/12. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and she did not mention to him about getting the wrong medications the night before. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic. She did state she thought she got the wrong medications the night before, but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars. The physician told her to just monitor the resident. No documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error. She also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator and the DON on 9/17/12 at about 4:15 p.m. they stated the facility had not had any medication errors for the last year so had not felt the need to complete a Quality Assurance plan on the issue. The nurse from the consultant pharmacy had done medication pass reviews with the nurses in July 2012 and had not identified any issues. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. Documentation was not available to show that the investigation included approaches which would ensure protection of all facility residents from harm. Both the Administrator and the DON continued to state the incident was only a "medication error" and the DON stated she should not have to suspend or terminate every nurse who makes a medication error. During an interview with the Corporate Long Term Care Consultant, the Nurse Consultant, the Administrator, and the DON on 9/18/12 at about 1:15 p.m., they stated they now recognize the possible medical neglect was more than a medication error and they need to complete a thorough investigation. They were in the process of interviewing residents and staff concerning accurate medication administration, especially not prepouring or leaving medications at the bedside without observing the resident taking the medications and prompt reporting of medications errors. The DON stated she is now developing quality assurance plans relative to timely reporting of medication errors and complete and accurate documentation.

Based on observations, record review and interviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 2 of 12 residents reviewed for medication administration (#1& 5) and the other 28 residents who were also provided care by Nurse A. The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took Metformin 500 milligrams (mg) an antidiabetic medication, Lisinopril 20 mg- antihypertensive, Glipizide 10 mg-antidiabetic, and Simvastatin 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings include: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took Metformin 500 mg, Lisinopril 20 mg, Glipizide 10 mg, and Simvastatin 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. by nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were Lisinopril 20 mg an antihypertensive, Metformin 500 mg an antidiabetic, Glipizide 10 mg an antidiabetic, and Simvastatin 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and she did not mention to him about getting the wrong medications the night before. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. 2. Record review for resident #5 showed she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Record review revealed she had physician orders and received Nu-Iron 150 milligrams (mg), Colace 250 mg, Eldertonic Elixir 30 milliliters (ml), and Oyster Shell Calcium-Vitamin D3 500 mg at 5:00 p.m. and Remoran 15 mg, Restoril 30 mg, Seroquel 12.5 mg, and Requip 2 mg at 9:00 p.m. administered by nurse A on 9/11/12 and 9/12/12. A review of the resident's Minimum Data Set (MDS) completed 8/20/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Under Section G on the MDS she is shown to be independent in Activities of Daily Living except setup for eating and personal hygiene. A nurse's note written 8/14/12 showed the resident is alert and oriented x 3 and able to make her needs known. She ambulates on her own without assistive device. During an interview with resident #5 on 9/18/12 at 10:10 a.m., she stated she knows her medications and when she is to receive them. She stated "Several times the evening nurse comes in, places them (medications) on my table, and then leaves without saying anything. Sometimes the medications in the cup are wrong, and I have to pull the call bell to get the nurse back to correct the medications. It is very frustrating." 3. During an interview with the pharmacy consultant on 9/18/12 at 11:44 a.m. he stated he reviews the residents' medications monthly and has seen no issues with medication administration. He stated that of all the medications administered in error on 9/11/12 to resident #1, the Glipizide 10 mg was the one medication which could have had the most serious effect on the resident and as a result her blood sugar dropped to a low level of 41. Normal fasting blood sugar levels are 80-100. As listed on www.emedicine.health.com Common symptoms of low blood sugar ([DIAGNOSES REDACTED]) are: trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability. When the brain remains deprived of glucose symptoms are: difficulty in thinking, confusion, headache, seizures, coma, and death. 4. A review of the facility policy and procedure (P&P) for "General Dose Preparation and Medication Administration showed under 3.2 that "Facility staff should only prepare medications for one resident at a time." and under 3.9 that Facility staff should not leave medications or chemicals unattended." The P&P does not address reporting of medication errors.

Based on interviews, observations, and record review failed to ensure that each resident is free from a significant medication error which resulted in potential serious harm for 1 of 12 sampled residents. (#1) The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took [MEDICATION NAME] 500 milligrams (mg) an antidiabetic medication, [MEDICATION NAME] 20 mg- antihypertensive, [MEDICATION NAME] 10 mg-antidiabetic, and [MEDICATION NAME] 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings are: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. by nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, an [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. 3. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and she did not mention to him about getting the wrong medications the night before. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic. She did state she thought she got the wrong medications the night before, but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars. The physician told her to just monitor the resident. No documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error. She also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. During an interview with the pharmacy consultant on 9/18/12 at 11:44 a.m. he stated he reviews the residents' medications monthly and has seen no issues with medication administration. He stated that of all the medications administered in error on 9/11/12, the [MEDICATION NAME] 10 mg was the one medication which could have had the most serious effect on the resident and as a result her blood sugar dropped to a low level of 41. Normal fasting blood sugar levels are 80-100. As listed on www.emedicine.health.com Common symptoms of low blood sugar ([DIAGNOSES REDACTED]) are: trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability. When the brain remains deprived of glucose symptoms are: difficulty in thinking, confusion, headache, [MEDICAL CONDITION], coma, and death. The resident has [DIAGNOSES REDACTED]. During an interview with the Medical Director on 9/18/12 at 12:01 p.m. he stated he had only been informed of the medication error and the negative outcome for resident #1 that morning. He stated he was not her attending physician but felt he should have been notified of the medication error when it was identified in his role as the medical director. He stated he would contact her attending physician to ensure the issue was resolved for the resident. He also stated he was coming to a quality assurance meeting at the facility on 9/19/12 to address the issue.

Based on record review and interviews the facility failed to maintain clinical records on each resident that were accurate and complete for 1 of 12 sampled residents. (#1) The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took [MEDICATION NAME] 500 milligrams (mg) an antidiabetic medication, [MEDICATION NAME] 20 mg- antihypertensive, [MEDICATION NAME] 10 mg-antidiabetic, and [MEDICATION NAME] 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings are: 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. 2. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by Nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. by Nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by Nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by Nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by Nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, and [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. 3. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic. She did state she thought she got the wrong medications the night before, but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars. The physician told her to just monitor the resident. No documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error. She also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator and the DON on 9/17/12 at about 4:15 p.m. they stated the facility had not had any medication errors for the last year so had not felt the need to complete a Quality Assurance plan on the issue. The nurse from the consultant pharmacy had done medication pass reviews with the nurses in July 2012 and had not identified any issues. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. Documentation was not available to show that the investigation included approaches which would ensure protection of all facility residents from harm. Both the Administrator and the DON continued to state the incident was only a " medication error " and the DON stated she should not have to suspend or terminate every nurse who makes a medication error. During an interview with the Corporate Long Term Care Consultant, the Nurse Consultant, the Administrator, and the DON on 9/18/12 at about 1:15 p.m., they stated they now recognize the possible medical neglect was more than a medication error and they need to complete a thorough investigation. They were in the process of interviewing residents and staff concerning accurate medication administration, especially not prepouring or leaving medications at the bedside without observing the resident taking the medications and prompt reporting of medications errors. The DON stated she is now developing quality assurance plans relative to timely reporting of medication errors and complete and accurate documentation.

Based on observations, interviews, and record review the facility failed to follow standards of practice for administration of medications and for 2 of 12 sampled residents. (#1 &5) The nurse administering medications did not administer medications to ensure resident #1 took the medications intended for her. Resident #1 mistakenly took roommate's medications, resulting in potential life threatening low blood sugar and low blood pressure. The resident took [MEDICATION NAME] 500 milligrams (mg) an antidiabetic medication, [MEDICATION NAME] 20 mg- antihypertensive, [MEDICATION NAME] 10 mg-antidiabetic, and [MEDICATION NAME] 10 mg-antilipemic. Additionally, the nurse failed to report this error after resident #1 told her that she took the incorrect medications. The nurse poured the medications for both residents at the same time and left the medications for both residents in their room without ensuring they took them. These practices resulted in the determination of Immediate Jeopardy starting on 9/11/12 and was determined to be ongoing as of the exit date of 9/18/12. The findings include: Florida Board of Nursing, Nurse Practice Act, 464.003(3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring specialized knowledge, judgment, and nursing skills based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. According to Lippincott's Nursing Center.com the 8 rights of medication administration for patient safety include: 1) right patient-Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system), 2) right medication-Check the medication label. Check the order, 3) right dose-Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well,4) right route-Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route, 5) right time-Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given, 6) right documentation-Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug, 7) right reason-Confirm the rationale for the ordered medication. What is the patient ' s history? Why is he/she taking this medication? Revisit the reasons for long-term medication use, and 8) right response-Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. 1. During an interview with resident #1 on 9/17/12 at about 8:30 a.m. she stated that on 9/11/12 at about 5:00 p.m. nurse A prepared medications belonging to her and her roommate. The nurse placed one cup of medications on a table between the 2 beds and the second cup of medications was placed on the table between her bed and the window and the nurse then left the room. She stated she came out of the bathroom, saw a cup of medications on the table between the 2 beds and took them, assuming they were hers. She then noticed the medication cup on the other side of her bed and realized she had taken the wrong medications. She took [MEDICATION NAME] 500 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. She stated she told the nurse who had prepared and left the medications that she had taken the wrong medications. She stated that nurse A then gave her the correct medications. The resident stated the biggest mistake the nurse made was not reporting the error to anyone. She stated she felt OK that evening, but she started feeling lightheaded and had sweats when she tried to make her bed in the morning. She stated it took her about 2 ? days to start feeling well and feeling better today, 9/17/12. She also stated that nurse has left medications in the room on her table on prior evenings for her to take when she was ready because, "they know I take it." The resident was observed ambulating in the hallway with her walker on 9/17/12 at about 10:00 a.m. She stated she felt good and was going to Bingo. Record review for resident #1 showed she was admitted to the facility on [DATE] with her last readmission from the hospital 9/6/10. Her primary [DIAGNOSES REDACTED]. A nurse's note written on 9/12/12 at 7:30 a.m. by nurse L showed "at 6:30 a.m. this nurse entered resident's room to administer medications. At this time the resident complained of feeling shaky and light headed. Resident's vital signs were stable, but her blood sugar was 41. Resident given 6 ounces (oz.) of orange juice and resident consumed 100%. Blood sugar rechecked and is currently 71. Resident stated I feel better now. Resident is currently sitting up in recliner without distress." The note stated the physician's answering service was called, currently awaiting return call, and she had notified the oncoming nurse of the low blood sugar and awaiting return call from the physician. Documentation was not evident of a return call from the physician or further orders. The next nurse's note written on 9/12/12 at 8:55 a.m. by Nurse B indicated her vital signs were stable and her blood sugar was 130. The resident was resting comfortably in bed with no further complaints of being cold or shaky. The resident stated she was feeling fine and just wanted to rest. The next nurse's notes written on 9/12/12 at 2:49 p.m. by Nurse B showed her blood sugar was 55 at 1:45 p.m. and the physician was notified. An order was received to monitor the resident's blood sugar every 4 hours. The next nurse's note written on 9/13/12 at 12:05 a.m. by Nurse A showed her blood sugar at 4:00 p.m. was 65 and orange juice was given. Her blood sugar was checked after dinner and it increased to 127. Blood sugar checked at 9:00 p.m. was 106 and the resident had no complaints. The next nurse's note written on 9/14/12 at 8:40 a.m. by Nurse M indicated, as a late entry for 9/13/12, that the " daughter-in-law was notified of low blood sugars. " During an interview with the North Wing Unit Manager (NWUM) on 9/18/12 at about 10:30 a.m. she stated she also told the daughter about the medication errors, but did not document this information. The next nurse's note written 9/14/12 at 3:58 p.m. by Nurse B showed the resident was sitting in a chair in her room with no signs and symptoms of distress. Her blood sugar was 124 at 11:30 a.m. and she stated she was feeling a lot better today. A review of her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in her medical record was not available to show that she was given 4 medications for which there was no physician's order. The medications were [MEDICATION NAME] 20 mg an antihypertensive, [MEDICATION NAME] 500 mg an antidiabetic, [MEDICATION NAME] 10 mg an antidiabetic, and [MEDICATION NAME] 10 mg an antilipemic. Documentation was not present in the clinical record that the resident had possibly taken the incorrect medications until late entries were made on 9/18/12 at 12:14 p.m., the day after the surveyor's inspection started on 9/17/12. A review of the resident's Quarterly Minimum Data Set (MDS) completed 6/26/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Her ability to see in adequate light under Section B was coded as " 1 " vision, " sees large print but not regular print in newspapers/books. " Her ability to eat as coded under section G showed she was independent in eating, requiring setup help only. The resident's care plan developed 1/27/12 and updated 10/10/12 showed the resident required limited assistance with dressing and hygiene and extensive assistance with bathing. She was independent in ambulation with a wheeled walker around the facility, inside and outside. During an interview with the Assistant Director of Nursing (ADON) on 9/17/12 at about 8:15 a.m. she stated the facility had an incident with a medication error and presented a packet of information showing the investigation of the event. This information included the following: the Federal Immediate Report for neglect, completed 9/13/12 at 11:30 a.m., the State Adverse Incident Report for transfer to a higher level of care, completed 9/13/12, the Fax form to Florida Department of Children and Families for neglect, completed 9/13/12, a signed letter from the nurse who committed the mediation error dated 9/12/12 with the pharmacy policy and procedure for "General Dose Preparation and Medication Administration" attached, a time line of the event from 9/11/12 at 5:00 p.m. to 9/12/12 at 5:30 p.m., a note showing discussion with the nurse consultant on 9/13/12 at 9:00 a.m., a signed note dated 9/13/12 (no time) showing that the ADON and unit manager (UM) "approached resident and roommate to explain our nurse's policy that only one roommate should receive medication at one time and if they should ever experience that please notify one of us," resident #1's face sheet, history and physical, physician's order form for September 2012, resident #12's physician's order form for September 2012, and a Medication Error Report dated 9/12/12 (no time or signature for Part 1). The Medication Error Report indicated the error occurred on 9/11/12 at 5:00 p.m., the director of nursing (DON) was notified on 9/12/12 at 10:50 a.m., the physician was notified at 11:00 a.m., and that the resident was given [MEDICATION NAME] 500 milligrams (mg), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. During an interview on 9/17/12 at 10:45 a.m. with the DON, ADON, and Administrator, the DON stated they found out about the event late in the day on 9/12/12 and talked to the nurse involved. During their discussion with the nurse on 9/12/12 at 5:30 p.m., nurse A admitted to the medication error and stated she "normally puts resident's medications on her table next to her window. So why she assumed they were her medications is very unfortunate." She stated did not report it because the resident did get her regular medication and seemed fine. The DON told her she would have to report the event to the state and the Nursing Board. The DON did not remove the nurse from direct resident care " because the medication pass was already done." She stated she did provide the nurse with education concerning correct medication administration using the pharmacy policy and procedure for "General Dose Preparation and Medication Administration." She and the administrator felt all residents were protected from harm since the nurse had received a thorough education concerning accurate medication administration and the investigation was completed at that time. The nurse was allowed to finish her shift. She continued to give medications at 8:30 p.m., checked a blood sugar at 10:14 p.m., and her last documentation was 9/13/12 at 12:05 a.m. The DON stated she discussed the event with the nurse consultant during a routine visit on 9/13/12 at 9:00 a.m. when she was told to suspend the nurse until the investigation could be completed. The DON stated the nurse was suspended on 9/13/12 at 2:00 p.m. and would be terminated 9/18/12. Nurse A was unavailable for interview during the survey. During an interview on 9/17/12 at 12:15 p.m. with nurse #B he stated he took care of resident #1 on 9/12/12 on the day shift. He stated she was very lethargic probably because of the low blood sugars and she did not mention to him about getting the wrong medications the night before. During an interview on 9/17/12 at 12:30 p.m. with the NWUM she stated she talked to resident on 9/12/12 at about 10:30 a.m. because of the issues with her level of consciousness and her blood sugars. She was very weak and lethargic. She did state she thought she got the wrong medications the night before, but she was not sure. The NWUM stated she did not document the conversation with the resident in the clinical record because the resident seemed confused and was not making sense. The NWUM stated she filled out a Medication Error Form and gave it to the DON. She stated she also contacted the physician to tell her that the resident felt she had taken her roommate's medication and she was experiencing low blood sugars. The physician told her to just monitor the resident. No documentation in the clinical record reflected this phone call. She stated she contacted the physician again at 2:30 p.m. on 9/12/12 to report the continuing low blood sugars and she received an order for [REDACTED]. The NWUM stated the Medication Error was discussed at the afternoon clinical meeting on 9/12/12 at 3:30 p.m. where it was determined that the wrong medications were taken by the resident and which nurse was likely responsible. The DON stated the afternoon clinical meeting is held at the change of shifts when department heads, unit managers and the evening supervisor discuss any issue pertinent to resident care. During an interview with the evening supervisor on 9/17/12 at about 5:30 p.m. she stated her workload sometimes prevents her from attending the afternoon clinical meeting and she does not remember attending that meeting so was unaware of the medication error. She also stated the nurse who had made the medication error had not told her about it. During an interview with the Administrator and the DON on 9/17/12 at about 4:15 p.m. they stated the facility had not had any medication errors for the last year so had not felt the need to complete a Quality Assurance plan on the issue. The nurse from the consultant pharmacy had done medication pass reviews with the nurses in July 2012 and had not identified any issues. During an interview with the Administrator, DON, and ADON on 9/17/12 at 5:10 p.m., they were informed of the Immediate Jeopardy in the areas of neglect and medication administration and the survey was extended with return onsite on 9/18/12. The DON continued to state that the investigation was totally completed on 9/12/12 after she talked to the nurse who made the medication error and did not report it. She stated she educated the nurse on proper medication administration and the Administrator stated they did not feel residents were in any harm due to the education of the nurse "concerning review of medication regimen" as stated in the facility's policy and procedure for Abuse Protection and Response. During an interview with the pharmacy consultant on 9/18/12 at 11:44 a.m. he stated he reviews the residents' medications monthly and has seen no issues with medication administration. He stated that of all the medications administered in error on 9/11/12, the [MEDICATION NAME] 10 mg was the one medication which could have had the most serious effect on the resident and as a result her blood sugar dropped to a low level of 41. Normal fasting blood sugar levels are 80-100. As listed on www.emedicine.health.com Common symptoms of low blood sugar ([DIAGNOSES REDACTED]) are: trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability. When the brain remains deprived of glucose symptoms are: difficulty in thinking, confusion, headache, [MEDICAL CONDITION], coma, and death. 2. Record review for resident #5 showed she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Record review revealed she had physician orders and received Nu-Iron 150 milligrams (mg), [MEDICATION NAME] 250 mg, [MEDICATION NAME] 30 milliliters (ml), and Oyster Shell Calcium-Vitamin D3 500 mg at 5:00 p.m. and Remoran 15 mg, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 12.5 mg, and Requip 2 mg at 9:00 p.m. administered by nurse A on 9/11/12 and 9/12/12. A review of the resident's Minimum Data Set (MDS) completed 8/20/12 under Section C showed her Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Under Section G on the MDS she is shown to be independent in Activities of Daily Living except setup for eating and personal hygiene. A nurse's note written on 8/14/12 at 8:07 p.m. by Nurse A showed the resident is " alert and oriented x 3 and able to make her needs known. Ambulates on her own without assistive device. " During an interview with resident #5 on 9/18/12 at 10:10 a.m., she stated she knows her medications and when she is to receive them. She stated "Several times the evening nurse comes in places them (medications) on my table, and then leaves without saying anything. Sometimes the medications in the cup are wrong, and I have to pull the call bell to get the nurse back to correct the medications. It is very frustrating." 3. A review of the facility policy and procedure (P&P) for "General Dose Preparation and Medication Administration showed under 3.2 that "Facility staff should only prepare medications for one resident at a time." and under 3.9 that Facility staff should not leave medications or chemicals unattended."