Every finding on record at Lake Wales Health and Rehabilitation Center

Based on observations, record reviews and interviews, the facility failed to ensure safe and comfortable temperatures were maintained in residents' bedrooms by failing to repair one of eight rooftop air-conditioning (A/C) units resulting in temperature readings between 89.8- and 90.0-degrees Fahrenheit (F) on 06/23/2025, for one resident (#5) of twenty sampled residents. These failures resulted in physical discomfort for a dependent resident and the likelihood of significant harm due to unsafe temperatures exceeding 81-degrees Fahrenheit. Findings included: During the tour of the facility on 06/23/2025 at 8:32 a.m. Resident #5 was observed in a private bedroom. Upon entering the room, noticeable uncomfortable room air temperature was identified due to excessive warmth with palpable humidity present. A fan, approximately 18 inches, was observed operating on an over the bed table. Resident #5 was observed in a low bed, in a curled position, eyes open, observed to be watching the television in the corner of the room. Two windows, that were approximately the length of the bed, were observed to be open approximately 1 inch. The room was observed to have no wall cooling A/C units. An air vent was observed to be located in the ceiling, right inside the resident's room door. During this tour, there was no noticeable cool air flow. During this tour, Resident #5 was noted not interviewable and could not speak of his temperature preferences. A review of Resident #5's admission Record revealed a re-admission date of 05/23/2025. The diagnosis information included, but not limited to: Severe intellectual disabilities, acute and chronic respiratory failure; contracture, unspecified joint, cognitive communication deficit, muscle weakness (generalized); and need for assistance with personal care. Review of a progress note dated 06/04/2025 at 4:13 p.m. revealed Resident #5 was unable to speak on behalf of self. It showed, Social Determinations of Health note by the Minimum Data Set Coordinator: Resident is unable to respond regarding ethnicity. Resident is unable to respond regarding race. Language: English. Residents do not need or want an interpreter to communicate with doctor or health care staff. Resident is unable to respond to lack of transportation. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy: Resident unable to respond. How often do you feel lonely or isolated from those around you: Resident unable to respond. On 06/23/2025 at 10:33 a.m., an interview was conducted with the Maintenance Director. He stated the facility had three ground unit air conditioners (A/C) and eight rooftop A/Cs. He stated, Yes, they are all keeping temperatures. He stated he checks the working order of the A/Cs by using the thermal gun, pointing it at the vents for temperature. He said he did this about once per month. On 06/23/2025 at 10:47 a.m., observations were conducted of Resident #5's room with the Maintenance Director. The windows were observed open in the same position. The Maintenance Director stated he was unaware of the warmth of the room, and he did not know why the residents' windows were open. He was observed to close the windows. When asked if he had a tool to measure the temperature in the room, he said he did and he was observed to leave to retrieve it. During the Maintenance Director's absence, at 10:50 a.m. Staff C, Licensed Practical Nurse (LPN) was observed outside of Resident #5's room, she confirmed she was assigned to Resident #5. When asked about the temperature in Resident #5's room, she said, it was warm in the room. She said, It has been like that for about one month. All of them are aware. On 06/23/2025 at 11:55 a.m., the Maintenance Director returned with a thermal temperature gun. He pointed the thermal gun at the ceiling and the reading on the tool was 90.0 degrees Fahrenheit. He pointed the thermal gun at the floor, approximately two and a half feet from Resident #5's bed, and the reading on the tool was 89.8 degrees Fahrenheit. The Maintenance Director said, It is very warm, we can see about moving him. On 06/23/2025 at 11:13 a.m. an interview was conducted with Staff C, LPN. When asked if and how the temperature was monitored in Resident #5's room, she stated she did not know how to take temperatures. She stated they were aware of it. She said, for maintenance issues, they enter maintenance requests electronically through a portal. An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 06/23/2025 at 11:38 a.m. She stated the Maintenance Assistant and Director knew about the warm temperatures in Resident #5's room. She said, He (The Maintenance Director) has been aware of it. I asked them if they are going to do anything about it. She said, (referring to Resident #5) you can go in there and he will be hot visibly, but he will say he is cold. Staff A stated, hot visibly, meant sweat. She stated the resident has a ten-word vocabulary and would not go in there expecting him to answer. On 06/23/2025 at 11:48 a.m., the Maintenance Director stated they were going to move Resident #5 out of the room today and they were currently working on another room for him. He stated this was the first time he had taken temperatures in the resident's room. He said his goal for the temperature level was to be no more than 82 degrees or below. On 6/23/2025 at 12:00 p.m., a telephone interview was conducted with the Maintenance Assistant. He stated (Resident #5)'s room was hooked up to a roof top unit; it should be cooling. When asked his expectation for the temperature of the air coming out of the vent in the room, he stated he would expect the temperature of the air coming out of the vent to be 75 degrees. He stated he was unaware of any problems in the last 30 days with Resident #5's room, hallway, or the A/C unit serving the area. He stated, Not that I am aware of. He stated, Yes he should be aware of any problems. He said, For the temperature in the room, the goal is to be 74 to 75 degrees; the maximum, believe it to be 80 degrees. He stated he had not received any concerns about warm temperatures in the resident's room. He stated, Not that I am aware of. When asked about the temperature obtained from (Resident #5's) room, the floor at 89.9 degrees Fahrenheit, the ceiling at 90.0 degrees Fahrenheit, he said, that is not suitable for a resident in there; it is definitely too hot. The Maintenance Assistant stated he had measured the temperature coming out of the vent at the end of last month but had not written it down. A second observation of air vent temperature located in Resident #5's room and vents in the hallway near Resident #5's room was conducted on 06/23/2025 at 12:10 p.m. with the Maintenance Director. The following was observed: Resident #5's doorway ceiling vent air output temperature reading was 87.4 degrees Fahrenheit. The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 84.2 degrees Fahrenheit. The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 86.4 degrees Fahrenheit. Observed outside of the resident's room was a thermostat on the wall which read a temperature of 79 degrees Fahrenheit, with a setting of 74 degrees Fahrenheit. The Maintenance Director was observed to remove the cover of the thermostat and lower the setting to 72 degrees Fahrenheit. A review of the facility's electronic communication log dated 04/01/2025 through 06/23/2025 revealed there were no listings for concerns of temperature submitted by staff. On 06/23/2025 at 2:15 p.m., an interview was conducted with the Director of Nursing (DON). She reported she had not been in (Resident #5's) room. She stated she had not noticed the temperature in the hall (near Resident #5's room) being warm. When asked what she would expect a staff member to do if they noticed a warm temperature in a resident room, she said, first find out if it is a preference; report it to management and maintenance that there may be a problem. On 06/23/2025 at 3:15 p.m., Staff C, LPN, was observed sitting at the nursing station between the 100 and the 200 halls, she was using a piece of paper to fan herself. She stated, it is very hot here, the west side is cooler. She stated, This is the east side. I have noticed it getting warm in May. When asked if she had reported the warm temperature, she stated Yes, everyone knows it is warm, it is an older building. On 06/23/2025 at 3:20 p.m. Staff E, CNA was observed standing at the nurses' station between the 100 and 200 halls. She confirmed she was assigned rooms in the 200 hall. She said regarding Resident #5's room, It is hot in his room; I think I had him last week. The Maintenance Assistant said they were working on it. An observation was conducted at this time of a digital wall clock on the wall at the end of the nursing station. The temperature of the wall clock read 83.3 degrees Fahrenheit. Staff E, CNA, said, the wall clock will register over 80 degrees frequently. On 06/23/2025 at 3:30 p.m., an interview was conducted with Staff F, Housekeeper. She confirmed she performed housekeeping on certain days of the week. She said regarding the temperature in Resident #5's room, Sometimes the room is cooler, sometimes warmer. I do not know if there is air conditioning in here (pointed to the ceiling). Staff F stated lately it has been warmer. On 06/24/2025 at 11:30 a.m., an observation and interview confirmed Resident #5 had been moved to another room. The Maintenance Director stated the roof top A/C unit, which was responsible to source the cool air for Resident #5's room, the fan was running, but he was not sure if it was cooling. He stated the thermostat in the hall was set at 72 degrees and the temperature in the hall had been between 76- and 77-degrees during frequent checks this morning. He stated he was told the A/C technician cannot come out today and is going to call back and see if another technician can come out. During the interview, the temperature in the room felt warm and the air coming from the vent was at a sparse rate. The Maintenance Director stated this air vent was sourced by the roof top A/C unit. He immediately used his thermal temperature gun, pointed at this air vent and obtained a temperature of 87 degrees Fahrenheit. Another temperature measurement was obtained inside the middle of Resident #5's room, by pointing the thermal temperature gun at the ceiling, which measured 87 degrees Fahrenheit, and then mid-floor, which measured 85 degrees Fahrenheit. The Maintenance Director confirmed air temperatures were not checked routinely. He stated they only checked if the A/C system goes out, then there would be frequent temperature checks done. On 06/24/2025 at 1:14 p.m. an interview was conducted with the Nursing Home Administrator (NHA). When asked if the facility had a policy for testing temperatures in the building, or what the process was to ensure temperatures were appropriate, the NHA said, if we have a loss of A/C, then we take temperatures, on a daily, weekly, monthly basis. She stated they just walk through. The NHA did not provide documentation to show they were monitoring temperatures. The NHA stated they can monitor temperatures by looking at the thermostats on the walls, and staff can tell if it is warm. The NHA stated she was not aware of an A/C unit that was not working. The NHA said, No, not that I'm aware of, no one had brought anything to me, and no one had voiced concerns about temperatures. The NHA stated for staff reporting maintenance issues, she said, they should use (the electronic communications) system, she stated it is a reporting system where you can put work orders in. She stated all staff had access to the generic login. She stated all staff were trained in the Electronic Communication System. The NHA said, Yes, they were trained on hire. I don't know the last time they were trained; I have to go look. The NHA stated her expectation for temperatures in resident rooms was to be between 71 and 81 degrees, unless it is resident preference to have it warmer. The NHA stated they were waiting on a technician to fix the roof-top unit located near 200 hall. The NHA stated she was not aware of Resident #5's room being warm. The NHA said, No. I have been in that room two-three times a week doing spot checks. The HNA stated she was in there and the window was not open. The NHA stated the window being open would have brought more heat inside. The NHA stated her expectation was when maintenance becomes aware of a non-functional A/C unit, they should get quotes and get it fixed. On 06/23/2025 at 12:40 p.m. the Maintenance Director was requested to provide the policy and procedure for monitoring temperatures in the building, and the policy and procedure for how staff communicate concerns to the maintenance personnel. The policies were not provided.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from neglect related to 1.) not providing physician ordered tube feeding and not providing assistance to get out of bed for 13 days, leading to a decline in functionality for one resident (#7) out of 12 sampled residents and 2.) failing to administer medications in accordance with physician orders for two residents (#7 and #4) out of twelve sampled residents. Findings included: 1. An observation and interview was conducted on 4/30/25 at 10:47 a.m. with a family member of Resident #7. The family member said she was concerned because the resident's tube feeding was supposed to be running all day, and she had been in a few times and it was not running. She said she was worried he was not getting the nutrition he needed. The family member said she talked to staff a few times and was told the pump for the tube feed was broken. She said the tube feed had not been running when she got to the facility that day and the day prior it ran for a while, then the pump broke. She said after a little bit, someone got it running again. The family member also stated Resident #7 had not been out of bed in the almost two weeks. She said when the resident came to the facility he was able to transfer and walk with assistance, but now he had gotten so much weaker. She said he was supposed to be there for rehab and then go home. The family member said she is now concerned Resident #7 won't be able to improve and go home. Review of Admission Records showed Resident #7 was admitted on [DATE] with diagnoses including sepsis, unspecified organism, pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, and protein-calorie malnutrition. Review of Resident #7's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008), dated 4/17/25, showed the resident ambulates with assistive device, transfers with 2 assistants, and is partial weight-bearing on the left and right sides. Review of Resident #7's Care Plan showed a focus area of Resident requires assist with ADLs [activities of daily living] R/T [related to] impaired mobility, dated 4/18/25. Interventions included substantial/maximum assistance with bed mobility and lying to sitting on the side of the bed and dependent for chair to bed and bed to chair transfers. Another focus area was PEG [percutaneous endoscopic gastrostomy] tube is utilized for all medications/nutrition and fluids, dated 4/18/25. Interventions included feeding/water flushes per doctor orders. Review of Resident #7's orders showed: #1 Nutren Renal Oral Liquid. Give 250 ml (milliliters) via g-tube four times a day for Nutritional Supplement. Start date 4/17/25. Discontinued 4/18/25. #2 Enteral Feed Order. Every shift for dysphasia. Nutrin 2.0 60 ml/hr (hour) x 20 hrs. Up at 6 a.m. and down at 2 a.m. Start date 4/18/25. Discontinued 4/19/25. #3 Enteral Feed Order. Every shift for dysphasia. Nutrin 2.0 60 ml/hr x 20 hrs. Up at 6 a.m. and down at 2 a.m. Start date 4/19/25. Discontinued 4/21/25. #4 Enter Feed Order. Five times a day. Nutren 2.0 bolus 1 can 5 times a day with 75 cc (cubic centimeters) water bolus. Start date 4/21/25. Discontinued 4/24/25. #5 Enteral Feed. In the morning for dysphasia Nutrin 2.0 60 ml/hr x 20 hrs up at 6 a.m. and one time a day for dysphasia Nutrin 2.0 60 ml/hr x 20 hrs down at 2 a.m. Dated 4/24/25. Review of Resident #7's progress notes showed the first note was entered into the medical record at 5:19 p.m. on 4/17/25, indicating the resident arrived prior to that time. Review of Resident #7's April 2025 Medication Administration Record (MAR) showed the resident did not receive enteral feeding on 4/17/25. The feeding at 9:00 p.m. on 4/17/25 was documented as 5 meaning Hold/See Progress Notes. The progress notes did not have any documentation as to why the enteral feeding was not provided. According to the MAR, the resident received his first enteral feeding at 9:00 a.m. on 4/18/25, over 15 hours after admission to the facility. The resident received another feeding at 1:00 p.m. on 4/18/25, and order #1 for bolus feeding was discontinued. Order #2 for continuous feeding to hang at 6 a.m. and take down at 2 p.m. was signed off for the night shift on 4/18/25, and it was discontinued. The MAR showed order #3 for continuous feeding was signed off for all shifts on 4/19/25 and 4/20/25 and for the morning shift on 4/21/25, but was not signed off on the evening shift of 4/21/25. Order #3 was discontinued on 4/21/25. Order #4 was documented as completed twice on 4/21/25 and five times each on 4/22/25 and 4/23/25. The order was discontinued the morning on 4/24/25. There is no order in place or documentation to show the resident received any tube feeding on 4/24/25. Order #5 began on the morning of 4/25/25 and was signed off as the tube feed being hung at 6:00 a.m. on 4/25/25, 4/27/25, 4/28/25, 4/29/25, and 4/30/25. On 4/26/25, the tube feed was not signed off as being hung and there is no documentation stating why it was not administered as ordered. An interview was conducted on 4/30/25 at 11:16 a.m. with Staff F, Licensed Practical Nurse (LPN). She stated she cared for Resident #7 on 4/29/25 starting at 7:00 a.m. She said when she came on shift, Resident #7's tube feed was not hanging. She confirmed it was supposed to be hung at 6:00 a.m. and didn't know why it wasn't hung up and why it was signed off. She said she did not notify anyone she just hung the tube feed around 10:00 a.m. and turned it on. Staff F, LPN said she did not know why the resident had been switched back and forth between continuous and bolus feedings. She said she did not think the pump was broken, she just didn't think the staff knew how to use it correctly. An observation was conducted on 4/30/25 at 10:47 a.m. of Resident #7 lying in bed. The tube feed pump was next to the bed and there was no tube feed hanging and the pump was turned off, although it was documented it had been hung at 6:00 a.m. on 4/30/25. An interview was conducted on 4/30/25 at 5:41 p.m. with the facility's Registered Dietician (RD). She said from her understanding, Resident #7 has switched from continuous pump feeding to bolus feeds and back again because the facility had issues with the pump. She said they do weekly weights on tube feed residents and Resident #7 was 145 pounds on admission 13 days ago and 142 pounds on 4/30/25. She said he was on a medication for edema, but in general, tube feed residents should never lose weight. The RD said not getting the required food intake can lead to a lot of problems. She said Resident #7 looks worse now than when she saw him after admission. She said the resident not getting the proper amount of nutrition and possible missing tube feedings could have led to the weakness he had been having, it certainly doesn't help. The RD said Resident #7 had gone down since he had been at the facility. An interview was conducted on 4/30/25 at 2:49 p.m. with the facility's Director of Nursing (DON). She said the facility was not notified of the type of tube feed Resident #7 was on until he arrived and it was a less common type. She said they did not have a tube feed pump available at the time he arrived due to an influx of tube feed residents. She said they found a pump in the back for the resident, but it was an older type. She said they also found a case of Nutrin renal containers in the facility after he arrived and that is why they were doing bolus feedings instead of continuous feed. She said the bags of tube feeding arrived and he began continuous tube feeding on the second day. An interview was conducted on 4/30/25 at 11:42 a.m. with Staff H, Occupational Therapy Assistant (OTA). Staff H, OTA said there is not a reason Resident #7 cannot get out of bed. She said he used a full body mechanical lift and the nursing staff should have been getting him up. Staff H, OTA said she took a wheelchair to the resident's room a week ago, but someone must have taken it out. She said the resident had been receiving therapy in bed due to nursing staff not having him up in a chair. A follow-up interview was conducted on 4/30/25 at 12:00 p.m. with Staff F, LPN. She said she had not seen Resident #7 out of bed since he had been in the facility. She said they were waiting on therapy and she didn't know if therapy had gotten him up or not. An interview was conducted on 4/30/25 at 12:05 p.m. with Staff J, Certified Nursing Assistant (CNA). She said she regularly took care of Resident #7. She confirmed the resident had not been out of bed and that was due to him not having a wheelchair. A follow-up interview was conducted with Staff H, OTA and the Director of Rehabilitation (DOR). Staff H, OTA said she had no idea where the wheelchair went that therapy provided to Resident #7. She said nursing should not have been waiting on therapy to get the resident out of bed, they should have been getting him up daily. The DOR said therapy does not tell nursing if they can or cannot get a resident out of bed. He said therapy did an evaluation of the resident and let nursing know the level of assistance needed. The DOR said Resident #7 needed a full body mechanical lift to get up and nursing should have been getting him out of bed. An interview was conducted on 4/30/25 at 5:38 p.m. with Staff I, Physical Therapist (PT). Staff I, PT reviewed Resident #7's initial evaluation on 4/17/25 and his current evaluation on 4/30/25. He said Resident #7 declined in his functionality since his admission. Staff I, PT said on 4/17/25 the resident completed sit to stand transfers with moderate assistance and on 4/30/25 he was totally dependent. He said on 4/17/25, the resident was able to ambulate 6 feet using a 2-wheel walker with moderate assistance and on 4/30/25 the resident was unable to do the task. The physical therapy evaluation provided noted Resident #7's decline in function. Staff I, PT said if a resident does not get out of bed it can cause their muscles to atrophy and the resident can weaken and decline in function. An interview was conducted on 4/30/25 at 6:44 p.m. with the Nursing Home Administrator (NHA). The NHA said she would expect staff to be following physician orders. She said she had not been aware of issues with Resident #7's tube feed, antibiotics not being administered correctly, or him being left in bed until today. She said the issues will be addressed. On 4/30/25, the DON stated the facility did not have the requested polices on getting residents out of bed or tube feedings. 37999 2. On 4/29/25 at 9:17 a.m., Resident #7 was observed lying in bed. The resident's bottom teeth were covered with a yellow/tan colored substance and a watery, tan colored liquid was observed in the resident's mouth. An intravenous (IV) pole was standing between the bed and window and hanging from the pole was an empty IV medication bag, labeled with the residents name, name of the medication Zerbaxa, and tubing wrapped around the wings of the pole. The IV medication was dated 4/28/25 and not running. Review of Resident #7s medical record showed a medication list from an acute care facility, printed on 4/17/25 at 10:46 a.m., revealing the resident was to receive ceftolozane-tazobactam 1.5-gram (g) in sodium chloride 0.9%, 100 milliliter (mL) IV piggyback (IVPB) - Infuse 1.5g into a venous catheter every 8 (eight) hours for 35 doses. Last time this was given: April 17, 2025, at 6:05 a.m. Review of Resident #7s Admit/Readmit Assessment, effective 4/17/25 at 5:15 p.m. revealed a temperature reading of 98.5 degrees Fahrenheit taken 4/17/25 at 2:36 p.m., a blood pressure and pulse taken on 4/17/25 at 5:07 p.m. and 5:08 p.m., a weight of 139.0 pounds taken on 3/9/22 at 1:44 p.m. (previous admission), respiration rate of 18 taken 3/13/22 at 3:47 a.m. (previous admission), and a height on 3/6/22 at 2:06 p.m. (previous admission). Review of Resident #7s April Medication Administration Record (MAR), printed on 4/30/25 at 11:45 a.m., revealed an order for Cetfolozane-Tazobactam Intravenous solution reconstituted 1.5 (1-0.5) gram (GM) (Ceftolozane Sulfate - Tazobactam Sodium) - Use 1.5 gm intravenously three times a day for urinary tract infection (UTI) for 35 administrations. The order was started on 4/17/25 at 10:00 p.m. and discontinued on 4/29/25 at 9:03 a.m. The MAR had X documentation for the 6:00 a.m. and 2:00 p.m. doses on 4/17/25, allowed for 35 doses to be administered, three doses daily on 4/18/25 to 4/28/25 (11 days) and one dose each on 4/17/25 and 4/29/25, the 35th dose to be administered on 4/29/25 at 6:00 a.m., the rest of the order was marked with X. The MAR included the following dosage documentation with corresponding chart codes related to the administration of the resident's antibiotic: - 4/17/25 at 10:00 p.m. - 1 = Absent from home without meds. - 4/18/25 at 6:00a.m. - 1 = Absent from home without meds. - 4/18/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/19/25 at 10:00 p.m. - no documentation. - 4/24/25 at 6:00 a.m. - 5 = Hold/See Progress Notes. - 4/24/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/26/25 at 6:00 a.m. - no documentation. - 4/28/25 at 6:00 a.m. - no documentation. The MAR showed the resident missed 8 of the 35 ordered doses. Review of Resident #7s progress notes included the following notes related to the missed doses of Ceftolozane-Tazobactam Intravenous solution: - 4/18 at 1:36 p.m.: Medication unavailable at this time. Not available in [electronic medication dispenser]. MD (Medical Doctor) and representative (RP) aware. No signs/symptoms (s/s) of any adverse reactions. No new orders. Pharmacy to deliver. Plan of care ongoing. - The notes revealed no progress note was written on 4/19/25 for the resident. - 4/24/25 at 8:19 a.m.: Med on hold, MD notified. - 4/24/25 at 8:22 a.m.: Resident antibiotic (ABT) on hold. MD notified. - 4/24/25 at 2:53 p.m.: MD ordered put in hold the medication. - 4/26/25 showed no progress note was written regarding the 6:00 a.m. dose. - 4/28/25 showed no progress notes was written on that day. A progress note written on 4/29/25 at 9:15 a.m. showed Review of resident's IV medication. Resident received the 35 required doses of the medication. Medication was discontinued. Will follow up with [Infectious Disease] ID. Review of Resident #7's Order Summary Report, active as of 4/30/25 at 11:43 a.m. showed an order Discontinue (D/C) PICC line. Therapy complete, dated 4/29/25. A note, effective 4/29/25 at 1:30 p.m. regarding the Normal Saline flush of Resident #7s Central line/ peripherally inserted central catheter (PICC)/Midline revealed line has been removed. The report did not reveal an active order for Ceftolozane-Tazobactam. An interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) on 4/30/25 at 1:15 p.m. The staff member stated, regarding Resident #7's Ceftolozane-Tazobactam, knowing the medication was hard to get from pharmacy due to the cost and the facility was only able to get a couple of days at a time. Staff L, LPN/UM reported there was a time the Director of Nursing (DON) was pre-approving it daily and if it was not available the doctor was to be notified. The staff member stated she was unaware of the physician holding the medication (4/24 doses) and stated wonder if it wasn't some of the nurses who don't speak well put the note in. The LPN/UM reviewed the resident's MAR and stated it did not look like the resident received the ordered 35 doses. The staff reported Staff E, LPN/Infection Preventionist (IP), counted the doses up yesterday and told her the resident received the 35 doses. An interview was conducted with Staff F, LPN on 4/30/25 at 1:31 p.m. The staff member reported administering all of Resident #7's IV antibiotics. The staff member reported not having the medication until pharmacy delivered it and there would have been no reason why the staff member would not have administered them. An interview was conducted with Staff E, LPN/IP on 4/30/25 at 1:40 p.m. The staff member reported starting to work for the facility on 4/17/25. The staff member confirmed Resident #7 was to receive the IV antibiotic Ceftolozane-Tazobactam for 35 doses and the facility had a hard time getting the medication from pharmacy. The staff member reported the facility kept adding doses to the end because of the missed doses. Staff E, LPN/IP stated the original order was for it to end on the 25th of April and the physician extended it out to the 29th. Staff E, LPN/IP stated All I know the nurses said the resident finished the IV's. She reported being unable to pull the MAR and spoken with Infectious Disease (ID) and the physician on the 29th. Staff E, LPN/IP reported informing ID and the physician that according to staff, the resident completed the 35 doses of the antibiotic, and the Assistant Director of Nursing (ADON) spoke with the physician and received an order to pull the IV line. During the interview, at 1:51 p.m. the ADON came into Staff E's office and said she had not spoken with the physician, the DON had spoken with him. The DON stepped into the office and said Staff L, LPN/UM spoke with the physician while in the DON's office. Staff E, LPN/IP reviewed Resident #7's MAR and confirmed No he did not the resident had not received the ordered 35 doses of antibiotic. The DON stated Staff E, LPN/IP came to her and said the resident had all the doses and Staff L, LPN/UM had gotten the order to pull the IV line. The DON reviewed the resident's MAR and said the facility was aware now the resident had not received the 35 doses and the physician was notified of the medication error. Review of Resident #7s MAR showed an order, started on 4/30/25 at 2:45 p.m., to Insert PICC [peripherally inserted central catheter] line. May use 1% lidocaine for insertion. One time only for medication administration for 2 days. A general nurse's note, created 4/30/25 at 3:03 p.m. by Staff E and effective 4/30/25 at 12:54 a.m., revealed Call placed to Nurse Practitioner (NP) regarding resident IV therapy. Resident requires 8 more doses of ABT. Discussed with NP and order was given to have PICC line reinserted and to give resident remaining required doses. Call made to RP by ADON with verbal consent to have PICC line reinserted. IV Team called and will be out to reinsert line. Resident to follow up with ID next Thursday. On 4/30/25 at 4:36 p.m., Resident #7 was observed lying on right side. The observation did not show a new IV catheter had been placed. Review of the MAR showed a new order for Ceftolozane-Tazobactam was to start on 4/30/25 at 10:00 p.m. The review revealed the resident missed 4 doses of the 8 already missed due to the facility not ensuring 35 doses had been administered and discontinued the PICC line requiring the resident to have another inserted before completing the doses of IV antibiotics. 3. Review of the facility's Incident Log revealed a medication error occurred on 3/28/25 at 5:50 p.m. with Resident #4. Review of Resident #4's Admission Record revealed the resident was admitted on [DATE] and 3/7/25. The record included diagnoses not limited to intraspinal abscess and granuloma, unspecified local infection of the skin and subcutaneous tissue, unspecified organism sepsis, unspecified disorder involving the immune mechanism, osteomyelitis of vertebra lumbar region, and chronic myeloproliferative disease. The resident was transferred to the hospital on 4/19/25 for uncontrolled pain. Review of Resident #4's progress notes revealed the following: - 3/27/25 at 2:58 p.m.: an order was entered for Daptomycin Intravenous Solution Reconstituted 500 mg. - 3/27/25 at 11:04 p.m.: Resident continue with IV treatment. No adverse reactions noted. PICC line on right arm, patent and intact. No redness or swelling noted. Flushed according medical orders. - 3/28/25 at 5:50 p.m.: Resident accidentally received Cefepime HCl (hydrochloride) Intravenous Solution 1 gram/50 milliliter. Family at bedside notified. DON notified. MD states to monitor resident for changes. MD states to perform 24 hour neuro checks. Resident denies pain or discomfort. Resident did not have signs of adverse reactions. Neuro in normal range. - 3/28/25 at 11:00 p.m.: Resident observed resting in bed. Resident denies pain or discomfort. Resident has no signs or symptoms of distress. Neuro check are with in normal range. - The progress notes did not contain a note written on 3/29/25. Review of Neurological Assessment Flow Sheet read *Med Error only for 24 hr neuro check. The instructions printed on top of the sheet showed neurological assessments to include level of consciousness, motor function (hand grasps), pain response, vital signs, pupil response, extremities (movement) and observations were to bed completed every 15 minutes for 2 hours, every 60 minutes for 4 hours, and every 8 hours for 16 hours. The sheet showed level of consciousness, pupil response, hand grasps, extremities, and vital signs continued as instructed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for 4 hours, stopping at 12:45 a.m., 6 hours and 45 minutes after the incident. The documentation did not reveal the neurological assessment had continued every 8 hours for 16 hours on 3/29/25. During an interview on 4/29/25 at 10:53 a.m., the DON reported having the position of DON for 2.5 weeks and provided one Investigation Statement regarding Resident #4's medication error. The DON stated Staff K, LPN was assisting another nurse, Staff M, LPN with hanging the IV medication for Resident #4, as Staff M, LPN was not IV certified and Staff K, LPN was. The DON stated Staff M, LPN gave Staff K, LPN the wrong medication. The DON reviewed the Investigation Statement from Staff K, LPN and stated the form was not filled out correctly, the incident was supposed to have been investigated, statements completed by those involved, and education should have been done. The DON reported she had not received education related to medication rights from the previous DON. An interview was conducted on 4/29/25 at 11:12 a.m. with Staff L, LPN/UM. Staff L, LPN/UM reported not finding out about the incident until the next day. Another nurse, Staff M, LPN, who wasn't IV certified, asked Staff K, LPN to hang the medication. Staff M, LPN had the medication all set up for Staff K, LPN and Staff K, LPN, had not checked it before administration. An interview was conducted on 4/30/25 at 6:35 p.m. with the Nursing Home Administrator/Risk Manager (NHA/RM). The NHA reported being informed of the incident when it occurred with the previous DON informing her that education had started. The NHA stated nurses are supposed to be IV certified, not all of them are and did not know if Staff M, LPN had been certified. An interview was conducted on 4/30/25 at 6:45 p.m. with Staff K, LPN. The staff member reported Resident #4 was not on assignment the day of the incident and the error was on him. Staff M, LPN couldn't hang the antibiotic, wasn't IV certified, and came to the staff member a couple of times. Staff K, LPN stated Staff M, LPN had the medication bag and tubing and told the staff member all that had to be done was to hang it. Staff K, LPN did not verify if the medication bag had been spiked prior to receiving it. Staff K, LPN reported asking the other staff member to verify the medication was for the B-bed. Staff K, LPN stated, I should have pulled my own stuff and the medication ran for approximately 5 minutes. Staff K, LPN reported taking over the resident and apologized to the family. Staff K, LPN reported talking to the family a couple of times to update on condition, wrote a statement day of the incident, started neuro checks. Review of the policy titled Medication Administration, undated, revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy instructed staff to correct any discrepancies and report to the nurse manager. The compliance guidelines instructed staff: - 10. Review MAR to identify medication to be administered. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. - 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. Review of the policy titled Abuse, Neglect, and Exploitation, undated, showed the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, in misappropriation of resident property. The policy defined neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy Explanation and Compliance Guidelines included: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Established policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention; and d. Establish coordination with the QAPI program. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect, and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/ or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of resources needed to provide care and services to all residents is included in the facility assessment; D. Identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents both needs and behaviors which might lead to a conflict or a neglect. IV. Prevention of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying the types of abuse - mental/ verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: . 8. Failure to provide caring needs such as feeding, bathing, dressing, turning and positioning.

Based on observations and interviews, the facility did not ensure the posted nurse staffing data was up-to-date and current from 4/18/25 to 4/30/25. Findings included: An observation was conducted on 4/29/25 at 6:15 a.m. of the Daily Nurse Staffing sheet posted in the front lobby of the facility. The posting was dated 4/17/25. The 4/17/25 posting remained in place on 4/29/25 at 1:28 p.m. An interview was conducted on 4/30/25 at 6:13 p.m. with the Staffing Coordinator. She stated she was the person responsible for posting the Daily Nurse Staffing data. She said she prints them out and hangs them or sometimes gives them to the front office to hang. She said she had been coming in later than usual and had not been ensuring it was done. She said she had not realized until 4/30/25 that it had not been updated since 4/17/25 and that is on her. An interview was conducted on 4/30/25 at 6:44 p.m. with the Nursing Home Administrator (NHA). She said she usually checked to ensure the nurse staffing information was posted but she had been slacking off on that. She confirmed it should have been updated daily. The NHA stated the facility did not have a policy related to posting the Daily Nurse Staffing data. Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to thoroughly investigate and provide staff with education following a medication error incident for one resident (#4) of one resident incident involving medication errors. Findings included: Review of Resident #4's Admission Record revealed the resident was admitted on [DATE] and 3/7/25. The record included diagnoses not limited to intraspinal abscess and granuloma, unspecified local infection of the skin and subcutaneous tissue, unspecified organism sepsis, unspecified disorder involving the immune mechanism, osteomyelitis of vertebra lumbar region, and chronic myeloproliferative disease. The resident was transferred to the hospital on 4/19/25 for uncontrolled pain. Review of the facility's Incident Log revealed a medication error occurred on 3/28/25 at 5:50 p.m. with Resident #4. Review of Resident #4's progress notes revealed the following: - 3/27/25 at 2:58 p.m.: an order was entered for Daptomycin Intravenous Solution Reconstituted 500 mg. - 3/27/25 at 11:04 p.m.: Resident continue with IV treatment. No adverse reactions noted. PICC line on right arm, patent and intact. No redness or swelling noted. Flushed according medical orders. - 3/28/25 at 5:50 p.m.: Resident accidentally received Cefepime HCl (hydrochloride) Intravenous Solution 1 gram/50 milliliter. Family at bedside notified. DON notified. MD states to monitor resident for changes. MD states to perform 24 hour neuro checks. Resident denies pain or discomfort. Resident did not have signs of adverse reactions. Neuro in normal range. - 3/28/25 at 11:00 p.m.: Resident observed resting in bed. Resident denies pain or discomfort. Resident has no signs or symptoms of distress. Neuro check are with in normal range. - The progress notes did not contain a note written on 3/29/25. During an interview on 4/29/25 at 10:53 a.m., the Director of Nursing (DON) reported having the position of DON for 2.5 weeks. The DON provided one Investigation Statement completed by Staff K, Licensed Practical Nurse (LPN) regarding Resident #4's medication error. The DON reported Staff K, LPN, hung the wrong medication for Resident #4. Staff M, LPN provided the medication to Staff K, LPN. The DON reviewed the Investigation Statement dated 3/28/25 with information provided by Staff K, LPN and stated the form was not filled out correctly, the incident was supposed to be investigated, statements completed by those involved, and education provided on the seven rights of medication administration. The DON stated the facility could not find any proof education had been at the time of the incident. She stated she would have gotten education from the previous DON related to medication administration at time of incident and had not received any. Review of the statement written by Staff K, LPN revealed the following questions and responses: - When did you last care for the resident? 3/28/25 5:30 p.m. (1730) - In what capacity were you caring for the resident? Help his nurse hang IV. - Did you witness the incident? Yes - How did you become aware of the incident? Told by fell ow nurse. - What did you see concerning the incident? Wrong IV Med hung. - What did you hear at the time of the incident? Nothing. - What immediate action did you take? MD notified, DON notified, son notified, Neuro check started. - Who did you report the incident to? MD, DON, son - When did you report the incident? 5:50 p.m. (1750) - Was someone assisting you at the time of the incident? No (check mark in box) - Who else may have information regarding the incident? Nurse [Staff M, LPN]. - What, if anything, is your knowledge of the resident? (blank) - What additional information do you have that has not already been discussed regarding the incident? (blank). During an interview on 4/29/25 at 11:12 a.m. Staff L, LPN/Unit Manager (UM) reported not knowing about Resident #4's medication error until the next day. The staff member stated another nurse, who wasn't IV certified, had asked Staff K, LPN to hang the resident's IV medication. Staff L, LPN/UM said Staff M, LPN had the medication all set and asked Staff K, LPN to hang it and the staff member did not check it before hanging. Staff L, LPN/UM stated the previous DON had been on call and, per her understanding, had gotten all the statements. Staff L, LPN/UM stated when the previous DON was talking about the incident, she asked the staff member what the 7 medication rights were. Staff L, LPN/UM reported today was the first time she received formal education on medication rights related to the incident and had not received education on what to do if there was an incident. An interview was conducted on 4/30/25 at 6:35 p.m. with the Nursing Home Administrator/Risk Manager (NHA/RM). The NHA reported being informed of the incident when it occurred with the previous DON informing her that education had started. The NHA stated nurses are supposed to be IV certified, not all of them are and did not know if Staff M, LPN had been certified. An interview was conducted on 4/30/25 at 6:45 p.m. with Staff K, LPN. The staff member reported Resident #4 was not on assignment the day of the incident and the error was on him. Staff M, LPN couldn't hang the antibiotic, wasn't IV certified, and came to the staff member a couple of times. Staff K, LPN stated Staff M, LPN had the medication bag and tubing and told the staff member all that had to be done was to hang it. Staff K, LPN did not verify if the medication bag had been spiked prior to receiving it. Staff K, LPN reported asking the other staff member to verify the medication was for the B-bed. Staff K, LPN stated, I should have pulled my own stuff and the medication ran for approximately 5 minutes. Staff K, LPN reported taking over the resident and apologized to the family. Staff K, LPN reported talking to the family a couple of times to update on condition and wrote a statement day of the incident. The staff member reviewed the written statement and confirmed it was not a thorough statement. Review of the policy titled Abuse, Neglect, and Exploitation, undated, showed the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, in misappropriation of resident property. The policy defined neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy Explanation and Compliance Guidelines included: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Established policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention; and d. Establish coordination with the QAPI program. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect, and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/ or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of resources needed to provide care and services to all residents is included in the facility assessment; D. Identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents both needs and behaviors which might lead to a conflict or a neglect. IV. Prevention of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying the types of abuse - mental/ verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: . 8. Failure to provide caring needs such as feeding, bathing, dressing, turning and positioning. V. Investigation of alleged abuse, neglect, and exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. Not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation and determining if abuse, neglect, exploitation, and/ or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on observations, interviews, and record reviews, the facility did not ensure oxygen therapy was provided as ordered for one resident (#6) out of three residents reviewed with continuous oxygen. Findings included: An observation and interview were conducted on 4/29/25 at 9:50 a.m. of Resident #6 sitting in a wheelchair in her room. The resident had a nasal cannula in place with oxygen tubing attached to a portable oxygen tank on her wheelchair. The oxygen tank was observed to be empty. The resident said she wore oxygen due to asthma and sometimes she wheezed when she was breathing. Review of Admission Records showed Resident #6 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). Review of Resident #6's care plan showed a focus area of risk for shortness of breath and/or respiratory distress related to diagnosis of COPD. Interventions included oxygen 2 liters (L) via nasal cannula continuous. Review of Resident #6's physician orders showed Oxygen 2L continuous every shift related to COPD, dated 9/30/24. An observation and interview were conducted on 4/29/25 at 11:25 a.m. of Resident #6 sitting in her wheelchair on the covered patio. The resident had the nasal cannula in place and the oxygen tank remained empty. At 1:51 p.m., the resident remained in the same location and her oxygen tank was empty. An interview was conducted on 4/29/25 at 1:19 p.m. with Staff A, Certified Nursing Assistant (CNA). She said if a CNA is getting a resident on continuous oxygen out of the bed to the wheelchair and they are leaving their room, the CNA would move the oxygen tubing from the oxygen concentrator to the portable oxygen tank on their wheelchair and turn it on. She said the CNA should check and make sure the oxygen tank was not on yellow or red, meaning low or empty, when they hook up the tubing and turn the oxygen on. An observation and interview was conducted on 4/29/25 at 1:24 p.m. with Staff B, CNA. Staff B, CNA was observed exiting a back door of the facility and showing where oxygen canisters were located. She showed several empty oxygen tanks and said the metal cage had several full oxygen tanks. Staff B, CNA said there was plenty of stock and she had never known them to run out of full oxygen tanks. Several full oxygen tanks were observed. An interview was conducted on 4/29/25 at 2:00 p.m. with Staff C, Registered Nurse (RN). She confirmed she was assigned to Resident #6 on 4/29/25 from 7:00 a.m. to 3:00 p.m. She reviewed Resident #6's physician orders and confirmed the resident had an order for oxygen 2 L continuously. She said the CNAs are the ones that hook the residents up to the portable oxygen tank when they transfer them to the wheelchair, and they will replace the tank if it was needed. Staff C, RN said it was unacceptable that Resident #6 had an empty oxygen tank since that morning, and she would get it switched out. An observation and interview was conducted on 4/29/25 at 2:10 p.m. with Staff D, CNA. She confirmed she was assigned Resident #6 on 4/29/25 from 7:00 a.m. to 3:00 p.m. She was observed bringing Resident #6 back to her room to change out the oxygen tank. She said for residents on oxygen, she changed the oxygen tank in the morning and sometimes again before her shift ended if it needed it. She said she changed Resident #6's oxygen tank that morning and even turned it on and heard air come out. Staff D, CNA said she didn't know why the tank was empty all day. Staff D, CNA was observed checking the oxygen tank on Resident #6's wheelchair and confirmed it was empty. An interview was conducted on 4/30/25 at 1:23 p.m. with Staff E, Licensed Practical Nurse (LPN)/Unit Manager (UM). She said she was notified of the concerns with Resident #6's oxygen and agreed it was not acceptable that the resident had an empty oxygen tank. An interview was conducted on 4/30/25 at 2:28 p.m. with the Director of Nursing (DON). She said the CNAs can get the oxygen tanks out of storage and bring them in, but nurses are the ones that should hook it up and turn the oxygen on. She said she was not aware CNAs were hooking up and starting oxygen. The DON said her expectation was oxygen tanks should have been checked and not be empty. Review of a facility policy titled Oxygen Administration, undated, showed: Policy Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanations and Compliance Guidelines 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Personnel authorized to initiate oxygen therapy include physicians, RN's, LPNs, and respiratory therapists. . Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to provide staff with the appropriate competencies and skill sets to assure three residents (#4, #7, and #9) received medications as ordered by the physician. Findings included: 1. Review of Resident #4's Admission Record revealed the resident was admitted on [DATE] and 3/7/25. The record included diagnoses not limited to intraspinal abscess and granuloma, unspecified local infection of the skin and subcutaneous tissue, unspecified organism sepsis, unspecified disorder involving the immune mechanism, osteomyelitis of vertebra lumbar region, and chronic myeloproliferative disease. The resident was transferred to the hospital on 4/19/25 for uncontrolled pain. Review of the facility's Incident Log revealed a medication error occurred on 3/28/25 at 5:50 p.m. with Resident #4. Review of Resident #4's progress notes revealed the following: - 3/27/25 at 2:58 p.m.: an order was entered for Daptomycin Intravenous Solution Reconstituted 500 mg. - 3/27/25 at 11:04 p.m.: Resident continue with IV treatment. No adverse reactions noted. PICC line on right arm, patent and intact. No redness or swelling noted. Flushed according medical orders. - 3/28/25 at 5:50 p.m.: Resident accidentally received Cefepime HCl (hydrochloride) Intravenous Solution 1 gram/50 milliliter. Family at bedside notified. DON notified. MD states to monitor resident for changes. MD states to perform 24 hour neuro checks. Resident denies pain or discomfort. Resident did not have signs of adverse reactions. Neuro in normal range. - 3/28/25 at 11:00 p.m.: Resident observed resting in bed. Resident denies pain or discomfort. Resident has no signs or symptoms of distress. Neuro check are with in normal range. - The progress notes did not contain a note written on 3/29/25. Review of Neurological Assessment Flow Sheet read *Med Error only for 24 hr neuro check. The instructions printed on top of the sheet showed neurological assessments to include level of consciousness, motor function (hand grasps), pain response, vital signs, pupil response, extremities (movement) and observations were to bed completed every 15 minutes for 2 hours, every 60 minutes for 4 hours, and every 8 hours for 16 hours. The sheet showed level of consciousness, pupil response, hand grasps, extremities, and vital signs continued as instructed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for 4 hours, stopping at 12:45 a.m., 6 hours and 45 minutes after the incident. The documentation did not reveal the neurological assessment had continued every 8 hours for 16 hours on 3/29/25. During an interview on 4/29/25 at 10:53 a.m., the DON reported having the position of DON for 2.5 weeks and provided one Investigation Statement regarding Resident #4's medication error. The DON stated Staff K, LPN was assisting another nurse, Staff M, LPN with hanging the IV medication for Resident #4, as Staff M, LPN was not IV certified and Staff K, LPN was. The DON stated Staff M, LPN gave Staff K, LPN the wrong medication. The DON reviewed the Investigation Statement from Staff K, LPN and stated the form was not filled out correctly, the incident was supposed to have been investigated, statements completed by those involved, and education should have been done. The DON reported she had not received education related to medication rights from the previous DON. During an interview on 4/29/25 at 11:12 a.m. Staff L, LPN/Unit Manager (UM) reported not knowing about Resident #4's medication error until the next day. The staff member stated another nurse, who wasn't IV certified, had asked Staff K, LPN to hang the resident's IV medication. Staff L, LPN/UM said Staff M, LPN had the medication all set and asked Staff K, LPN to hang it and the staff member did not check it before hanging. Staff L, LPN/UM stated the previous DON had been on call and, per her understanding, had gotten all the statements. Staff L, LPN/UM stated when the previous DON was talking about the incident, she asked the staff member what the 7 medication rights were. Staff L, LPN/UM reported today was the first time she received formal education on medication rights related to the incident and had not received education on what to do if there was an incident. An interview was conducted on 4/30/25 at 6:35 p.m. with the Nursing Home Administrator/Risk Manager (NHA/RM). The NHA reported being informed of the incident when it occurred with the previous DON informing her that education had started. The NHA stated nurses are supposed to be IV certified, not all of them are and did not know if Staff M, LPN had been certified. An interview was conducted on 4/30/25 at 6:45 p.m. with Staff K, LPN. The staff member reported Resident #4 was not on assignment the day of the incident and the error was on him. Staff M, LPN couldn't hang the antibiotic, wasn't IV certified, and came to the staff member a couple of times. Staff K, LPN stated Staff M, LPN had the medication bag and tubing and told the staff member all that had to be done was to hang it. Staff K, LPN did not verify if the medication bag had been spiked prior to receiving it. Staff K, LPN reported asking the other staff member to verify the medication was for the B-bed. Staff K, LPN stated, I should have pulled my own stuff and the medication ran for approximately 5 minutes. Staff K, LPN reported taking over the resident and apologized to the family. Staff K, LPN reported talking to the family a couple of times to update on condition, wrote a statement day of the incident, started neuro checks. 2. On 4/29/25 at 9:17 a.m., Resident #7 was observed lying in bed. The resident's bottom teeth were covered with a yellow/tan colored substance and a watery, tan colored liquid was observed in the resident's mouth. An intravenous (IV) pole was standing between the bed and window and hanging from the pole was an empty IV medication bag, labeled with the residents name, name of the medication Zerbaxa, and tubing wrapped around the wings of the pole. The IV medication was dated 4/28/25 and not running. Review of Resident #7's Admission Record revealed the resident was admitted [DATE] and readmitted on [DATE], with diagnoses including unspecified organism sepsis, pneumonitis due to inhalation of food and vomit, and resistance to multiple antimicrobial drugs. Review of Resident #7s Admit/Readmit Assessment, effective 4/17/25 at 5:15 p.m. revealed a temperature reading of 98.5 degrees Fahrenheit taken 4/17/25 at 2:36 p.m., a blood pressure and pulse taken on 4/17/25 at 5:07 p.m. and 5:08 p.m., a weight of 139.0 pounds taken on 3/9/22 at 1:44 p.m. (previous admission), respiration rate of 18 taken 3/13/22 at 3:47 a.m. (previous admission), and a height on 3/6/22 at 2:06 p.m. (previous admission). Review of Resident #7s medical record showed a medication list from an acute care facility, printed on 4/17/25 at 10:46 a.m., revealing the resident was to receive ceftolozane-tazobactam 1.5-gram (g) in sodium chloride 0.9%, 100 milliliter (mL) IV piggyback (IVPB) - Infuse 1.5g into a venous catheter every 8 (eight) hours for 35 doses. Last time this was given: April 17, 2025, at 6:05 a.m. Review of Resident #7s April Medication Administration Record (MAR), printed on 4/30/25 at 11:45 a.m., revealed an order for Cetfolozane-Tazobactam Intravenous solution reconstituted 1.5 (1-0.5) gram (GM) (Ceftolozane Sulfate - Tazobactam Sodium) - Use 1.5 gm intravenously three times a day for urinary tract infection (UTI) for 35 administrations. The order was started on 4/17/25 at 10:00 p.m. and discontinued on 4/29/25 at 9:03 a.m. The MAR had X documentation for the 6:00 a.m. and 2:00 p.m. doses on 4/17/25, allowed for 35 doses to be administered, three doses daily on 4/18/25 to 4/28/25 (11 days) and one dose each on 4/17/25 and 4/29/25, the 35th dose to be administered on 4/29/25 at 6:00 a.m., the rest of the order was marked with X. The MAR included the following dosage documentation with corresponding chart codes related to the administration of the resident's antibiotic: - 4/17/25 at 10:00 p.m. - 1 = Absent from home without meds. - 4/18/25 at 6:00a.m. - 1 = Absent from home without meds. - 4/18/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/19/25 at 10:00 p.m. - no documentation. - 4/24/25 at 6:00 a.m. - 5 = Hold/See Progress Notes. - 4/24/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/26/25 at 6:00 a.m. - no documentation. - 4/28/25 at 6:00 a.m. - no documentation. The MAR showed the resident missed 8 of the 35 ordered doses. Review of Resident #7s progress notes included the following notes related to the missed doses of Ceftolozane-Tazobactam Intravenous solution: - 4/18 at 1:36 p.m.: Medication unavailable at this time. Not available in [electronic medication dispenser]. MD (Medical Doctor) and representative (RP) aware. No signs/symptoms (s/s) of any adverse reactions. No new orders. Pharmacy to deliver. Plan of care ongoing. - The notes revealed no progress note was written on 4/19/25 for the resident. - 4/24/25 at 8:19 a.m.: Med on hold, MD notified. - 4/24/25 at 8:22 a.m.: Resident antibiotic (ABT) on hold. MD notified. - 4/24/25 at 2:53 p.m.: MD ordered put in hold the medication. - 4/26/25 showed no progress note was written regarding the 6:00 a.m. dose. - 4/28/25 showed no progress notes was written on that day. A progress note written on 4/29/25 at 9:15 a.m. showed Review of resident's IV medication. Resident received the 35 required doses of the medication. Medication was discontinued. Will follow up with [Infectious Disease] ID. Review of Resident #7's Order Summary Report, active as of 4/30/25 at 11:43 a.m. showed an order Discontinue (D/C) PICC line. Therapy complete, dated 4/29/25. A note, effective 4/29/25 at 1:30 p.m. regarding the Normal Saline flush of Resident #7s Central line/ peripherally inserted central catheter (PICC)/Midline revealed line has been removed. The report did not reveal an active order for Ceftolozane-Tazobactam. An interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) on 4/30/25 at 1:15 p.m. The staff member stated, regarding Resident #7's Ceftolozane-Tazobactam, knowing the medication was hard to get from pharmacy due to the cost and the facility was only able to get a couple of days at a time. Staff L, LPN/UM reported there was a time the Director of Nursing (DON) was pre-approving it daily and if it was not available the doctor was to be notified. The staff member stated she was unaware of the physician holding the medication (4/24 doses) and stated wonder if it wasn't some of the nurses who don't speak well put the note in. The LPN/UM reviewed the resident's MAR and stated it did not look like the resident received the ordered 35 doses. The staff reported Staff E, LPN/Infection Preventionist (IP), counted the doses up yesterday and told her the resident received the 35 doses. An interview was conducted with Staff F, LPN on 4/30/25 at 1:31 p.m. The staff member reported administering all of Resident #7's IV antibiotics. The staff member reported not having the medication until pharmacy delivered it and there would have been no reason why the staff member would not have administered them. An interview was conducted with Staff E, LPN/IP on 4/30/25 at 1:40 p.m. The staff member reported starting to work for the facility on 4/17/25. The staff member confirmed Resident #7 was to receive the IV antibiotic Ceftolozane-Tazobactam for 35 doses and the facility had a hard time getting the medication from pharmacy. The staff member reported the facility kept adding doses to the end because of the missed doses. Staff E, LPN/IP stated the original order was for it to end on the 25th of April and the physician extended it out to the 29th. Staff E, LPN/IP stated All I know the nurses said the resident finished the IV's. She reported being unable to pull the MAR and spoken with Infectious Disease (ID) and the physician on the 29th. Staff E, LPN/IP reported informing ID and the physician that according to staff, the resident completed the 35 doses of the antibiotic, and the Assistant Director of Nursing (ADON) spoke with the physician and received an order to pull the IV line. During the interview, at 1:51 p.m. the ADON came into Staff E's office and said she had not spoken with the physician, the DON had spoken with him. The DON stepped into the office and said Staff L, LPN/UM spoke with the physician while in the DON's office. Staff E, LPN/IP reviewed Resident #7's MAR and confirmed No he did not the resident had not received the ordered 35 doses of antibiotic. The DON stated Staff E, LPN/IP came to her and said the resident had all the doses and Staff L, LPN/UM had gotten the order to pull the IV line. The DON reviewed the resident's MAR and said the facility was aware now the resident had not received the 35 doses and the physician was notified of the medication error. Review of Resident #7s MAR showed an order, started on 4/30/25 at 2:45 p.m., to Insert PICC [peripherally inserted central catheter] line. May use 1% lidocaine for insertion. One time only for medication administration for 2 days. A general nurse's note, created 4/30/25 at 3:03 p.m. by Staff E and effective 4/30/25 at 12:54 a.m., revealed Call placed to Nurse Practitioner (NP) regarding resident IV therapy. Resident requires 8 more doses of ABT. Discussed with NP and order was given to have PICC line reinserted and to give resident remaining required doses. Call made to RP by ADON with verbal consent to have PICC line reinserted. IV Team called and will be out to reinsert line. Resident to follow up with ID next Thursday. On 4/30/25 at 4:36 p.m., Resident #7 was observed lying on right side. The observation did not show a new IV catheter had been placed. Review of the MAR showed a new order for Ceftolozane-Tazobactam was to start on 4/30/25 at 10:00 p.m. The review revealed the resident missed 4 doses of the 8 already missed due to the facility not ensuring 35 doses had been administered and discontinued the PICC line requiring the resident to have another inserted before completing the doses of IV antibiotics. 3. On 4/30/25 at 9:37 a.m., an observation of medication administration with Staff G, Licensed Practical Nurse (LPN) was conducted with Resident #9. The staff member dispensed the following medications for administration to Resident #9: - alprazolam 0.25 milligram (mg) tablet - dicyclomine 10 mg capsule - Aspirin 81mg enteric coated over-the-counter (otc) tablet - bupropion 75 mg tablet - gabapentin 300 mg capsule - Multi vitamin otc tablet - senna 8.6 mg otc tablet - sucralfate 1 gram (gm) tablet - timolol 0.5% eye drops - latanoprost 0.005% eye drops The staff member confirmed dispensing 8 oral medications and 2 eye drops. Staff G, LPN returned to the resident room and handed the medication cup to the resident, who swallowed medications at one time. The staff member applied gloves, then ungloved to retrieve a roll of paper towel from closet for the resident. Staff G, LPN washed her hands, applied gloves, and administered, at 10:02 a.m., one drop of Latanoprost into the residents left eye, immediately followed by one drop of Timolol in the left eye. Staff G, LPN confirmed both eye drops went into the same eye. The resident reported recently having eye surgery. The staff member left the room, went to the Unit Manager's office, and spoke for a moment before retrieving, at 10:08 a.m., Resident #9's Lantus insulin pen from the medication refrigerator. Staff G, LPN dispensed one capsule of saccharomyces boulardii 500 mg from an over-the-counter bottle in med cart. Staff G, LPN returned to the room, spilled the saccharomyces boulardii capsule on the floor, returned to the medication cart, and re-dispensed the capsule. The staff member washed her hands and administered the probiotic, before returning to the med cart to retrieve an insulin needle. The staff member primed the insulin pen using 2 units, dialed to 35 units, and injected insulin into the upper right arm of Resident #9. Immediately following the observation, Staff G, LPN stated the probiotic saccharomyces given was the generic of Lactobacillus ordered. Review of Resident #9s Medication Administration Record (MAR) revealed the following orders scheduled for 9:00 a.m. - Lactobacillus capsule - Give 1 capsule by mouth two times a day for Diabetes Mellitus (DM), started on 2/6/25 and discontinued on 4/30/25 at 10:56 a.m. The MAR showed the resident received this medication twice daily during the month of April. - Timolol Maleate Ophthalmic solution 0.5% - Instill one drop in left eye one time a day for glaucoma. - Latanoprost Ophthalmic emulsion 0.005% - Instill one drop in left eye two times a day for glaucoma. During an interview on 4/30/25 at 11:16 a.m., Staff L, LPN/Unit Manager (UM) stated Lactobacillus and Saccharomyces were not technically the same thing. Staff L, LPN/UM stated when a resident came in with Lactobacillus, they were supposed to be changed over to the stock probiotic saccharomyces. Staff L, LPN UM stated staff were supposed to wait 5-10 minutes between administering different types of eye drops. An interview was conducted on 4/30/25 at 2:42 p.m. with the Director of Nursing (DON). The DON stated since we were notified, we changed the order to the stock probiotic saccharomyces but the administration still constituted an error. She reported the facility does not have a policy/procedure for the administration of eye drops, but according to the nurse practice there should be 5-10 minutes between different eye drops. According to the American Academy of Ophthalmology, if taking more than one type of eye drop, wait 3 to 5 minutes between the different drops. https://www.aao.org/eye-health/treatments/how-to-put-in-eye-drops Review of the facility policy titled Medication Administration, undated, instructed staff to: . 10. MAR to identify the medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer 2 drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. c. If other than oral (PO) route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.).

Based on record review and interviews, the facility did not ensure routine physician-ordered medications were acquired and provided upon admission for two residents (#3 and #8) of two residents reviewed. Findings included: 1. A review of Resident #3's Admission Record revealed an admitted [DATE], and a discharge date of [DATE], with diagnoses to include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, acute pain due to trauma, chronic pain syndrome, unspecified asthma, uncomplicated, fibromyalgia, and migraine without aura, not intractable, with status migrainosus. A review of Resident #3's Admission Assessment, dated 1/24/25, revealed she came to the facility at approximately 6:30 p.m. A review of the Admission Assessment revealed it was completed by Staff K, Licensed Practical Nurse (LPN). Further review of the assessment revealed no documentation related to medications or communicating with the physician. A review of Resident #3's progress notes revealed the following: - On 1/25/25 at 11:52 p.m., meds have not arrived from pharmacy. new admission. unable to pull. pharmacy stated medication should arrive today. - On 1/26/25 at 7:19 a.m., Slept well. Wanted a pain pill not in from pharmacy yet offered her Tylenol which she didn't. - On 1/26/25 at 3:42 p.m., Lyrica Capsule 300 MG [milligrams] Give 1 capsule by mouth two times a day for Pain Medication not available, medication not administered, PT [patient] needs a script. MD [medical doctor] notified. PT husband notified. PT shows no s/s [signs and symptoms] of distress. - On 1/26/25 at 3:44 p.m., Eletriptan Hydrobromide Oral Tablet 40 MG Give 1 tablet by mouth one time a day for migraine Medication not available; Medication not administered. MD notified. PT husband notified. Pharmacy notified with an eta [estimated time of arrival] of 1/26/25. PT shows no s/s of distress. - On 1/26/25 at 8:15 p.m., Lyrica Capsule 300 MG Give 1 capsule by mouth two times a day for Pain medication not available. contacted pharmacy. MD notified. Resident and family notified. No signs of distress. Offered patient PRN [as needed] ibuprofen for pain. resident refused. A review of Resident #3's physician orders on admission to the facility revealed the following: - Venlafaxine HCl (hydrochloride) Oral Tablet 75 MG. Give 2 tablet by mouth at bedtime for depression, with an order date of 1/25/25. - Eletriptan Hydrobromide Oral Tablet 40 MG (Eletriptan Hydrobromide). Give 1 tablet by mouth one time a day for migraine, with an order date of 1/25/25. - Lyrica Capsule 300 MG (Pregabalin) *Controlled Drug* Give 1 capsule by mouth two times a day for pain, with an order date of 1/24/25. - Senokot S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth at bedtime for constipation, with an order date of 1/25/25. A review of Resident #3's January 2025 Medication Administration Record (MAR) revealed the following: - Eletriptan Hydrobromide Oral Tablet 40 MG, give 1 tablet by mouth one time a day for migraine, with a start date of 1/25/25, was not administered on 1/25/25 to 1/27/25. On 1/25/25, it was documented with a code of, 5=Hold/See Progress Notes. - Lyrica Capsule 300 MG (Pregabalin), give 1 capsule by mouth two times a day for pain, with a start date of 1/24/25, was not administered on 1/25/25 to 1/27/25. On 1/25/25 and 1/26/25, it was documented with a code of, 5=Hold/See Progress Notes. - Venlafaxine HCl Oral Tablet 75 MG, give 2 tablet by mouth at bedtime for depression, with an order date of 1/25/25, was not administered on 1/25/25. - Senokot S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium), give 2 tablet by mouth at bedtime for constipation, with an order date of 1/25/25, was not administered on 1/25/25. 2. On 4/29/25 at 12:53 p.m., Resident #8 was observed sitting up in bed watching television. An interview was conducted where he stated, It was the worst night I ever had, and I want to leave. He said there were no medications last night for him. Resident #8 said he has diabetes and takes medications for that, but it was not provided. A review of Resident #8's Admission Record revealed an admitted [DATE], and a discharge date of [DATE], with diagnoses to include spondylosis without myelopathy or radiculopathy, lumbar region, type 2 diabetes mellitus diabetic nephropathy, other muscle spasm, bacteremia, and repeated falls. A review of Resident #8's Admission Assessment, dated 4/28/25, revealed he came to the facility at approximately 11:19 p.m. A review of the admission assessment revealed it was completed by Staff L, LPN. Further review of the assessment revealed no documentation related to medications or communicating with the physician. A review of Resident #8's progress notes revealed the following: - On 4/28/25, Rosuvastatin Calcium Oral Tablet 5 MG Give 1 tablet by mouth at bedtime for hyperlipidemia new admit. meds pending delivery. - On 4/28/25, Metformin HCl ER Tablet Extended Release 24 Hour 500 MG Give 2 tablet by mouth at bedtime for Diabetes new admit. meds pending delivery. A review of Resident #8's physician orders on admission to the facility revealed the following to include: - Metformin HCl ER (extended release) Tablet Extended Release 24 Hour 500 MG Give 2 tablet by mouth at bedtime for Diabetes, with an order date of 4/28/25. - Rosuvastatin Calcium Oral Tablet 5 MG. Give 1 tablet by mouth at bedtime for hyperlipidemia, with an order date of 4/28/25. A review of Resident #8's April 2025 MAR revealed the following: - metformin HCI ER 500 mg, give 2 tablet by mouth at bedtime for Diabetes, was not provided. On 4/28/25, it was documented with a code of, 5=Hold/See Progress Notes. - rosuvastatin calcium oral tablet 5 mg, give 1 tablet by mouth at bedtime for hyperlipidemia, was not provided On 4/28/25, it was documented with a code of, 5=Hold/See Progress Notes. On 4/30/25 at 11:48 a.m., an interview was conducted with the Social Service Director (SSD) related to Resident #8. She said she spoke to Resident #8 and completed a grievance for him. The SSD confirmed the resident told her he didn't get his medications. She said she reviewed the electronic health record and his medications are, As needed. She said his medications are at the facility, but he needed to request them. A review of the facility's emergency drug kit (EDK) inventory list from 1/31/25 revealed the following medications were available: - pregabalin 25 mg capsules [generic for Lyrica] with 20 capsules on hand at that time. A review of the facility's EDK inventory list from 4/30/25 revealed the following medications are available: - atorvastatin 10 mg tablet with 8 tablets on hand. - metformin 500 mg tablet with 11 tablets on hand. An attempt was made during the survey to conduct phone interviews with Staff K, LPN and Staff N, LPN regarding Resident #3 and Resident #8. The attempts made were unsuccessful. On 4/29/25 at 11:29 a.m., an interview was conducted with Staff L, LPN/Unit Manager. She said the re-admission/admission process included obtaining a list of medications to process. She said the admitting nurse is supposed to input medications from the list. She said during daily morning meetings re-admission/new admission medications are reviewed, To make sure that's what it's supposed to be. Staff L, LPN/UM stated, If it's a house med [medication] and we don't have that particular dose, they can call the doctor, and they might say use what you got. She said if the facility does not have the medication, they try to obtain it from the EDK. Staff L, LPN/UM said if the medication is not in the EDK, they call the doctor. She said they call the pharmacy if the medication is a narcotic. She said the facility received medications from the pharmacy for new admissions, Depending on when it's entered. She said the pharmacy staff comes twice a day. She said for the, Night run, the cut off time is 10:00 p.m. She said when there is clarification needed, a high-cost medication or therapeutic interchange, there might be a delay in getting the medication. On 4/30/25 at 1:24 p.m., an interview with Staff F, LPN regarding the admission process, for a resident who comes from the hospital, revealed she receives the paperwork and reviews it. She said she goes through the resident's hospital medication list and checks if there's medication that have been stopped or re-ordered. Staff F, LPN said she puts the medications in the pharmacy order to be delivered. She said there are two cut-off times for pharmacy delivery. She said one of them is 10:00 a.m. for the 2:00 p.m. run. Staff F, LPN said for new admissions, most of the medications can be accessed from the EDK. She said if the medication is not in the facility, they wait for the medication delivery from the pharmacy or try to obtain them from the EDK. She said if it's a 3:00 p.m. admission, the resident is not going to receive the medication until 4:00 or 5:00 a.m. She said most emergency medications, narcotics and metformin, are in the EDK. On 4/30/25 at 3:10 p.m., an interview with the Director of Nursing (DON) was conducted. She said for admissions, staff obtain the discharge summary from the hospital to reconcile medications. She said the expectation is to order medications from the pharmacy and check the EDK to see if the medications are available. The DON said if the medications are not available, the admitting staff should call the doctor and ask for an alternative they might have at the facility. She confirmed nursing staff should have access to the EDK. She said pharmacy delivery comes twice a day, in the middle of night and in the morning around 11:00 a.m. The DON said there should be documentation in the progress notes about the medications not being available or a conversation with the doctor about approving an alternative. For Resident #8, she confirmed the facility has metformin and rosuvastatin in the EDK. She said she could not confirm why the resident did not receive those medications. She stated, Unless we were out of it in the EDK, and confirmed there was no documentation in Resident #8's progress notes. She said there was possibly a lot of other residents who were prescribed the same medications. She said the admitting nurse should have asked the doctor if they would approve rosuvastatin, instead of atorvastatin, for Resident #8. Regarding Resident #2, she stated there was, A totally different pharmacy in January. She said at that time, they had difficulty with obtaining approval for medications and refills. The DON said she is unsure if the medication Resident #2 was prescribed was in that EDK at that time. She stated, I cannot speak on what was in the [vendor name] at that time. On 4/30/25 at 3:32 p.m., an observation of the EDK system, with the DON, revealed there were 11 tablets of metformin 500 mg. She said she doesn't know when the EDK was last refilled by the pharmacy. On 4/30/25 at 4:42 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA said they do not have policies related to acquiring medications from pharmacy services or obtaining medications from the EDK system.

Based on observations, record review, and interviews, the facility failed to ensure a medication administration error rate of less than 5.00%. Twelve medication administration opportunities were observed, and three errors were identified for one resident (#9) of one residents observed. These errors constituted a 25% medication error rate. Findings included: On 4/30/25 at 9:37 a.m., an observation of medication administration with Staff G, Licensed Practical Nurse (LPN) was conducted with Resident #9. The staff member dispensed the following medications for administration to Resident #9: - alprazolam 0.25 milligram (mg) tablet - dicyclomine 10 mg capsule - Aspirin 81mg enteric coated over-the-counter (otc) tablet - bupropion 75 mg tablet - gabapentin 300 mg capsule - Multi vitamin otc tablet - senna 8.6 mg otc tablet - sucralfate 1 gram (gm) tablet - timolol 0.5% eye drops - latanoprost 0.005% eye drops The staff member confirmed dispensing 8 oral medications and 2 eye drops. Staff G, LPN returned to the resident room and handed the medication cup to the resident, who swallowed medications at one time. The staff member applied gloves, then ungloved to retrieve a roll of paper towel from closet for the resident. Staff G, LPN washed her hands, applied gloves, and administered, at 10:02 a.m., one drop of Latanoprost into the residents left eye, immediately followed by one drop of Timolol in the left eye. Staff G, LPN confirmed both eye drops went into the same eye. The resident reported recently having eye surgery. The staff member left the room, went to the Unit Manager's office, and spoke for a moment before retrieving, at 10:08 a.m., Resident #9's Lantus insulin pen from the medication refrigerator. Staff G, LPN dispensed one capsule of saccharomyces boulardii 500 mg from an over-the-counter bottle in med cart. Staff G, LPN returned to the room, spilled the saccharomyces boulardii capsule on the floor, returned to the medication cart, and re-dispensed the capsule. The staff member washed her hands and administered the probiotic, before returning to the med cart to retrieve an insulin needle. The staff member primed the insulin pen using 2 units, dialed to 35 units, and injected insulin into the upper right arm of Resident #9. Immediately following the observation, Staff G, LPN stated the probiotic saccharomyces given was the generic of Lactobacillus ordered. Review of Resident #9s Medication Administration Record (MAR) revealed the following orders scheduled for 9:00 a.m. - Lactobacillus capsule - Give 1 capsule by mouth two times a day for Diabetes Mellitus (DM), started on 2/6/25 and discontinued on 4/30/25 at 10:56 a.m. The MAR showed the resident received this medication twice daily during the month of April. - Timolol Maleate Ophthalmic solution 0.5% - Instill one drop in left eye one time a day for glaucoma. - Latanoprost Ophthalmic emulsion 0.005% - Instill one drop in left eye two times a day for glaucoma. During an interview on 4/30/25 at 11:16 a.m., Staff L, LPN/Unit Manager (UM) stated Lactobacillus and Saccharomyces were not technically the same thing. Staff L, LPN/UM stated when a resident came in with Lactobacillus, they were supposed to be changed over to the stock probiotic saccharomyces. Staff L, LPN UM stated staff were supposed to wait 5-10 minutes between administering different types of eye drops. An interview was conducted on 4/30/25 at 2:42 p.m. with the Director of Nursing (DON). The DON stated since we were notified, we changed the order to the stock probiotic saccharomyces but the administration still constituted an error. She reported the facility does not have a policy/procedure for the administration of eye drops, but according to the nurse practice there should be 5-10 minutes between different eye drops. According to the American Academy of Ophthalmology, if taking more than one type of eye drop, wait 3 to 5 minutes between the different drops. https://www.aao.org/eye-health/treatments/how-to-put-in-eye-drops Review of the facility policy titled Medication Administration, undated, instructed staff to: . 10. MAR to identify the medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer 2 drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. c. If other than oral (PO) route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.).

Based on interview, record review and observation, the facility failed to ensure the reach-in cooler was maintained in a sanitary manner in one of one kitchen. Findings included: During an observation of the kitchen on 06/23/2024 at 9:38 a.m. the reach-in cooler was observed with a variety of food items to include: a container of prepared food covered with plastic wrap, an open carton of eggs, container of turkey, half a head of lettuce with plastic wrap, a cucumber with plastic wrap, a package of meat, a silver pan of corn with plastic wrap. In addition, the multiple white racks, in the reach-in cooler holding the food and containers, were observed to have the white coating peeling and exposing the brown rusted individual bars on each rack. There was also a brownish yellow staining collected on each rack. (Photographic Evidence Obtained) During an interview with the Dietary Director on 6/23/2024 at 11:11 a.m., she stated she knew the racks needed to be replaced and would like to replace the whole cooler. Additionally, she stated they use an on-line system for work orders but did not know when it was put in. During an interview with the Maintenance Director on 6/24/2024 at 3:44 p.m., he stated he had not received any work orders for the reach-in cooler. On 06/24/2024 a report listing the facility work orders was reviewed for the months of May 2024 and June 2024 and revealed the report was silent of work orders for the reach-in cooler.

Based on interview and record review, the facility failed to ensure the facility had an Infection Control Preventionist (ICP), who had specialized training in Infection Control and Prevention. Findings included: An interview was conducted on 06/24/2024 at 11:29 PM with the Director of Nursing (DON). The DON stated she was in training to be the facility's ICP as well as Staff C, Licensed Practical Nurse (LPN), who was also in training. The DON confirmed neither herself nor Staff C had completed specialized training related to infection control and prevention. The DON also stated she and Staff C were assisted in their training by the Regional Nurse Consultant (RNC), who comes to the facility on ce a month. During an interview on 06/24/2024 at 1:53 PM, the Nursing Home Administrator (NHA) confirmed the previous ICP left in May 2024 and currently Staff C, LPN and the DON are in training with assistance from the RNC. Review of the policy titled, Infection Preventionist, dated 10/18/2022, showed: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. 2. The facility will ensure the Infection Preventionist (IP) is qualified by education, training, experience or certification. 6. The IP must be employed at least part-time . 8. The IP will physically work onsite in the facility. 10. The IP must have obtained specialized IPC [infection prevention and control] training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation.

Based on interview, record review, and observation, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition in one of one kitchen. Findings included: During an observation of the kitchen on 06/22/2024 at 9:44 a.m. the reach-in cooler had a wet towel under it and puddles of water were pooling from underneath and into the floor. In addition, the steam table was observed with wet towels and buckets on the lower shelf catching water dripping from the upper shelf that contained the food storage compartments. (Photographic Evidence Obtained) During an interview with Staff E, Dietary [NAME] on 6/22/2024 at 10:00 a.m., she stated, Yes, it leaks. I am not gonna lie. It has been a while. We put in a maintenance request. She also stated the drain was missing on the steam table, so they used buckets to catch the water. During an interview with the Dietary Director on 6/23/2024 at 9:40 a.m. she stated, The reach-in has been temporarily fixed by on-site maintenance, he is trying to fix it first. The steam table does not leak all the time. Maintenance is working on it too. During an interview with the Dietary Director on 06/23/2024 at 11:11 a.m. she stated they use an on-line system for work orders but did not know when it was put in. She stated, I know I had told them about the steam table. He has worked on it a few times. He is responsive to work orders, they work on it right away unless they need parts from an outside source. During an interview with the Maintenance Director on 6/24/2024 at 3:44 p.m., he stated he had not received any work orders for the reach-in cooler or the steam table. He also stated, I was told by the kitchen staff since you have been here; asking me to look at the reach in cooler. No one has mentioned the steam table. On 06/24/2024 a report listing the facility work orders was reviewed for the months of May 2024 and June 2024 and revealed the report was silent of work orders for the reach-in cooler or steam table.

Based on interview and record review, the facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) and failed to update the Level I PASRR upon the addition of new diagnoses for thirteen (#43, #40, #6, #59, #37, #11, #12, #14, #64, #29, #42, #38 and #36) of sixteen residents reviewed for PASRR. Findings included: 1. Review of the Admission Record for Resident #43 revealed an admission to the facility on [DATE] with diagnoses to include vascular dementia (02/20/2024), adjustment disorder with mixed anxiety and depressed mood (02/20/2024), and dementia (03/15/2024). Review of the June 2024 Medication Administration Record (MAR) for Resident #43 revealed: -Alprazolam Tablet 0.25 MG (milligrams) - Give 1 tablet by mouth one time a day for anxiety; start date 02/16/2024. -Aricept Tablet 10 MG - Give 1 tablet by mouth at bedtime for dementia; start date 11/18/2023. -Mirtazapine Tablet 7.5 MG - Give 1 tablet by mouth at bedtime related to major depressive disorder; start date 02/06/2024. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #43, dated 05/31/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia checked. -Under Section N Medications: antianxiety and antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #43, dated 12/05/2023, revealed: -Section IA - anxiety and depressive disorder checked, -Section IB - none checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. 2. Review of the Admission Record for Resident #40 revealed an admission to the facility on [DATE], and a readmission on 01/17/2023 with diagnoses to include unspecified dementia (08/18/2020), and major depressive disorder (01/12/2024). Review of the June 2024 MAR for Resident #40 revealed: - Duloxetine HCl Oral Capsule Delayed Release Particles 20 MG - Give 20 mg capsule by mouth one time a day for depression; start date 04/09/2024. Review of the Quarterly MDS assessment for Resident #40, dated 04/20/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia and depression checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #40, dated 01/17/2023, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. 3. Review of the Admission Record for Resident #6 revealed an admission to the facility on [DATE], and a readmission on 08/20/2023 with diagnoses to include psychosis (03/17/2015), schizophrenia (08/20/2023), and anxiety (03/10/2015). Review of the June 2024 MAR for Resident #6 revealed: -Propranolol Oral Tablet 20 MG - Give 1 tablet via PEG Tube every morning and at bedtime for Anxiety; start date 08/20/2023. -Clonazepam Oral Tablet 1 MG - Give 1 tablet via PEG Tube three times a day for Anxiety; start date 11/15/2023. -Valproic Acid Oral Solution 250 MG/5 ML (milliliters) Give 10 ml via PEG Tube every 6 hours for bipolar disorder; start date 08/21/2023. Review of the Quarterly MDS assessment for Resident #6, dated 06/09/2024, showed: -Under Section I Diagnoses: anxiety, psychotic disorder, schizophrenia checked. -Under Section N Medications: antianxiety checked. Review of the Level I PASRR form located in the clinical record for Resident #6, dated 03/17/2015, revealed: -Section IA: nothing checked, and mental retardation written under other. -all other sections were checked no. No additional PASRR forms were available in the clinical record for review. 4. Review of the Admission Record for Resident #59 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder (04/01/2023) and anxiety (04/01/2023). Review of the June 2024 MAR for Resident #59 revealed: -Amitriptyline HCl Tablet 50 MG - Give 1 tablet by mouth one time a day for depression; start date 06/13/2024. -Duloxetine HCl Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth two times a day for depression; start date 03/28/2024. Review of the Annual MDS assessment for Resident #59, dated 03/30/2024, showed: -Under Section I Diagnoses: anxiety and depression checked. -Under Section N Medications: hypnotic and antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #59, dated 03/18/2023, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II all sections are checked no. 5. Review of the Admission Record for Resident #37 revealed an admission to the facility on [DATE] and a readmission on 05/26/2024 with diagnoses to include unspecified dementia (01/21/2020 and major depressive disorder (09/01/2020). Review of the Quarterly MDS assessment for Resident #37, dated 04/09/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia and depression checked. Review of the Level I PASRR form located in the clinical record for Resident #37, dated 01/20/2020, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. An interview was conducted on 06/24/24 at 12:14 PM with the Director of Nursing (DON) and Staff D, Social Services Director (SSD). The DON said it was her, and the previous SSD's responsibility to ensure PASRR Level I forms were accurate upon the resident's admission to the facility. She stated if the PASRR Level I form was not correct, she would submit an updated version. The DON also confirmed if a resident had a new diagnoses added during their stay at the facility, a new PASRR Level I form should be completed. The DON confirmed the residents listed above had inaccurate/incorrect PASRR Level I forms related to diagnoses. During an interview on 06/24/24 at 02:02 PM, the Nursing Home Administrator (NHA) confirmed PASRR Level I forms should have an accurate and complete diagnoses listed. 38007 6. Review of the Admission Record for Resident #11 revealed an admission to the facility on [DATE], and a readmission on 11/29/2023 with diagnoses to include Alzheimer's disease (05/06/2014), mood disorder due to known physiological condition with depressive features (04/25/2016), schizoaffective disorder, bipolar type (07/22/2019), anxiety disorder, unspecified (03/06/2016), other recurrent depressive disorders (10/01/2015), and unspecified psychosis not due to a substance or known physiological condition (05/06/2014). Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 06/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 11/23/2023 and discontinued 06/12/24. - carBAMazepine Oral Suspension 100 MG/5ML (millileters) - Give 5 ml by mouth three times a day related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date 12/05/2023. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #11, dated 04/21/2024, showed: -Under Section I Diagnoses: Alzheimer's Disease, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR forms located in the clinical record for Resident #11, dated 09/04/2020 and 07/24/2020, revealed: -Section IA - no diagnoses were checked (09/04/2020 & 07/04/2020) and Alzheimer's was not checked (07/04/2020), -Section II #5 - Related Neurocognitive Disorder (including Alzheimer's disease) checked no. 7. Review of the Admission Record for Resident #12 revealed an admission to the facility on [DATE] with diagnoses to include generalized anxiety disorder (11/21/23), other recurrent depressive disorders (7/18/22), and excoriation (skin-picking) disorder (5/10/22). Review of the June 2024 MAR for Resident #12 revealed: - FLUoxetine HCl Oral Tablet 10 MG - Give 10 mg by mouth one time a day for depression; start date of 12/20/2023, -Doxepin HCl Capsule 10 MG - Give 10 mg by mouth three times a day for depression with excessive skin picking, start date of 5/24/24. Review of the Quarterly MDS assessment for Resident #, dated 04/19/2024, showed: -Under Section I Diagnoses: anxiety disorder, depression and excoriation (skin-picking) disorder checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #12, dated 11/17/2023, revealed: -Section IA - depressive disorder checked, -Section IB - nothing checked. 8. Review of the Admission Record for Resident #14 revealed an admission to the facility on [DATE], and a readmission on 04/09/2024 with diagnoses to include depression (12/29/2023). Review of the June 2024 MAR for Resident #14 revealed: - Sertraline HCI Oral Tablet 50 MG - give 1 tablet by mouth one time a day for depression 4/13/24. Review of the MDS assessments for Resident #14, dated 04/04/2024 and 05/02/2024, showed: -Under Section I Diagnoses (04/04/2024): depression checked. -Under Section N Medications (05/02/2024): antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #14, dated 12/27/2023, revealed: -Section IA - anxiety order was checked and depressive disorder was not checked, -Section IB - nothing checked. 9. Review of the Admission Record for Resident #64 revealed an admission to the facility on [DATE] with diagnoses to include other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions, bipolar disorder unspecified and bipolar disorder current episode depressed, moderate. Review of the June 2024 MAR for Resident #64 revealed: - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth one time a day for depression; start date 6/21/2024. - DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG - Give 3 capsule by mouth one time a day for depression; start date 11/08/2023 and d/c date 6/20/2024. - Depakote Oral Tablet Delayed Release 250 MG - Give 3 tablet by mouth at bedtime for mood disorder; start date 6/6/2024. - Divalproex Sodium Oral Tablet Delayed Release 500 MG - Give 2 tablet by mouth at bedtime for mood disorder; start date 11/07/2023 and d/c date 6/6/2024. Review of the Quarterly MDS assessment for Resident #64, dated 05/15/2024, showed: -Under Section I Diagnoses: bipolar disorder and psychotic disorder checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #64, dated 10/30/2023, revealed: -Section IA - bipolar disorder, depressive disorder, other: adjustment disorder checked. substance abuse was not checked. -Section IB - nothing checked, -Section II - 3. A. Psychiatric treatment more intensive than outpatient care checked yes. The medical record was silent of any other PASRRs for Resident #64. An interview was conducted on 06/24/24 at 12:04 PM with the Director of Nursing (DON). The DON stated if the PASRR Level I form was not correct, she would submit an updated version. The DON also confirmed if a resident had a new diagnoses added during their stay at the facility, a new PASRR Level I form should be completed. 36273 10. Review of the Admission Record for Resident #42 revealed an admission to the facility on [DATE] with diagnoses to include depression, adjustment disorder with depressed mood and Non-Alzheimer's Dementia. Review of the June 2024 Medication Administration Record (MAR) for Resident #42 revealed: -Depakote Oral tablet delayed release-Give 125 mg by mouth two times a day for mood disorder; start date: 06/11/2024, -FLUoxetine HCI Oral tablet 20 MG-Give 1 tablet by mouth one time a day for depression; start date: 09/21/2023, and -ABH Cream 1-25-1Mg/mL-Apply 1 mL topically to inner wrist or other hairless area three times a day for anxiety or restlessness; start date: 01/10/2024. Review of the Quarterly Minimum Data Set (MDS) for Resident #42, dated 06/02/2024, showed: -Section I Diagnosis: Depression checked; Non-Alzheimer's Dementia checked. -Section N Medications: Antipsychotic, Antianxiety, Antidepressant checked. -Antipsychotic Medication Review: Code 1 indicated Antipsychotics were received on a daily basis. Review of the Level I PASRR form located in the clinical record for Resident #42, dated 09/12/2023, revealed: -Section IA - Depressive Disorder checked, -Section II #2 C. Adaption to change -checked yes, -Section II #4- Has the individual exhibited actions or behaviors that may make them a danger to themselves or others was checked yes, -Section II #5-a primary diagnosis of Dementia -checked yes, -Section III: Not a provisional admission checked, -Section IV: PASRR Screen Completion- Serious Mental Illness checked. Verbal consent for a required Level II PASRR was given by Resident #42's spouse on 09/12/2023 at 9:54 a.m. Review of Resident #42's clinical record did not include a Level II PASRR as required. 11. Review of the Admission Record for Resident #36 revealed an admission to the facility on [DATE] and a readmission on 05/24/2024 with diagnoses to include major depressive disorder, generalized anxiety disorder (07/20/2023) and Alzheimer's Disease with late onset (07/18/2023). Review of the June 2024 MAR for Resident #36 revealed: -Ativan Oral Tablet 0.5 MG *controlled drug* Give 0.25 mg by mouth every 12 hours as needed for anxiety; agitation for 14 days start: 06/20/2024 end: 07/04/2024, -Setraline HCI Oral Tablet 100 mg Give 100 mg by mouth one time a day related to Major Depressive Disorder, recurrent, moderate start: 06/07/2024, -Buspirone HCI Oral tablet Give 1 tablet by mouth two times a day for treat anxiety start 06/07/2024. Review of the Quarterly MDS for Resident #36, dated 05/30/2024, showed: -Section I Diagnosis: Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression. -Section N Medications: Antianxiety, Antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #36, dated 07/10/2023, revealed: -Section IA - no diagnosis checked (07/20/2023), Alzheimer's not checked (07/18/2023), -Section II #7-checked yes-HX (history): Dementia. 12. Review of the Admission Record for Resident #38 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder recurrent severe without psychotic features, and adjustment disorder with anxiety (06/16/2020). Review of the June 2024 MAR for Resident #38 revealed: No medications related to a mental diagnosis were ordered. Review of the Quarterly MDS for Resident #38, dated 4/23/2024, showed: -Section I Diagnosis: Depression. Review of the Level I PASRR form located in the clinical record for Resident #38, dated 03/23/2020, revealed: -Section IA - no diagnosis checked (06/16/2020), -Section IB-nothing checked. 13. Review of the Admission Record for Resident #29 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder, recurrent, unspecified (01/31/2023). Review of the June 2024 MAR for Resident #29 revealed: Mirtazapine Oral Tablet 7.5 MG Give 1 tablet by mouth at bedtime for depression start: 10/26/2023. Review of the Quarterly MDS for Resident #29, dated 04/11/2024, showed: -Section I Diagnosis: Depression. -Section N Medications: Antianxiety checked. Review of the Level I PASRR form located in the clinical record for Resident #29, dated 01/24/2022, revealed: -Section IA- no diagnosis checked (01/31/2023), -Section IB-nothing checked. Review of the policy titled, Resident Assessment - Coordination with PASRR Program, undated, revealed: This facility coordinates assessments with the preadmission and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 5. The facility will have a designated staff member, such as Social Services Director or designee, responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 8. Any resident who exhibits a newly evident behavioral or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II reviewed.

Based on interview and record review, the facility failed to ensure timely completion of the Minimum Data Set (MDS) assessment for four (#47, #273, #57, and #17) of thirty-two sampled residents. Findings included: A review of Resident #47's Admission Record revealed Resident #47 was admitted to the facility on [DATE]. A review of Resident #47's Admission MDS assessment, with an Assessment Reference Date (ARD) of 5/28/2024 revealed the assessment was not completed until 6/5/2024. A review of Resident #273's Admission Record revealed Resident #273 was admitted to the facility on [DATE]. A review of Resident #273's Admission MDS assessment, with an ARD of 6/12/2024 revealed the assessment was not completed until 6/20/2024. A review of Resident #57's Admission Record revealed Resident #57 was admitted to the facility on [DATE]. Resident #57 was discharged from the facility on 2/3/2024. A review of Resident #57's Medicare 5-day MDS assessment, with an ARD of 2/3/2024 revealed the assessment was not completed until 3/20/2024. A review of Resident #17's Admission Record revealed Resident #17 was admitted to the facility on [DATE]. Resident #17 was discharged from the facility on 1/4/2024. A review of Resident #17's Medicare 5-day MDS assessment, with an ARD of 1/4/2024 revealed the assessment was not completed until 3/20/2024. An interview was conducted on 6/24/2024 at 10:34 AM with Staff B, Registered Nurse (RN) and MDS Coordinator. Staff B, RN/MDS stated admission MDS assessments are to be completed within 14 days from the date the resident is admitted to the facility. Staff B, RN/MDS reviewed Resident #47's and Resident #237's admission assessments and addressed the assessments were completed late. Staff B, RN/MDS stated the assessment includes input from other departments and those departments do not always completed their section of the assessment timely, which results in the entire MDS assessment being completed late. Staff B, RN/MDS reviewed the Medicare 5-day MDS assessments for Resident #57 and Resident #17 and was not able to state why the assessments were not completed timely because she was not working for the facility at the time. According to Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.18.1, the admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if this is the resident's first time in this facility, the resident has been admitted to this facility and was discharged return not anticipated, or the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Prospective Payment System (PPS) Assessments for a Medicare Part A, stay including 5-Day assessments, must be completed within 14 days after the ARD (ARD + 14 days).

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (#1) of thirty-two sampled residents. Findings included: A review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of unspecified hearing loss. An observation was conducted on 6/22/2024 at 10:41 AM with Resident #1 in the resident's room. Resident #1 was observed in a wheelchair watching television. After attempting to conduct an interview, Resident #1 stated, You're going to have to write it down, I can't hear. He pointed to a dry erase board and dry erase marker on a nearby table. An interview was conducted with Resident #1 using the dry erase board and dry erase marker. Resident #1 stated he did not use any hearing devices and required an operation in order to use hearing aides. A review of Resident #1's care plan revealed a focus area, initiated 11/20/2023, [Resident #1] has difficulty hearing and will often misunderstand situations due to hearing impairment. Interventions included to use a dry erase board or writing pad and allow the resident time to respond. A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/16/2024, revealed under Section B - Hearing, Speech, and Vision, Resident #1's ability to hear (with hearing aid or hearing appliances if normally used) was adequate - no difficulty in normal conversation, social interaction, or listing to TV. The MDS assessment also revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #1 was cognitively intact. An interview was conducted on 6/24/2024 at 10:34 AM with Staff B, Registered Nurse (RN) and MDS Coordinator. Staff B, RN/MDS stated completion of the MDS assessments included reviewing the resident's administration records, pain assessments, physician's orders, and the charting completed by the nursing staff during the look back period. Staff B, RN/MDS also stated she will conduct interviews with the residents if they are able to communicate. Staff B, RN/MDS reviewed Resident #1's care plan and MDS assessment and addressed the information in Section B of the MDS assessment was incorrect because the resident was care planned for difficulty hearing. An interview was conducted on 6/24/2024 at 12:38 PM with the Director of Nursing (DON). The DON stated Resident #1 was not able to hear and staff used the dry erase board to communicate with the resident. The DON stated she would not agree Resident #1 had adequate hearing. A review of the policy titled, Comprehensive Care Plans, undated, revealed under the section titled Policy it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed under the section titled Policy Explanation the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals or care.

Based on interview and record review, the facility failed to complete the baseline care plan in a timely manner for one (#274) of thirty-two sampled residents. Findings included: A review of Resident #274's Admission Record revealed Resident #274 was admitted to the facility on [DATE]. A review of Resident #274's baseline care plan revealed a completion date of 6/17/2024. An interview was conducted on 6/24/2024 at 12:32 PM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated unit managers would normally initiate the baseline care plan and the care plan should be completed as soon as possible. Staff C, LPN was not able to state when the baseline care plan should be completed. An interview was conducted on 6/24/2024 at 12:49 PM with the Director of Nursing (DON). The DON stated baseline care plans were to be completed by the resident's admitting nurse and should be completed within 48 hours. A request for a facility policy for baseline care plans was requested on 6/24/2024 at 11:28 AM. Then at 1:25 PM, the DON stated the facility did not have a policy for baseline care plans.

Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for four (#55, #11, #12, and #14) of 32 residents reviewed. Findings included: 1. Review of the Admission Record for Resident #55 revealed admission to the facility on [DATE] and a readmission on 04/19/2024 with diagnoses to include congestive heart failure, acute kidney failure, chronic kidney disease, and ESBL (extended-spectrum beta- lactamases). Review of the care plan for Resident #55 on 06/22/2024 revealed: Focus: -[Resident #55] requires Isolation Precautions r/t [related to] ESBL in urine. Goals: -No problems or negative complications r/t Isolation Precautions until infection is resolved. Interventions: -Don proper PPE [personal protective equipment] when providing care. -Observe Isolation Precautions Date initiated: 05/24/2024; a resolved or completed date was not present. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2024 and June 2024 revealed: - contact isolation related to ESBL start date on 5/24/24 and discontinue on 6/3/24 (10 days). On 06/23/2024 at 12:30 PM, Resident #55 was observed in room and laying on the bed, dressed and groomed. The resident was not interviewable at that time. Further observation revealed no contact isolation signage or PPE caddy at the room door entrance. During an interview on 06/23/2024 at 12:32 PM, with Staff A, Licensed Practical Nurse (LPN), she confirmed Resident #55 had been treated for a urine infection several weeks ago, and said at that time she was on transmission-based precautions (TBP). Staff A said the precautions were discontinued but she could not recall the date. On 06/23/2024 at 12:56 PM an interview was conducted with Staff B, Minimum Data Set (MDS) Coordinator, Registered Nurse (RN). The RN/MDS Coordinator confirmed she was responsible for the MDS assessments and the care plans. Staff B stated the care plan focus should be resolved when it was no longer an issue for the resident/staff. Reviewing the resident's care plan, the RN/MDS Coordinator confirmed the care plan should have been updated to remove the TBP focus when the TBP were discontinued and stated, I missed that. The RN/MDS Coordinator continued, saying the focus was resolved yesterday (06/22/2024). Review of a printed care plan, provided by the RN/MDS Coordinator, showed the TBP focus had a resolved dated on 06/22/2024 (after the survey team entered the facility and reviewed the care plan). During an interview with the Director of Nursing (DON) on 06/24/2023 at 12:10 PM, she said it would be her expectation that care plans are updated and revised to reflect the resident's current care needs. 38007 2. On 06/22/2024 at 11:49 AM during an observation of the lunch service for fourteen residents in the main dining room, Resident #11 was sitting at a table in her wheelchair by herself having sporadic outbursts of laughing. Review of the Admission Record for Resident #11 revealed an admission to the facility on [DATE], and a readmission on 11/29/2023 with diagnoses to include Alzheimer's disease, mood disorder due to known physiological condition with depressive features, schizoaffective disorder, bipolar type, anxiety disorder, unspecified, other recurrent depressive disorders, and unspecified psychosis not due to a substance or known physiological condition. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #11, dated 04/21/2024, showed: - Section C - Cognitive Patterns - the resident was rarely/never understood. - Section I Diagnoses: Alzheimer's Disease, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia checked. Review of the care plan, initiated 09/30/20, for Resident #11 revealed: - Focus: She has dx (diagnoses) of dementia, schizoaffective disorder, and mood disorder. She is at risk for her psychosocial well-being needs not being met. She takes psychotropic medication, she is at risk for adverse reactions and complications. Goal: She will not experience any adverse reactions secondary to antidepressant medication through review. Interventions included: meds (medications) per orders, observe for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion, Provide calm environment as needed, observe for non-verbal signs of distress/discomfort/anxiety such as insomnia, fidgeting, restlessness, psych consult prn (as needed). -Focus: Behaviors: [Resident #11] has a behavior problem r/t (related to) refuses medications at times. Goal: Encourage resident to take medications however, staff will honor resident's right to refuse; The resident will have fewer episodes of unwanted behavior through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. -Focus: Cognition: [Resident #11] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. Goal: Staff will anticipate resident's needs, if she is unable to make them known. The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents capabilities and needs. COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. Provide the resident with a homelike environment. Reminisce with the resident using photos of family and friends. The resident needs [sic] with all decision making. The active care plan was silent of a focus, goal or intervention related to the behavior of laughing outbursts. Review of a Psychotropic Medication Interdisciplinary Review, dated 06/05/2024, revealed, Patient presents with involuntary, sudden and frequent episodes of laughing and/or crying. The episodes are consistent with PBA [pseudobulbar affect], and typically occur out of proportion or incongruent to the underlying emotional state. ,[sic] trialing nudexta at this time. Documented in the DX (diagnoses) section was the following: 5: Pseudobulbar affect - start Nuedexta 20 mg (milligrams) qd (once a day) for 7 days then q (once) 12 hours when the medication comes for [vendor name] pharmacy. Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 06/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 11/23/2023 and discontinued 06/12/24. - carBAMazepine Oral Suspension 100 MG/5ML (milliliters) - Give 5 ml by mouth three times a day related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date 12/05/2023. The June 2024 MAR was silent of any administration for Nudexta. During an interview on 06/23/2024 at 12:12 PM Staff J, Certified Nursing Assistant (CNA) stated normally she crawls out of bed, but for the noise thing; she does it a lot. It is between a laugh and cry. She confirmed she has doing this for a few months. Staff J stated she will ask Resident #11 if she is crying, but Resident #11 will say no I'm laughing. She will make the same noise all the time and you just ask her what is wrong. During an interview on 06/23/2024 at 1:07 PM Staff I, Licensed Practical Nurse (LPN) confirmed there were no orders for Nuedexta in Resident #11's record. She reviewed the progress notes for Resident #11 and confirmed there were no notes related to the outbursts of laughing or administration of Nuedexta. Staff I stated if you ask her if she is laughing, crying, hurting or in pain; she will answer appropriately and she will acknowledge if she is in pain. Staff I stated they do not know what triggers the laughing. She stated it was sporadic. She stated we start asking her to rule out what it is. She stated that most of the time it is laughing and we ask her what she is laughing at and she will tell you she doesn't know. Staff I stated Resident #11 has been doing this for a little over a month and that it comes and goes. She reviewed the current care plan to see if this was addressed and she stated, I don't see it anywhere in here, but aware of what to do. During an interview on 06/23/0204 at 1:25 PM Staff B, RN/MDS confirmed Resident #11's care plan did not include information related to the outbursts of laughing and stated that nursing would tell her if there was a new diagnosis to be added. She stated, I would add that new diagnosis and a care plan. She stated she was not made aware of the PBA diagnosis. She stated nursing attends the psych meetings and they communicate that in the meetings the next day they talk about new orders and new diagnosis. During an interview on 06/23/2024 at 1:47 PM the Director of Nursing (DON) stated the ARNP (advanced practice registered nurse) was trying to get the Nuedexta from another pharmacy the facility doesn't use. She stated that it was her understanding they would start the medication once they received it. She confirmed there was no documentation of communication between the pharmacy and the facility to follow up on the status of the medication. She confirmed the outbursts of laughing and diagnosis of PBA should have been in Resident #11's care plan. She confirmed someone should have told Staff B, RN/MDS. On 06/23/2024 at 4:30 PM Resident #11 was observed in her wheelchair in the hall and having sporadic outbursts of laughing. Two staff members were with her and one was trying to straighten Resident #11's jacket. Resident #11 shouted, Don't touch me. The staff member stopped and walked away. Another staff member yelled from the other end of the hall asking what was wrong, and the staff member standing next to Resident #11 stated, She is just being [Resident #11]. Resident #11 continued with sporadic laughing outbursts. 3. On 06/22/2024 at 10:02 AM Resident #12 was observed in bed with a red ulcer on her right lower shin and crusted discharge on the corner of her toenail on her big toe, a dressing was not observed on either location. Resident #12 stated they were taking care of her open sore. She stated, They had it (toe) wrapped so tight. I pulled it off and it had all this junk oozing. I need them to do something about that toe. Review of the Admission Record for Resident #12 revealed an admission to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; acquired absence of left leg above knee; excoriation (skin-picking) disorder, and peripheral vascular disease. Review of the June 2024 MAR for Resident #12 revealed: -Doxepin HCl Capsule 10 MG - Give 10 mg by mouth three times a day for depression with excessive skin picking, start date of 5/24/24. This medication was administered as ordered. - Podiatrist, Audiologist, Vision and Dental Consult; start date of 3/18/22. - BEHAVIORS - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift document yes for active behaviors this shift, no if not actively having behaviors this shift. document type of behavior document number of times noted this shift, Start date of 9/10/22. NO was documented for each shift from 06/01/2024 to 06/23/2024 except for the evening shift on 06/21/2024 there was no behavior documented. Review of the June 2024 Treatment Administration Record (TAR) on 06/23/2024 at 2:20 PM for Resident #12 revealed: - PO cleanse right shin with nss (normal saline solution) pat dry apply hydrophilic ointment wrap with gauze wrap and coban every two days and as needed - every day shift every 2 days (s) for wound care, start date 5/18/24. Review of the June 2024 TAR provided by facility on 06/24/2024 revealed and additional physician order for: -cleanse right great toe with nss, pat dry apply TAO and Band Aid daily until resolved - every evening shift for wound care, start date, [sic]/25/2024 1500 (3:00 p.m.) - with no documentation of administration. Review of the Quarterly MDS assessment for Resident #12, dated 04/19/2024, showed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section I Diagnoses showed anxiety disorder, depression and excoriation (skin-picking) disorder were checked. Section M - Skin Conditions showed Resident #12 had other open lesion(s) on the foot and application of dressings to feet (with or without topical medications). Review of the active care plan for Resident #12 revealed: - Focus: Venous Ulcer to Right shin, Left leg r/t (related to) DX (diagnosis) of PVD. Goal and Interventions were blank. -Focus: Behaviors: [Resident #12] has a behavior problem r/t picking at skin and pulling scabs of healed areas. Goal: The resident will have fewer episodes of behavior by review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Staff to keep nails trimmed and cleaned as she allows. When staff observe resident picking at skin attempt to redirect the behavior. -Focus: Impaired skin integrity with risk for further decline r/t Hx (history) of picking at skin. Incontinence and impaired mobility, she frequently picks at her skin, venous ulcer (R)leg, (L)leg. Goal: No problems or negative complications r/t impaired skin integrity with skin integrity with skin being kept intact daily through next review. Interventions included: head to toe skin check weekly, observe skin during care for any s/s (signs/symptoms) of redness and report to nurse immediately and wound care consult/weekly visit treatment as ordered. The active care plan was silent of a focus, goal or intervention related to the behavior of pulling off gauze/dressings to open wounds and care for the right big toe. In addition, the care plan did not document a goal or interventions for the focus related to the venous ulcers. During an interview on 06/23/2024 at 4:31 PM Staff A, LPN stated Resident #12 picks at her skin. She stated Resident #12 receives an ointment for the ulcer and it is wrapped with gauze. Staff A stated Resident #12 refuses it (gauze) and she takes it off. She stated Resident #12 doesn't like the compression. Staff A placed this information in an observed progress note. She stated, today Resident #12 refused for me to wrap it. She stated the toe is scabbed and a CNA came to me today to tell me about the resident's concern with the toe. She stated, I am looking into it. She stated Resident #12 takes the gauze off using her grabber. During an interview on 06/24/2024 at 11:13 AM Staff B, RN/MDS stated she was not aware of Resident #12's toe and that she removes the gauze placed on her wounds. She stated, I would think that would be a behavior. She stated no one had brought this up. She stated there was nothing about the toe in the nurses' notes. She said, I don't see a note about taking the gauze off. She reviewed and read aloud part of the general nurse note, dated 5/24/2024, Resident alert and verbal . Facility MD here for visit . continue current wound care treatment and discussed importance of leaving dressing on and not taking them off and picking at skin. She stated this was addressing pulling off gauze as a behavior. She stated nursing would have to bring that to my attention and social services. She stated care plans should have the behaviors. She confirmed the current care plan did not have anything referencing care for Resident #12's big toe. During an interview on 06/24/2024 at 1:26 PM Staff K, RN stated Resident #12 picks. She stated the podiatrist trimmed her nails. She stated a wrap is put on it and she pulls it and picks it. She confirmed Resident #12 pulls the gauze by nodding her head up and down. She stated that wound care was there on Friday and there was a dressing on her toe then. During an interview on 06/24/2024 at 12:27 PM the DON stated the behavior of taking off the gauze was new to her. She stated nurses should inform her and she would let Staff B, RN/MDS Coordinator know. She confirmed she hadn't seen anything about Resident #12's toe and staff should have informed her. 4. Resident #14 was observed on 06/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. Resident #14 was observed on 06/22/2024 at 11:52 AM in bed receiving oxygen at 4 LPM (liters per minute). She stated she sleeps a lot and was not having any concern with her oxygen. Review of the Admission Record for Resident #14 revealed a readmitted [DATE] and 04/09/2024 and an original admitted [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, type 2 diabetes mellitus with diabetic neuropathy, dysphagia oropharyngeal phase, and dysphagia following cerebral infarction Review of the June 2024 Physician Orders revealed: - Oxygen @ 2L (liters) via nasal cannula as needed for SOB (shortness of breath); start date of 04/05/2024, - Check Oxygen Saturation Q (every) Shift and Document every shift for Covid Monitor; start date of 12/28/2023, - Increase o2 to keep 02sat>92%, order date of 5/9/24, - Ipratropium-albuterol solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters)- 3 ml inhale orally every 4 hours as needed for SOB or wheezing via nebulizer, start date of 5/9/24, - HOB is elevated to prevent of SOB while lying flat r/t (related to) chronic lung disease (bed or pillows), every shift for COPD; start date of 04/10/2024, - Fast Blood Glucose - one time a day for DM (diabetes mellitus); start date of 12/30/2023, - Bydureon BCise Subcutaneous Auto-injector 2 MG/0.85ML (Exenatide) - Inject 2 mg subcutaneously one time a day every Fri for DM; start date of 4/19/2024, - Glucagon (rDNA) Kit 1 MG - Inject 1 mg intramuscularly every 15 minutes as needed for blood sugar less than 60 give 1 mg IM (intramuscular) if blood sugar less than 60 and resident unable to swallow without risk of aspiration due to lethargy. Recheck blood sugar in 15 minutes if still less than 60 notify medical provider; start date 3/18/2024, - metFORMIN HCl Oral Tablet 1000 MG (Metformin HCl) - Give 1000 mg by mouth two times a day related to Type 2 Diabetes Mellitus Without Complications; start date of 04/12/2024, - Insulin Glargine Solution 100 UNIT/ML Inject 98 unit subcutaneously one time a day for diabetes; start date of 6/17/2024, - Insulin Glargine Solution 100 UNIT/ML Inject 57 unit subcutaneously at bedtime for diabetes; start date of 06/21/2024. Review of the MDS assessment for Resident #14, dated 05/02/2024, showed: -Under Section N Medications: hypoglycemic checked. Review of the MDS assessment for Resident #14, dated 09/17/2023, showed: -Under Section I Active Diagnoses: diabetes mellitus, COPD, and dysphagia as checked. Review of the O2 (oxygen) sats (saturation) Summary for the dates of 05/31/2024 to 06/24/2024 showed Resident #14 received oxygen via a nasal cannula everyday. Review of the active care plan, initiated on 12/29/2023 revealed it was silent of focuses related to oxygen therapy, and the diagnoses and care related to dysphagia and diabetes. The care plan only had diabetes mentioned as part of the focuses for the resident being at risk for pain, skin breakdown and incontinence. During an interview on 06/23/2024 at 12:20 PM Staff J, CNA stated Resident #14 always wears it (nasal cannula). She stated confirmed she was aware Resident #14 had diabetes and if she wasn't feeling good she would get a nurse. She didn't think there was anything on the Kardex related to diabetes for Resident #14. During an interview on 06/23/2024 at 12:34 PM Staff I, LPN confirmed the oxygen order for Resident #12 and the care plan did not include anything related to the oxygen she received. She stated Resident #14 received snacks when requested and the care plan did not include diabetes care. During an interview on 06/23/2024 at 1:21 PM Staff B, RN/MDS Coordinator confirmed Resident #12 did not have a care plan for oxygen, diabetes or dysphagia. She said, Yes, it should be. She stated if Resident #14 had a care plan it would trigger on the Kardex. Review of a policy titled, Comprehensive Care Plans, undated, revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team .

Based on observations, interviews, and record reviews, the facility failed to provide oxygen therapy in accordance with professional standards for four (#14, #274, #47 and #29) of four residents sampled for oxygen therapy. Findings included: 1. A review of Resident #47's medical record revealed Resident #47 was admitted to the facility on [DATE]. An observation was conducted on 06/22/2024 at 9:49 AM of Resident #47 in the unit hallway. Resident #47 was observed wearing an oxygen nasal cannula with oxygen flowing from a portable tank hanging from the back of the wheelchair. A review of Resident #47's physician orders revealed an order, dated 5/23/2024, for oxygen at 2 liters per minute via nasal cannula as needed (PRN). An observation was conducted on 6/23/2024 at 1:58 PM of Resident #47 in the resident's room. Resident #47 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator. No signage was observed outside of Resident #47's room indicating the oxygen was in use. A review of Resident #47's medication administration record for June 2024 did not reveal oxygen at 2 liters per minute via nasal cannula was being administered. 2. A review of Resident #274 medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and dependence on supplemental oxygen. An interview was conducted on 6/22/2024 at 1:45 PM with Resident #274 in the residents room. Resident #274 stated wears oxygen continuously and used oxygen at home prior to her admission to the facility. Resident #274 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator at 3 liters per minute. No signage was observed outside of Resident #274's room indicating the oxygen was in use. A review of Resident #274's physician orders did not reveal an order for oxygen. A review of Resident #274's admission assessment dated [DATE] revealed the resident used oxygen at 3 liters per minute via nasal cannula and reported shortness of breath. An observation was conducted on 6/23/2024 at 2:55 PM of Resident #274 in the resident's room. Resident #274 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator. No signage was observed outside of Resident #274's room indicating the oxygen was in use. An interview was conducted on 6/24/2024 at 11:52 AM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated when a resident is admitted to the facility, they review with resident's transfer documentation to check if the resident is using supplemental oxygen. Staff C, LPN also stated if a resident uses oxygen, a physician order should be in the resident's chart for the oxygen use. Staff C, LPN reviewed Resident #274's physician orders and addressed the resident did not have an order for oxygen. Staff C, LPN stated she was not sure if the facility utilized signage related to oxygen usage in the resident's rooms. Staff C, LPN was not able to state if a PRN oxygen order should be documented on the administration record when it's in use. An interview was conducted on 6/24/2024 at 12:41 PM with the facility's Director of Nursing (DON). The DON stated if a resident used oxygen, a physician order should be in place. The DON reviewed Resident #274's physician orders and addressed the resident did not have an order for oxygen. The DON also stated if a resident used oxygen on a PRN basis, it should be documented in the resident's medication administration record. The DON stated resident's using oxygen should have signage displayed on the outside of the room indicating oxygen is in use. A review of the facility policy Oxygen Administration, with no effective date, revealed under the section titled Policy oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. A review of the facility policy Provider Orders, with no effective date, revealed under the section titled Policy Explanation and Compliance Guidelines each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the medication administration record. 38007 3. Resident #14 was observed on 06/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. No signage was observed outside of Resident #14's room indicating the oxygen was in use. Resident #14 was observed on 06/22/2024 at 11:52 AM in bed receiving oxygen at 4 LPM (liters per minute) via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. No signage was observed outside of Resident #14's room indicating the oxygen was in use. Review of the Admission Record for Resident #14 revealed a readmitted [DATE] and 04/09/2024 and an original admitted [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD). Review of the June 2024 Physician Orders revealed: - Oxygen @ 2L (liters) via nasal cannula as needed for SOB (shortness of breath); start date of 04/05/2024, - Check Oxygen Saturation Q (every) Shift and Document every shift for Covid Monitor; start date of 12/28/2023, - Increase o2 to keep 02sat>92%, order date of 5/9/24. Review of the O2 (oxygen) sats (saturation) Summary for the dates of 05/31/2024 to 06/24/2024 showed Resident #14 received oxygen via a nasal cannula everyday. A review of Resident #14's medication administration record for June 2024 did not reveal oxygen at 2 liters per minute via nasal cannula was being administered. Review of the active care plan, initiated on 12/29/2023 revealed it was silent of focuses related to oxygen therapy. Resident #14 was observed on 06/23/2024 at 09:34 AM in bed receiving oxygen at 4 LPM (liters per minute) via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. No signage was observed outside of Resident #14's room indicating the oxygen was in use. During an interview on 06/23/2024 at 12:20 PM Staff J, Certified Nursing Assistant (CNA) stated Resident #14 always wears it (nasal cannula). During an interview on 06/23/2024 at 12:34 PM Staff I, LPN confirmed the oxygen order was for 2L for Resident #12 and then on 5/5/24 it was increased based on sats (saturation). She stated when she checks the oxygen level she would not turn it to 2L if at 4L the resident was stable. 36273 4. Review of the Admission Record for Resident #29 revealed an admission to the facility on [DATE] with a diagnoses not limited to: chronic obstructive pulmonary disease (COPD), unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral. Review of Resident #29's active physician orders, dated 6/24/2024, revealed: -Oxygen @ 2LPM (liters per minute) via nasal cannula PRN as needed for SOB (shortness of breath) start: 02/21/2024. -HOB (head of bed) is elevated to prevent SOB while laying flat for chronic lung disease (COPD) every shift for COPD start: 10/27/2023. -change oxygen tubing weekly. Review of the June 2024 MAR for Resident #29 revealed: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for shortness of breath or wheezing. -Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT 2 puff inhale orally one time a day for COPD. Review of the care plan for Resident #29, dated 10/20/2023, revealed: Focus: Resident is at risk for shortness of breath and/or respiratory distress. Goal: No problems or negative complications r/t shortness of breath and /or respiratory distress through next review. Interventions included: -change oxygen tubing weekly, -Elevate HOB as needed for ease of breathing, -Observe respiratory status and report difficulty breathing immediately, -oxygen per MD (medical doctor) order, -oxygen sats per MD order and as needed. On 06/22/2024 at 10:41 a.m. Resident #29 was observed sleeping in bed wearing a nasal cannula with oxygen flowing from an oxygen concentrator and set at 1L (liter). On 06/23/2024 at 11:18 a.m. Resident #29 was observed resting in bed wearing a nasal cannula with oxygen flowing from an oxygen concentrator and set at 1L. On 06/24/2024 at 12:47 p.m. Resident #29 was observed resting in bed wearing a nasal cannula with oxygen flowing from an oxygen concentrator and set at 1L. During an interview with Resident #29 on 6/24/2024 at 12:47 p.m., she stated she did not know how many liters of oxygen she should be getting, and she was not sure if she felt like she was getting enough oxygen. During an interview with Staff I, Licensed Practical Nurse (LPN) on 06/24/2024 at 2:04 p.m., she stated Resident #29 was supposed to be on 2L of oxygen. She stated the nurse is responsible for it, but they usually keep it at the level it is set at or the level it is supposed to be set at. They keep it on her and the tubing is changed every Sunday night. During an interview with Staff H, Certified Nursing Assistant (CNA) on 06/24/2024 at 2:06 p.m., she stated Resident #29 was on 1 or 2 liters of oxygen and the nurse is responsible for checking it.

Based on interview, observation and record review, the facility failed to ensure physician ordered psychotropic medications used on an as needed basis were limited to 14 days use for one (#273) of five residents sampled for unnecessary medication use, and failed to ensure behavior and side effect monitoring of psychotropic medication use was completed in accordance with physician orders for four (#11, #14, #24, and #64) of eight residents sampled for medication monitoring. Findings included: 1. A review of Resident #273's Admission Record revealed Resident #273 was admitted to the facility on [DATE] with diagnoses of mood disorder and dementia. A review of Resident #273's physician orders revealed an order, dated 6/13/2024, for Lorazepam 0.5 milligrams (mg). Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation/anxiety. The order did not have an end date. An interview was conducted on 6/24/2024 at 11:52 AM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated when a resident is admitted to the facility, the admitting nurse will review with resident's admission packet and review the discharge medication list. The nurse will enter the order into the electronic health record how they are written and the order will be reviewed with the resident's physician. Staff C, LPN also stated if a resident is ordered a psychotropic medication, a batch order is included for monitoring of side effects and behaviors related to the use of the medication. An interview was conducted on 6/24/2024 at 12:46 PM with the Director of Nursing (DON). The DON stated psychotropic medications used on an as-needed basis should be limited to 14 days. The DON reviewed Resident #273's physician orders and addressed the order for Lorazepam should be limited to 14 days. The DON stated if a resident still needs the psychotropic medication after the 14 day duration, it will be reviewed by the resident's physician. A review of the facility policy titled, Use of Psychotropic Drugs, implemented 10/21/2022, revealed under the section titled Policy residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy also revealed under the section titled Policy Explanation and Compliance Guidelines, PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) or as physician prescribes. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 38007 2. On 6/22/2024 at 11:49 AM during an observation of the lunch service for fourteen residents in the main dining room, Resident #11 was in her wheelchair sitting at a table by herself, and having sporadic outbursts of laughing. Review of the medical record for Resident #11 revealed an admission to the facility on [DATE], and a readmission on 11/29/2023 with diagnoses to include Alzheimer's disease, mood disorder due to known physiological condition with depressive features, schizoaffective disorder, bipolar type, anxiety disorder, unspecified, other recurrent depressive disorders, and unspecified psychosis not due to a substance or known physiological condition. Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date of 6/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date of 11/23/2023 and discontinued on 6/12/2024. - carBAMazepine Oral Suspension 100 MG/5ML (milliliters) - Give 5 ml by mouth three times a day related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date of 12/05/2023. - Sedative/Hypnotic Medication - Monitor or burning or tingling in hands/feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness. Document: 'Y' if monitored and above observed. 'N' if monitored and none of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every day and night shift; start date of 11/30/2023. For the month of June 2024 (06/01/2024 to 06/22/2024) each day and night shift was marked with a check mark not a Y or N. - Behaviors - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift; start date of 12/22/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. Review of the care plan, initiated 9/30/2020, for Resident #11 revealed: - Focus: She has dx (diagnoses) of dementia, schizoaffective disorder, and mood disorder. She is at risk for her psychosocial well-being needs not being met. She takes psychotropic medication, she is at risk for adverse reactions and complications. Goal: She will not experience any adverse reactions secondary to antidepressant medication through review. Interventions included: meds (medications) per orders, observe for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion, observe for non-verbal signs of distress/discomfort/anxiety such as insomnia, fidgeting, restlessness, psych consult prn (as needed). -Focus: Behaviors: [Resident #11] has a behavior problem r/t (related to) refuses medications at times. Goal: Encourage resident to take medications however, staff will honor resident's right to refuse; The resident will have fewer episodes of unwanted behavior through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. -Focus: Cognition: [Resident #11] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. Goal: Staff will anticipate resident's needs, if she is unable to make them known. The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of a Psychotropic Medication Interdisciplinary Review, dated 6/05/2024, revealed, Patient presents with involuntary, sudden and frequent episodes of laughing and/or crying. The episodes are consistent with PBA [pseudobulbar affect], and typically occur out of proportion or incongruent to the underlying emotional state. ,[sic] trialing Nuedexta at this time. Documented in the DX (diagnoses) section was the following: 5: Pseudobulbar affect - start Nuedexta 20 mg (milligrams) qd (once a day) for 7 days then q (once) 12 hours when the medication comes for [vendor name] pharmacy. During an interview on 06/23/2024 at 12:12 PM Staff J, Certified Nursing Assistant (CNA) stated normally she crawls out of bed, but for the noise thing; she does it a lot. It is between a laugh and cry. She confirmed she has been doing this for a few months. Staff J stated she will ask Resident #11 if she is crying, but Resident #11 will say no I'm laughing. She will make the same noise all the time and you just ask her what is wrong. During an interview on 6/23/2024 starting at 1:00 PM Staff I, Licensed Practical Nurse (LPN) reviewed the June 2024 MAR for Resident #11. In reviewing the behavior monitoring she acknowledged the checkmarks entered, and stated, It doesn't drop open. She confirmed there were no orders for Nuedexta in Resident #11's record. She reviewed the progress notes for Resident #11 and confirmed there were no notes related to the outbursts of laughing or administration of Nuedexta. Staff I stated if you ask her if she is laughing, crying, hurting or in pain; she will answer appropriately and she will acknowledge if she is in pain. Staff I stated they do not know what triggers the laughing. She stated it was sporadic. During an interview on 6/23/2024 at 1:47 PM the DON explained the Nuedexta was coming from another pharmacy the facility doesn't use. She stated that it was her understanding they would start the medication once they received it. She confirmed there was no documentation of communication between the pharmacy and the facility to follow up on the status of the medication. In review of the MAR, she stated if there aren't any behaviors then there will just be a checkmark, and if there are behaviors it will have a number. The check mark means they are monitoring behaviors. If there are behaviors we would notate it. It is how they put in the order. She acknowledged the physician order instructed the documentation should be a Y or N, or a Yes or No. On 6/23/2024 at 4:30 PM Resident #11 was observed in her wheelchair in the hall and having sporadic outbursts of laughing. Two staff members were with her and one was trying to straighten Resident #11's jacket. Resident #11 shouted, Don't touch me. The staff member stopped and walked away. Another staff member yelled from the other end of the hall asking what was wrong, and the staff member standing next to Resident #11 stated, She is just being [Resident #11]. Resident #11 continued with sporadic laughing outbursts. 3. Resident #14 was observed on 6/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. Resident #14 was observed on 6/22/2024 at 11:52 AM in bed receiving oxygen via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. Review of the Admission Record for Resident #14 revealed a readmitted [DATE] and 4/09/2024 and an original admitted [DATE] with diagnoses to include depression. Review of the June 2024 MAR revealed: - Sertraline HCI Oral Tablet 50 MG - give 1 tablet by mouth one time a day for depression, start date of 4/13/2024. - Antidepressant: Monitor for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion. Type yes when adverse effects are present. Type No when adverse effects absent every shift for depression. Type yes if having adverse side effects, type no if no adverse side effects; start date of 4/10/2024. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. -BEHAVIORS - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present. Document number of times per shift every shift document yes for active behaviors this shift, no if not actively having behaviors this shift. Document type of behavior document number of times noted this shift.; start date of 12/29/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. Review of Resident #14's care plan, initiated 12/29/2023, revealed: Focus: [Resident #14] is at risk for potential adverse reactions to psychotropic medications r/t DX (Depression). Interventions included to observe for behaviors and report immediately, observe for s/s (signs/symptoms) of increased, (depression, anxiousness, sleeplessness) and report immediately to nurse and MD (medical doctor) if needed, psych services to eval and treat per md order. 4. Review of the Administration Record for Resident #64 revealed an admitted [DATE] with diagnoses to include other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions, bipolar disorder unspecified and bipolar disorder current episode depressed. Review of the June 2024 MAR for Resident #64 revealed: - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth one time a day for depression; start date of 6/21/2024. - DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG - Give 3 capsule by mouth one time a day for depression; start date 11/08/2023 and discontinued on 6/20/2024. - Depakote Oral Tablet Delayed Release 250 MG - Give 3 tablet by mouth at bedtime for mood disorder; start date of 6/06/2024. - Divalproex Sodium Oral Tablet Delayed Release 500 MG - Give 2 tablet by mouth at bedtime for mood disorder; start date 11/07/2023 and discontinued on 6/06/2024. - Sedative/Hypnotic Medication - Monitor or burning or tingling in hands/feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness. Document: 'Y' if monitored and above observed. 'N' if monitored and none of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every day and night shift; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, and night shift was marked with a check mark and not a Y or N. - Behaviors - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. - Antidepressant: Monitor for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion. Type yes when adverse effects are present. Type No when adverse effects absent every shift for depression. Type yes if having adverse side effects, type no if no adverse side effects; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. 5. Review of the medical record for Resident #24 revealed a readmitted [DATE]. Resident #24's diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance, Alzheimer's disease with late onset, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, vascular dementia moderate with other behavioral disturbance, major depressive disorder severe with psychotic symptoms, schizoaffective disorder, mood disorder due to known physiological condition with depressive features and paranoid schizophrenia. Review of the June 2024 MAR revealed the following: - Citalopram Hydrobromide Tablet 10 MG Give 1 tablet by mouth one time a day for depression; start date of 5/09/2024. - Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day related to Mood Disorder Due To Known Physiological Condition With Depressive Features; start date of 4/29/2024. - busPIRone HCl Oral Tablet 7.5 MG (Buspirone HCl) Give 7.5 mg by mouth two times a day for anxiety; start date of 1/10/2024. - Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for dementia; start date of 12/07/2023. - ABH Gel 2mg-25mg-2mg per 1 ml Apply one ml to wrist BID two times a day for Anxiety; start date of 7/19/2023. - Namenda Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth two times a day for Dementia; start date of 4/19/2023. - BEHAVIORS - Monitor for: itching, picking at skin, restless (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift, document yes for active behaviors this shift, no if not actively having behaviors this shift. document type of behavior document number of times noted this shift; start date of 4/18/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. - Monitor resident for NEW onset Covid symptoms: (New Onset cough, New Onset Shortness of breath, New Onset Diarrhea) Document Y if new onset symptom is present or N if no new symptoms present every shift for Covid Monitor; Start date of 12/28/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Y or N. - Short of Breath - Did the Resident have shortness of breath? Every shift Answer Yes or No on the appropriate answer. EX = exertion, Ly=lying, Res=resting; start date of 04/18/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Y or N. During an interview with on 6/24/2024 at 11:32 AM Staff C, LPN reviewed the process for behavior monitoring documentation in the MAR. She stated when you acknowledge; it should have supplementary information. During an interview on 6/24/2024 starting at 12:13 PM the DON stated she (Resident #24) has had medication changes due to her recent falls and psych is following her and confirmed interventions are reviewed and implemented. In review of the MAR and behavior monitoring she stated that it is the way the order was put in. It doesn't have the supplemental documentation. It wasn't put in correctly. A review of the facility policy titled, Use of Psychotropic Drugs, implemented 10/21/2022, revealed under the section titled Policy residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy also revealed under the section titled Policy Explanation and Compliance Guidelines, .12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation routine and as needed, .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.

Based on interview, record review and policy review, the facility failed to protect the resident's right to be free from verbal abuse one resident (#2) of three residents. Findings Includes: On 06/19/2023 at 10:30 a.m., Resident # 2 was observed in bed, dressed in her nightgown, with her call light within her reach. Resident # 2 was observed as comfortable with no signs of distress or pain. Review of Resident #2's clinical record revealed initial admission to the facility on [DATE] and readmission on 08/21/2022 according to the face sheet, with diagnosis to include but not limited to Type 2 Diabetes Mellitus with Diabetic Nephropathy, Major Depressive Disorder Recurrent, Mild, Unspecified Mood (Affective) Disorder, Other Psychotic Disorder not due to a substance or known physiological condition, Alzheimer's Disease, and schizoaffective disorder. Review of Resident #2's Annual Minimum Data Set (MDS) dated : 5/25/2023, Section C, Cognitive Patterns, Brief Interview for Mental Status, (BIMS), showed a score of 99, indicating the resident was unable to complete the interview. Further review of the MDS, section G, Functional Status, showed that the resident needs extensive assistance for bed mobility, dress transferring, locomotion on and off the unit. Additional review showed that Resident #2 needed total dependence for toileting and bathing. Review of Resident #2s care plan with initial date of 9/10/2022 and revision on 3/14/2023, showed that the resident has a diagnosis of depression, dementia, anxiety, and schizoaffective disorder, she takes psychotropic medication. Review of the care plan intervention with initial date 3/14/2023, showed to provide a calm environment as needed. On 6/19/2023 at 10:40 a.m., an interview was conducted with Staff H, Dietary Aide. Staff H reported having two incidents with Resident #2. The first event took place in the dining room a few months ago. She said Resident #2 was shouting in the dining room and she asked Resident #2 to stop yelling. Eventually, the resident quieted down, and Staff H said she headed back toward the kitchen area. The Dietary Aide said Resident #2 began to act out more and the resident bit her on her left arm as she walked up to remove the resident from the dining area. Staff H said she and Resident #2 were arguing in the dining room when the Nursing Home Administrator (NHA) heard them and removed Resident #2 from the area. Staff H said she and Resident #2 had another argument in the dining room area about a week later. Staff H said Resident #2 was behaving out of control in the dining room and was [NAME] her wheelchair towards her. At that point, Staff H said she told Resident #2 that she owed her an ass whooping. 0n 6/19/2023 at 11:30 a.m. an interview was conducted with Staff I, Speech Therapist. Staff I while she was at the vending machine, she heard Staff H yelling at Resident #2, and telling her she owed her an ass whooping and she would slap the piss out of her. Staff I said she went to the director of nursing's (DON) office to report Staff H. On 6/19/2023 at 12:38 p.m., an interview was conducted with Staff J, Certified Nursing Assistant (CNA). Staff J said she witnessed both incidences with Staff H and Resident #2. She said the first incidence happened when Staff H was bringing out the trash in the afternoon and Resident #2 was attempting to maneuver her wheelchair out of Staff H's way. Staff J said Staff F was yelling at the resident to leave the dining area. Staff F said the NHA overheard the commotion and had to separate the resident and Staff H. Staff J said the second incident was not long after and she overheard Staff H telling Resident #2 that she will slap the dog piss out of her and that she owed her an ass whooping. Staff J said the resident wheeled herself out of the dining room she watched to make sure that the resident returned to her room. Staff J said she the reported the incident to the DON. On 6/19/2023 at 1:00 p.m., an interview was conducted with Resident #2's, Nurse Practitioner (NP). The NP said Resident #2 was demented and had episodes of sundowning (confusion in the evenings). She said she was not aware of the incident between Staff H and Resident # 2 and that no Staff member should speak to any resident in that way. On 6/19/2023 at 1:55 p.m., an interview was conducted with the DON. The DON said she was aware of the way Staff F had spoken to Resident #2. She said she gathered testimony from the staff members who overheard the incident and Staff H had been suspended pending an investigation. The DON said Staff F received training in communication, and then was allowed to resume work. The DON said that DCF (Department of Children and Families) and law enforcement was informed. A review of the facility policy's titled, Freedom from Abuse, Neglect and Exploitation, dated 11/28/2017, showed to comply with Federal regulation 483.12, The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Definitions per 483. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff to Resident Abuse of Any Type The facility has diverse populations including, among others, residents with dementia, mental disorders, intellectual disabilities, ethnic/cultural differences, speech/language challenges, and generational differences. Once a resident is accepted for admission, the facility assume the responsibility of ensuring the safety and well-being of the resident. It is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behaviors. All staff are expected to be in control of their own behaviors, are to behave professionally, and should appropriately understand how to work with the nursing home population. III. Prevention of Abuse , Neglect and Exploitation The facility has implemented this policy and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: b) Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient number to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; h) Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. XVIII. Protection of Resident The facility will make effects to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples include but not limited to: C. Increase supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident (s) from the alleged perpetrator F. Providing emotional support and counseling to the resident during and after the investigation, as needed.

Based on record review, interviews, and review of facility policies and medical records, the facility failed to ensure supervision was provided to prevent a fall which resulted in injuries for one resident (#1) of two residents sampled. Findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include displaced unspecified condyle fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified lack of coordination, other abnormalities of gait and mobility, unspecified fracture of right wrist and hand, subsequent encounter for fracture with routine healing, unspecified fall, subsequent encounter, unspecified osteoarthritis, unspecified site. On 06/19/23 at 10:20 a.m., an interview was conducted with Resident #1. She was observed in her room, lying on the bed. The resident recalled the fall and stated she had mobility limitations prior to the fall. The resident stated on the day she fell , the certified nursing aide (CNA) [Staff A] was standing on the right side of the bed assisting her with toileting. Resident #1 said, I don't know what happened, I remember rolling over and fell on the window side to my left. The CNA could not catch me. I am almost 300 pounds. The problem was gravity. I could not catch myself. The resident stated the CNA was providing care by herself and confirmed she usually gets care from one CNA. Resident #1 stated she does not get out of bed because of her weight and her limited mobility. On 06/19/23 at 11:53 a.m., an interview was conducted with Staff A, CNA assigned to Resident #1 the day she fell . Staff A said, the resident was a one person assist, I went into the room to toilet her. She likes to lay on her side. After toileting I asked her to turn toward me so I could clean her up, but she turned the opposite way. The CNA confirmed the resident was a one personal assist, stating that was what her Kardex [an informational filing system that is used for quick reference for nursing staff] said. Continuing, the CNA said Since the fall, she has been a two-person assist. I had assisted her multiple times before. I was always able to care for her by myself. I got the nurse right away and stayed in the room with the resident. Staff A stated she had not experienced any problems prior to this, and the Resident #1 could assist in turning herself. A review of a progress note dated 05/27/23 showed a late entry, Resident is sent out to ER for further evaluations for post fall. The resident was discharged to ER (emergency room ) via stretcher with 4 paramedics and the Responsible Party .Pain level is 10. A review of a progress note dated 06/8/23 showed, Resident sitting up in bed with eyes closed. This nurse spoke with the resident regarding past medical history. Resident was readmitted to facility on 06/5/23 under [name of doctor] services. Resident has a fracture of left distal femur and tibia/fibula. Resident has orders to follow up with orthopedic. Resident informed this nurse that she has history of fractures, right foot, right wrist and hand, osteoarthritis to bilateral knees and hips, left knee meniscus tear. Resident informed nurse that she was to follow up for bilateral knee braces. Resident is NWB (Non-Weight Bearing) to left lower extremity and WBAT (Weight Bearing As Tolerated) to right lower extremity. Resident has pain in her right foot and states that she was informed in hospital that she had fractured toes on left foot. Medical Doctor (MD) in today for visit, new orders in place to x-ray both feet . A review of a Minimum Data Set (MDS) dated [DATE], section C showed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15. Section G showed: Bed mobility, dressing, toilet use, bathing, Total dependence, one-person physical assist. An undated Care plan showed a focus on ADLs (Activities of Daily Living)/Mobility which indicated Resident #1 required assistance with ADLS related to weakness, decreased mobility, and wrist fracture. The Resident will have ADL needs met daily with appropriate assist through next review. Interventions included activities as tolerated, anticipate, and meet residents needs as necessary, observe for signs/symptoms of fatigue during tasks and allow resident rest breaks as needed, Oral care BID (twice daily) and PRN (as needed) and Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to screen and if indicated eval and treat per MD orders. A focus in the undated care plan showed Resident #1 is at risk for falls related to weakness and decreased mobility. The goal indicated the resident would have no problems or negative implications. Interventions included to anticipate and meet the residents need if unable to voice needs, fall risk assessment completed and reviewed quarterly and PRN, keep room clutter free and PT/OT to screen PRN and if indicated to treat per MD orders. On 06/19/23 at 12:25 p.m., a telephone interview was conducted with Staff E, LPN (Licensed Practical Nurse) weekend supervisor. She confirmed she worked the day Resident #1 fell . Staff E said, I am familiar with the resident. The resident fell on [DATE]. When I came on the shift her call light was on. It was around 10:30 a.m. I answered her call light. The resident told me she needed to use the bathroom. I asked her to wait so I could get the CNA which I did. [Resident #1] was heavy, and she does not walk. At the time she was in a bariatric bed. It was about 20-30 minutes later when the CNA came and got me and said the resident had fallen. I went to the room and saw her on the floor. She was lying on the floor facing the window, on the left side of the bed. She was talking to the CNA, [Staff A]. She was conscious. Her nurse was already in the room cleaning her up and assessing her. EMS (Emergency Medical Service) was called. A family member happened to arrive for his usual visit and was present during the transfer. It took the EMS a long time to get her off the floor, they had to use a Hoyer lift. She was gone for a week. Staff E said the incident was unusual because the CNA was familiar with the resident and her bed mobility status. She had taken care of her before, and she was comfortable. On 06/19/23 at 11:20 a.m. an interview was conducted with the Advanced Registered Nurse Practitioner (ARNP). She stated she was not on call but became aware that Resident #1 fell and was sent out to the ER. She stated the resident has been back and has resumed regular care and therapy. She stated their goal was to manage her pain so the resident can resume full therapy. She stated she was not aware if this resident was receiving psych services. She stated Resident #1 might be depressed because she was not moving up to her goal of weight loss. The ARNP stated, it does not help that she does not get out of bed. On 06/19/23 at 11:35 a.m., an interview was conducted with Staff C, CNA. She stated she did not remember specifically how Resident #1 fell . She said, I don't know how she may have fallen. When I assist the resident, I always pull curtain, get what I need, and then tell her which way to turn. I show them with my hand in case they are not sure. I make sure the resident is not too far in the bed. On 06/19/23 at 11:40 a.m. an interview was conducted with Staff D, Staffing coordinator. She confirmed the facility did not have any staffing shortages around the time Resident #1 fell . On 06/19/23 at 2:12 p.m., an interview was conducted with the Director of Rehab, (DOR). She stated Resident #1 had been assessed by physical therapy (PT) for mobility. She said, the resident was able to roll to her left side facing the window, most of the time. She was not noted to roll to her right. She has a limited range of motion due to a pre-existing injury. On 06/19/23 at 2:29 p.m., an interview was conducted with the Director of Nursing (DON). She stated it was reported to her Resident #1 had a fallen when a CNA [Staff A] was giving care on 5/27/23. She stated one CNA was providing care by herself because the resident was a one person assist. The DON said, The CNA had reported the resident was lying on her side facing the window. The CNA said she told the resident to roll to her right, but the resident rolled to her left and fell . The DON stated after the fall, the resident was complaining of pain in her left knee and was sent out to the emergency room (ER). The DON said, the following Monday we received hospital paperwork showing she had suffered a Tibia fracture. She was hospitalized from 5/27/23 to 6/5/23. I conducted a full investigation, received statements from staff, and I asked the CNA to explain what happened and she did. She demonstrated what happened. We did not anticipate that she would fall and break her leg. The CNA reported gravity took hold of her and she rolled off bed. I did not consider the incident as abuse or neglect because the CNA was working with a patient who was alert and oriented and was previously able to follow commands. I reported the incident because the resident suffered injuries. The DON stated since the fall her transfer status was adjusted to a two person assist. The DON stated they had discussed the fall in their QAPI and had initiated an improvement plan. A review of an undated facility policy titled, Activities of Daily Living (ADLs), showing, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to transfer and ambulate. Under policy explanation and compliance guidelines, the facility will maintain individual objectives of the care plan and periodic review and evaluation. A review of an undated facility policy titled, Fall Prevention Program, showed each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level but not as a result of an overwhelming external force e.g., (resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Under policy explanation and compliance guidelines, (1) the facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. (2) Upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. (3) The nurse will indicate the resident's fall risk in the medical record and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. (4.) Facilities standards to prevent falls includes implementing universal interventions that decrease the risk of resident falling, implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed. When any resident experiences a fall, the facility will assess the resident, complete a fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.

Based on observation, interview, and record review the facility did not ensure pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (#35) out of three residents sampled for pain. Findings included: An interview was conducted with Resident #35 on 8/8/22 at 1:09 p.m. He stated he was in so much pain last night (8/7/22) at 11:00 p.m. He described his pain as 10/10 on the pain scale. Resident #35 stated he was not able to get his pain medication, because there wasn't any available. He stated this has happened to him four or five times. The resident began to get upset and cry explaining this and stated when this happens it hurts so bad, he feels like he could die. The resident stated he was given Tylenol and it doesn't do anything for his pain. He stated he was not able to get pain medication until lunchtime today (8/8/22). He stated at lunch the nurse was able to give him two tablets to combined to get his normal dose. The resident couldn't recall the name of the pain medication he normally receives. A review of admission records indicated Resident #35 was readmitted on [DATE] with an initial admission of 4/22/21. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of orders revealed the following: [MEDICATION(S)] patch 75 micrograms (mcg)/hour (hr) 72 hour. Apply 1 patch transdermal every 72 hours for pain. Document site and remove per schedule. Order date was 8/9/22. [MEDICATION(S)] 10 milligrams (mg). Give 1 tablet by mouth every 3 hours as needed (PRN) for non-acute pain. Order date was 8/8/22. Acetaminophen tablet 650 mg. Give 1 tablet by mouth every 4 hours as needed for general discomfort. Order date was 8/4/22. [MEDICATION(S)] capsule 100 mg. Give 1 capsule by mouth every 8 hours for never pain. Order date 8/4/22 (This was previously given via a feeding tube.) An order, dated 2/23/22, was in place to access and document pain level every shift using pain scale. A pain management evaluation was ordered for 8/8/22 A previous pain management evaluation was completed for Resident #35 on 1/8/22. The evaluation showed the resident has a terminal disease process and was able to verbalize his pain. The evaluation indicated the pain was chronic, occurring all the time at a severe level (7,8,9,10 on pain scale.) A care plan is in place for: risk for pain related to actual pain, [CONDITION(S)], pressure areas, poor mobility and contractures. The care plan goal is for resident to be kept comfortable daily through next review. Interventions included: contact Medical Doctor (MD) for pain not relieved by current order, medications per MD order, pain assessment completed and reviewed quarterly and PRN, assist resident with re-positioning or other non-pharmacological aspect of pain relief. Resident #35's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C, Cognitive Patterns, indicated the resident has a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Resident #35's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The eMAR indicated Resident #35 was administered Acetaminophen 8/7/22 at 11:17 p.m., noting it was ineffective. The resident was again given Acetaminophen on 8/8/22 at 3:19 a.m., again noting it was ineffective. On 8/8/22 at 11:00 a.m. a one-time order was entered for two 5 mg tablets of [MEDICATION(S)] for pain, this was administered on 8/8/22 at 11:53 a.m. The resident resumed his normal ordered dosage of one 10 mg tablet on 8/8/22 at 2:20 p.m. A review of the July 2022 and August 2022 eMAR indicated Resident #35 takes his PRN (as needed) [MEDICATION(S)] around the clock daily with Acetaminophen not being utilized. A review of Resident #35's progress notes did not indicate any additional nursing notes regarding ineffective pain control, notification of the doctor, or notification of the pharmacy. Resident #35's Controlled Drug Receipt/Record/Disposition Forms were reviewed. The forms revealed the delivery of [MEDICATION(S)] to the facility on [DATE], with the medication card running out on 8/7/22 at 1:15 p.m. An interview was conducted with Staff B, Licensed Practical Nurse (LPN,) on 8/9/22 at 4:00 p.m. Staff B stated Resident #35 receives his pain medication routinely every 3 hours. Staff B stated he has never run out of the resident's [MEDICATION(S)] on his shift. He stated some shifts may have issues due to waiting on the pharmacy to deliver, but if the card is empty, they should be able to get the medication from the medication dispensing machine on the north unit. He stated when the medication card is down to only have 5-6 pills left, the nurse is supposed to notify the pharmacy. He said he didn't have any way to confirm a nurse before him notified the pharmacy or not. An interview was conducted with Staff O, LPN on 8/9/22 at 4:06 p.m. She sated there is a medication dispensing machine in the medication room on the north unit. She said to access the [MEDICATION(S)] the nurse would need an Emergency Drug Kit (EDK) code from the pharmacy. She stated the pharmacy can be reached in the middle of the night if needed. She also stated the pharmacy can tell the nurse if there is [MEDICATION(S)] in the machine. She said she has never seen it out of [MEDICATION(S)]. On 8/10/22 at 11:41 a.m. the west hall medication card was inspected with Staff C, LPN. Staff C confirmed Resident #35 currently had two cards of [MEDICATION(S)] that were both delivered on 8/8/22. She stated one card now has 19 pills remaining and one card is full. Narcotics counts were verified in the narcotics book. Staff C stated the medication card shows the resident currently has 180 pills left on this prescription. Staff C stated as long as the resident has pills left on their prescription, the nurse can get an access code from the pharmacist at any time to get [MEDICATION(S)] out of the medication dispensing machine. She stated the only reason a resident can run out of medication is because no one ordered it, or the nurse didn't follow up. Staff C explained when the medication card gets to the last row, indicated in red, the nurse knows to reorder the medication. She stated she would know if it was reordered because a small sicker on the top is pulled off and faxed to the pharmacy, if the sticker is gone the medication was ordered. She confirmed the pharmacy will deliver narcotics every day of the week. An interview was conducted with the Director of Nursing (DON) on 8/1/22 at 2:03 p.m. She confirmed Resident #35 receives his PRN [MEDICATION(S)] every 3 hours. She stated if the medication cards are out, staff should check the medication dispensing machine to see if it is in and get a code from the pharmacy. She stated, if the machine was out of the medication, the doctor would be notified. She stated he should never go without his pain medication. She confirmed the process is to reorder medication when the card has 7 pills remaining. After hearing the situation from the night of 8/7/22 and the morning of 8/8/22, she stated on Sunday night, 8/7/22, the doctor should have been notified or the pharmacy should have been called. The DON also stated, if [Acetaminophen} gave multiple times and it's ineffective should have notified the doctor. She stated the nurse taking care of Resident #35 on Sunday night was an agency nurse, but she should have still had access to the medication dispensing machine. She said all agency nurses are orientated to the building and where things are. She confirmed the nurse should have been able to get the [MEDICATION(S)]. An interview was conducted with facility's Consultant Pharmacist on 8/11/22 at 2:58 p.m. She stated there is no reason Resident #35 shouldn't have been able to receive pain medication on the weekend. She stated the pharmacy does stat runs if there is something needed that can not wait until the next delivery. An interview was conducted with Staff T, Pharmacist currently working in the pharmacy. Staff T reviewed Resident #35's medication orders and deliveries. She stated there was a refill requested on 7/26/22 and 60 pills were delivered the same day. She also stated she can see where a new [MEDICATION(S)] prescription for Resident #35 was sent in from a doctor on 8/8/22 at 10:45 a.m. She stated the resident was due for a new prescription. Staff T stated the card on 7/26/22 indicated to the facility there were no refills remaining and a new prescription was needed. She stated the facility should have requested a new prescription at that time. She stated this request was not put in until Sunday, 8/7/22. Staff T said the pharmacy received the request on Sunday and it was delivered Monday. She confirmed it is the facility's responsibility to follow-up and get new prescriptions. Staff T reviewed the stock of the facility's medication dispensing machine. She stated the machine had 5 mg tablets in stock and the resident's prescription was for 10 mg. She stated the doctor could have been called at any time for a prescription for two 5 mg tablets to be given. Staff T stated there would have been no issue with the nurse being able to access the [MEDICATION(S)] in the middle of the night on 8/7/22. Staff T stated she is able to see Monday morning (8/8/22) an order was put in for two 5 mg tablets of [MEDICATION(S)] and access to the medication was provided by the pharmacy. An interview was conducted with the Nursing Home Administrator on 8/11/22 at 3:50 p.m. The NHA stated they are looking for a Pain Management doctor to come to the facility. She agreed Resident #35 should never have to go without pain medication. She confirmed nurses are responsible for tracking medication and requesting refills. A facility policy titled, Pain Management Program, was reviewed. The policy stated, Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. It also stated, If resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on review of resident medical records, the Medical Examiner's report, facility policies/procedures; and interviews with the Nursing Home Administrator (NHA), the Director of Nursing (DON), Regional Director of Clinical Reimbursement, nursing staff members, the facility Medical Director, and Resident #2's family member, the facility failed to provide a systematic process to implement their abuse, neglect and exploitation policies for one (Resident #2) of three residents reviewed for accidents. The facility failed to take actions to report, investigate, and prevent accidents to its residents. The facility neglected to suspend staff alleged to be involved in a resident fall that resulted in death and failed to determine the root cause of the accident to ensure the safety of the resident involved and ensure all facility residents would remain safe from a similar incident. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE], who required extensive assistance from staff to provide all nursing care and services. During incontinence care on [DATE], a Certified Nursing Assistant (CNA) left Resident #2, unattended, on his side, with the bed in an elevated position. The resident fell from the bed to the floor, landing in between bed A and bed B, on his left side. Additionally, the resident hit his head which caused a laceration to the head that bled uncontrollably. The fall resulted in a fracture of the neck region of the spine. As a result of the fall, Resident #2 subsequently had a rapid decline in health status and died on [DATE]. This resulted in the finding of Immediate Jeopardy, occurring on [DATE] and removed on [DATE] at 6:15 p.m. with a scope and severity reduced to a D. Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation with no date specified revealed: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Neglect means failure of the facility , its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that a. Prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegation. c. Training for new and existing staff on activities that constitute abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. d. Establish coordination with the QAPI program. 2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility Abuse Coordinator will be the Administrator. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Prevention: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift to meet the needs of the residents, and assure that the staff assigned have knowledge if the individual residents' care needs and behavioral symptoms. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. Investigation: A. An immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur: B. Written procedures for investigation include: 1 Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation. 3. Investigation different types of alleged violations. 4 Identifying and interviewing all involved persons, including the alleged victim. Alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent , and cause. Providing complete and thorough documentation of the investigation. Reporting/Response: A. The facility will have written procedures that include: 4. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. b. Defining how care provision will be change and/or improve to protect the residents receiving services. c. Training of staff on changes made and demonstration of staff competency after training is implemented. d. Identification of staff responsible for implementation of corrective actions. e. The expected date for implementation f. Identification of staff responsible for monitoring the implementation of the plan. A review of the facility policy titled Accidents and Supervision with no date specified revealed: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives supervision and assistive devices to prevent accidents. Fundamental Information: Definitions Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. 2. Evaluation and Analysis: The process of examining data to identify specific hazards and risks to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. 3. Implementation of Interventions: Using specific interventions to try to reduce a resident's risks from hazards in the environment. 4. Monitoring for effectiveness and modifying interventions when necessary. 5. Supervision. A review of the facility policy titled Risk Management Process dated ,d+[DATE] revealed: 1. Assess the resident for incident related injury and initiate Falling Star: all available staff attend fall to assist with moving the resident, preparing chart if transfer is to occur, review of site of incident. 2. New intervention must be implemented as a preventative measure and placed on the care plan following the investigation to reduce risk of future occurrence ex. [DATE] fall mats to bedside when in bed. i.e., Wing tip mattress to define parameter, pad wheelchair, maintenance to evaluate for sharp edges, fall mats to bedside when in bed, bed in low position when in bed. 3. Complete fall assessment for all falls. 4. Witness statements are taken by the charge nurse and placed directly in incident note. 5. If route [root]cause for occurrence can be determined than the post occurrence evaluation is complete. If a route [root] cause cannot be determined, then complete the post occurrence tool. We should never have an unknown. If you feel unknown is the answer, you must call administrative staff. 6. MD made aware, and family made aware should be documented in [Electronic Medical Record (EMR] action tab of incident. Care plan must be checked to ensure new interventions in action tab of incident. Progress note should be entered in action tab. 10. Interdisciplinary team (IDT) will review fall at next clinical meeting: Care plan, progress note, incident, witness statements, and sign off in [EMR] and enter the IDT note such as IDT met and discussed fall, current fall intervention in place and functioning or IDT met and discussed fall intervention and initiated _____________ intervention for fall on _____________. On [DATE] at 1:17 p.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated Resident #2 could not walk and used a mechanical lift for transfers. The CNA confirmed there was one floor mat on the floor in between bed A and bed B, and the resident's bed was not at the lowest position. The CNA said the resident was known to try and get out of bed. Staff B said when he did this, she would try to stop him from getting up or she would go ahead and put him into his wheelchair; the resident was not a fall risk according to the CNA. She confirmed the aides usually found out in report which residents were fall risks. The CNA said nobody on her set was a fall risk, and if a resident was a fall risk, a sign that says fall risk was placed on the door; she confirmed the resident did not have one of those signs on his room door. The CNA confirmed she had in-services about falls, but she could not remember if they had an in-service related to falls following the incident. Staff B stated she was changing the resident alone and turned away to get a clean brief. She said she heard a noise, looked back, and saw the resident on floor and called for the nurse; the CNA confirmed Staff A, Licensed Practical Nurse (LPN) came into the resident's room. The CNA said the resident's head was bleeding, and she thought he may have hit his head on the floor. Staff B confirmed the resident did not have side rails on his bed. She said she did not need two people to change him; he could have been changed by one person. The CNA confirmed the DON did ask her questions about the fall, but she did not know if there was an investigation. The CNA said she was not suspended and did not receive disciplinary action. Staff B confirmed the incident occurred around 1:00 p.m. or 2:00 p.m. A review of a State Agency Death Certificate Replica certified [DATE] revealed, the cause of death for Resident #2 was Sequelae of cervical vertebra fracture fall from bed. There was a contributory cause of death Dementia, and the manner of death is accident. A review of the hospital Emergency Documentation dated [DATE] revealed the following. CT (Computerized Tomography) Spine Cervical (neck) without Contrast: Impression: 1. Fracture through the anterior and posterior arch of C1 (first cervical vertebra) are noted with the lateral masses being displaced posteriorly Reexamination/Reevaluation: He [Resident #2] will be admitted to the trauma ICU (intensive care unit) for his unstable C1 fracture A review of the facility medical record for Resident #2 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) assessment completed on [DATE] showed: -Section C: Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) score of 07, which indicated severely impaired cognition. -Section G: Functional Status revealed, Resident #2 required extensive assistance of at minimum, one person for Activities of Daily Living (ADLs). A review of the Comprehensive Care Plan for Resident #2 indicated the following: -Focus Area: created on [DATE] revealed, the resident required assistance with ADLs related to weakness and poor activity tolerance. The goal was to have ADL needs met daily with appropriate assistance. Interventions included: anticipate and meet resident needs as necessary, call light kept within reach and answered promptly with resident being checked frequently, resident needs extensive assistance of one person for ADL's (bathing, dressing, personal hygiene, bed mobility, locomotion on and off the unit). Resident #2 required a mechanical lift with the assistance of two people for transfers. -Focus Area: created on [DATE] revealed, the resident was resistive to care related to Dementia. The goal was to have the resident cooperate with care through next review date. Interventions included: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care and give clear explanation of all care activities prior to and as they occur during each contact. -Focus Area: created on [DATE] revealed, the resident had impaired cognitive function/dementia, or the thought processes related to Dementia. The goal was for the resident to be able to communicate basic needs daily. Interventions included: Ask yes/no questions to determine the resident's needs and cue, reorient and supervise as needed. -Focus Area: created on [DATE] revealed, the resident was at risk for falls related to poor safety awareness, weakness, and antidepressant use. The goals were to have no problems or negative complications related to falls with the resident being kept safe daily through next review. Interventions included: Anticipate and meet the needs of the resident if he was unable to voice needs, call light kept within reach and answered promptly with resident being checked frequently, fall risk assessment completed and reviewed quarterly and as needed (PRN). A review of the most recent Fall Risk assessment completed on [DATE] placed Resident #2 in a high risk for falls category. A review of the nursing progress notes revealed a note dated [DATE] at 1:34 p.m. written by the Staff D, Unit Manager, LPN: Resident alert & verbal resting on bed with wife at bedside. Continued review of the nursing progress notes revealed a note dated [DATE] at 4:09 p.m. written by Staff A, LPN: This nurse was alerted by CNA that resident had fallen out of bed. Upon going into room resident was laying on floor in room beside bed. Resident was asked what happened, he stated [he fell out of the bed and hit his head.] Staff assisted resident back into bed and applied pressure to laceration on his head. Physician notified. Resident being sent to local hospital. Family notified. A review of an incident/event report dated [DATE] at 4:01 p.m. written by Staff A, LPN revealed: This nurse was alerted by CNA that resident had fallen out of bed. Upon going into room resident was laying on floor in room beside bed. Resident stated he fell out of bed and hit his head. Resident was assisted back into bed with assistance from staff. Pressure applied to laceration on front of head. Emergency Medical Services (EMS) called to send resident out to the hospital for evaluation and treatment. The incident was described as an unwitnessed fall. On [DATE] at 03:50 p.m., an interview was conducted with Staff E, Minimum Data Set (MDS) Coordinator. She said the process after a resident had a fall included, putting in place additional interventions and updating the care plan. The MDS Coordinator said an immediate report was completed by the resident's nurse and the DON was notified, stating, the following day after the fall occurred, it would have been discussed in the morning meeting. A review of an incident log provided by the facility did not reveal Resident #2's name. On [DATE] at 10:19 a.m. an interview was conducted with the NHA and DON. The DON confirmed the resident was sent out to the hospital and the incident log that was previously provided did not include Resident #2's name. The DON said she was not sure why the resident was not listed on the incident log. She stated the purpose of the log was to list and track the falls. The DON said the resident's fall occurred on [DATE] at approximately 2:00 p.m. in the resident's room, and the incident report identified it as an unwitnessed fall. The DON said, Staff A, LPN was the nurse alerted by Staff B, CNA that the resident fell out of the bed. She confirmed she did not interview the staff following the incident. The DON said they (Staff A and B) said the resident fell on the floor, had a laceration, and was sent out to the hospital. Reading the progress notes, the DON said Staff B alerted Staff A. Staff A walked into the room and saw the resident was bleeding. Staff A called EMS because the resident was bleeding from his head. The DON confirmed she was in the building, but she was not immediately aware of the incident. The DON said she was not sure where she was or what was going on at the time of the incident. The DON confirmed she was told that the nurses could not tell where the bleeding came from, and the doctor said to send him out to the hospital. The DON said she would have expected to be informed when a resident was being sent out to the hospital. The DON said the hospital called the facility the next day and informed the Unit Manager the resident had a neck fracture. The DON confirmed she did not interview the CNA nor obtain a written statement from her, stating, the nurse got a statement from her. Additionally, she confirmed the facility did not file an adverse report. Both the NHA and DON, stated that they did not believe an adverse report should have been filed because the incident was beyond their control due to the resident's medical history. The DON confirmed she talked with Staff B, CNA on [DATE] (during the survey) and confirmed she was not aware of the circumstances related to the mechanism of the fall prior to this date. The DON restated prior to [DATE], her knowledge of the incident was just that the resident fell out of bed and had been sent to the hospital. The DON stated the resident's wife visited him the day of the incident but was not present when it occurred. On [DATE] at 10:52 a.m., an interview was conducted with Staff A, LPN who confirmed that she was working the 7:00 a.m. to 3:00 p.m. shift on the day the resident fell . She stated when she walked into the room the resident was on the floor, near the left side of the bed, facing toward the bed. The resident's forehead was bleeding, and he denied being in pain. Staff A confirmed she assessed the resident at that time, and he was assisted back into bed using the mechanical lift. Staff A said she called the doctor, the resident's wife, and EMS. Staff A confirmed the DON was in the building and said she was notified at the time she called EMS. She did not recall seeing the DON when the incident occurred. Staff A confirmed Resident #2 was sent to the local hospital, and she was notified later that he had a broken neck. Staff A said an incident report was filled out in the computer (EMR). On [DATE] at 11:12 a.m., a telephone interview was conducted with Resident #2's family member. She stated, her family member died because of a broken neck that he received at the facility. She confirmed Resident #2 passed away under the care of Hospice on [DATE]. On [DATE] at 11:18 a.m., a telephone interview was conducted with the facility Medical Director (MD), who was also listed as the resident's physician. He confirmed the resident was his patient and the facility communicated with him following the incident. The MD confirmed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the resident was sent out to the hospital as the nurses could not stop the bleeding. On [DATE] at 1:16 p.m., an interview was conducted with the NHA and DON. The NHA and the DON confirmed The Department of Childern and Families Adult Protective Services came into the facility to investigate the incident; they were both unsure of the date. The DON confirmed the facility did not file an adverse report after The Department of Childern and Families Adult Protective Services visit. The DON and the NHA confirmed an allegation of neglect, and an incident resulting in a transfer to a higher level of care, a fracture, or death was reportable. The DON said the facility did investigate the incident; however, they realized it was not an unwitnessed fall after re-interviewing Staff B on [DATE] (during the survey). On [DATE] at 6:15 p.m., an interview was conducted with the Regional Director of Clinical Reimbursement, Registered Nurse (RN). She confirmed she had provided in-servicing and training to the NHA, and DON related to Conducting investigations related to accidents. On [DATE] from 9:38 a.m. to 10:00 a.m., interviews were conducted with five CNAs and one RN. All verified they had received and understood the education. Facility actions to remove Immediate Jeopardy were submitted by the NHA on [DATE] at 6:15 p.m. 1. On [DATE] The Director of Nursing with Nursing Management have reviewed by [DATE], all falls on the incident log for major injury and found one other issue with correction. 2. On [DATE] The Regional Director of Clinical Reimbursement provided education for the facility Administrator and the facility Director of Nursing on: 1) What is to be reported, 2) Conducting Investigations as related to incidents, accidents, falls, and adverse events. 3. Staff B, CNA was provided the policy for completing peri care and one to one education by the Director of Nursing for process and procedure for completing peri care on [DATE]. 4. Education provided on ,d+[DATE] and [DATE], by the Director of Nursing and nursing management to all clinical caregivers, CNAs, and Licensed Nurses related to: 1. Resident Safety in the Abundance of Caution when patients have been identified/care planned for aggressive behaviors. Residents with behaviors will have two staff members assist when performing ADL care. 2. Abuse, Neglect, Exploitation. 3. Demonstration of proper peri care and return demonstration/video was shown on peri care with return demonstration. 4. Policy on peri care. 5. When providing peri care to residents always maintaining safety, gathering all supplies and equipment needed prior to starting resident's care. Any clinical staff not on site was provided the education by telephone. Return demonstration will be completed upon return to work. Any staff member unable to attend in person or by telephone will receive the complete education when returning to work, prior to taking a resident assignment. Education will continue each shift until 100% of the staff are educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. 5. Beginning [DATE], all incidents will be reviewed in the morning clinical meeting by the IDT for any injury, focusing on major injury. The clinical team consist of the DON, Unit Manager, Minimum Data Set Coordinator, Social Services Director (SSD), Dietary manager, and other clinical staff as needed. As the incident is reviewed, education and reeducation will be provided to clinical staff applicable to the incident. 6. Audits will be completed to observe direct care of all care givers, by the Director of Nursing and her designated clinical staff. Audits will be completed daily for 4 weeks, then 3 times a week for 4 weeks, then weekly for 4 weeks. Results of the audits will be taken to the Quality Assurance and Performance Improvement (QAPI) for review and recommendations and will continue until 100% compliance has been reached. The QAPI Committee is compiled of the Medical Director, The NHA, DON, MDS, SS Director, Unit Managers, Dietary Director, Maintenance Director, Activities Director, and other staff as deemed necessary. The facility removal plan included that by [DATE]: 82% CNAs; 100% RNs, 60% LPNs had completed the education. Immediate Jeopardy was determined to be removed on [DATE] at 6:15 p.m. and reduced to a sope and severity of D.

Based on review of resident medical records, the Medical Examiner's report, and facility policies/procedures; and interviews with the Nursing Home Administrator (NHA), the Director of Nursing (DON), Regional Director of Clinical Reimbursement, nursing staff members, the facility Medical Director, and Resident #2's family member, the facility failed to provide the level of supervision required to prevent a fall with major and fatal injuries for one (Resident #2) of three residents sampled for accidents. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] who required extensive assistance from staff to provide all nursing care and services. During incontinence care on [DATE], a Certified Nursing Assistant (CNA) left Resident #2, unattended, on his side, with the bed in an elevated position. The resident fell from the bed to the floor, landing in between bed A and bed B, on his left side. Additionally, the resident hit his head which caused a laceration to the head that bled uncontrollably. The fall resulted in a fracture of the neck region of the spine. As a result of the fall, Resident #2 subsequently had a rapid decline in health status and died on [DATE]. This resulted in the finding of Immediate Jeopardy, occurring on [DATE] and removed on [DATE] at 6:15 p.m. with a scope and severity reduced to a D. Findings included: On [DATE] at 1:17 p.m. an interview was conducted with Staff B, CNA. She stated Resident #2 could not walk and used a mechanical lift for transfers. There was one floor mat on the floor in between bed A and bed B, and the resident's bed was not at the lowest position. The CNA said the resident was known to try to get out of bed. When he did this, she would try to stop him from getting up or she would go ahead and put him into his wheelchair. The resident was not a fall risk according to the CNA. She confirmed the aides usually found out in report, which residents were fall risks. The CNA said nobody on her set was a fall risk, and if a resident was a fall risk, a sign that says fall risk was placed on the door; she confirmed the resident did not have one of those signs on his room door. The CNA confirmed she had in-services about falls, but she could not remember if they had an in-service related to falls following the incident. Staff B stated she was changing the resident alone and turned away to get a clean brief. She said she heard a noise, looked back, and saw the resident on floor and called for the nurse; the CNA confirmed Staff A, Licensed Practical Nurse (LPN) came into the resident's room. The CNA said the resident's head was bleeding, and she thought he might have hit his head on the floor. Staff B confirmed the resident did not have side rails on his bed. She said she did not need two people to change him; he could have been changed by one person. The CNA confirmed the DON asked her questions about the fall, but she did not know if there was an investigation. The CNA said she was not suspended and had not received disciplinary action. Staff B confirmed the incident occurred around 1:00 p.m. or 2:00 p.m. A review of the medical record for Resident #2 revealed an admitted [DATE] and diagnoses included dementia, adult failure to thrive, type 2 diabetes mellitus with diabetic [CONDITION(S)], systolic congestive heart failure, major depressive disorder severe with psychotic symptoms, cognitive communication deficit, presence of a cardiac pacemaker, spondylosis of the cervical and lumbosacral region, muscle wasting atrophy, chronic [CONDITION(S)], metabolic [CONDITION(S)], contracture of the right and left ankle abnormalities of gait and mobility, limitation of activities due to disability, reduced mobility, history of falling. A review of the Quarterly Minimum Data Set (MDS) assessment completed on [DATE], Section C: Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) score of 07, which indicated severely impaired cognition. Section G: Functional Status revealed, Resident #2 required extensive assistance of at minimum, one person for Activities of Daily Living (ADL's). A review of the Comprehensive Care Plan for Resident #2 indicated the following: -Focus Area: created on [DATE] revealed, the resident required assistance with ADL's related to weakness and poor activity tolerance. The goal was to have ADL needs met daily with appropriate assistance. Interventions included: anticipate and meet resident needs as necessary, call light kept within reach and answered promptly with resident being checked frequently, resident needs extensive assistance of one person for ADL's (bathing, dressing, personal hygiene, bed mobility, locomotion on and off the unit). Resident #2 required a mechanical lift with the assistance of two people for transfers. -Focus Area: created on [DATE] revealed, the resident was resistive to care related to Dementia. The goal was to have resident cooperate with care through next review date. Interventions included: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care and give clear explanation of all care activities prior to and as they occur during each contact. -Focus Area: created on [DATE] revealed, the resident had impaired cognitive function/dementia, or the thought processes related to Dementia. The goal was for the resident to be able to communicate basic needs daily. Interventions included: Ask yes/no questions to determine the resident's needs and cue, reorient and supervise as needed. -Focus Area: created on [DATE] revealed, the resident was at risk for falls related to poor safety awareness, weakness, and antidepressant use. The goals were to have no problems or negative complications related to falls with the resident being kept safe daily through next review. Interventions included: Anticipate and meet the needs of the resident if he was unable to voice needs, call light kept within reach and answered promptly with resident being checked frequently, fall risk assessment completed and reviewed quarterly and as needed (PRN). A review of the most recent Fall Risk assessment completed on [DATE] placed Resident #2 in a high risk for falls category. A review of the nursing progress notes dated [DATE] at 1:34 p.m., written by the Unit Manager, LPN, revealed: Resident alert & verbal resting on bed with wife at bedside. A review of the incident/event report dated [DATE] at 4:01 p.m. written by Staff A, LPN revealed: This nurse was alerted by CNA that resident had fallen out of bed. Upon going into room resident was laying on floor in room beside bed. Resident stated he fell out of bed and hit his head. Resident was assisted back into bed with assistance from staff. Pressure applied to laceration on front of head. Emergency Medical Services called to send resident out to the hospital for evaluation and treatment. The incident was described as an unwitnessed fall. A review of the nursing progress notes revealed a note dated [DATE] at 4:09 p.m. written by Staff A, Licensed Practical Nurse (LPN): This nurse was alerted by CNA that resident had fallen out of bed. Upon going into room resident was laying on floor in room beside bed. Resident was asked what happened, he stated [he fell out of the bed and hit his head.] Staff assisted resident back into bed and applied pressure to laceration on his head. Physician notified. Resident being sent to local hospital. Family notified. A review of the hospital Emergency Documentation dated [DATE] revealed the following. CT (Computerized Tomography) Spine Cervical (neck) without Contrast: Impression: 1. Fracture through the anterior and posterior arch of C1 (first cervical vertebra) are noted with the lateral masses being displaced posteriorly Reexamination/Reevaluation: He [Resident #2] will be admitted to the trauma ICU (intensive care unit) for his unstable C1 fracture A review of a State Agency Death Certificate Replica certified [DATE] revealed, the cause of death for Resident #2 was Sequelae of cervical vertebra fracture fall from bed. There was a contributory cause of death Dementia, and the manner of death is accident. On [DATE] at 3:50 p.m. an interview was conducted with the Minimum Data Set (MDS) Coordinator. She stated that the process after a resident had a fall included, putting in place additional interventions and updating the care plan. An immediate report was completed by the resident's nurse and the DON was notified. The following day after the fall occurred, it would be discussed in the morning meeting. A review of the incident log provided by the facility did not reveal Resident # 2's name. On [DATE] at 10:19 a.m. an interview was conducted with the NHA and DON. The DON confirmed the resident was sent out to the hospital and the incident log that was previously provided did not include Resident #2's name. The DON said she was not sure why the resident was not listed on the incident log. She stated the purpose of the log was to list and track the falls. The DON said the resident's fall occurred on [DATE] at approximately 2:00 p.m. in the resident's room, and the incident report identified it as an unwitnessed fall. The DON said, Staff A, LPN was the nurse alerted by Staff B, CNA that the resident fell out of the bed. She confirmed she did not interview the staff following the incident. The DON said they (Staff A and B) said the resident fell on the floor, had a laceration, and was sent out to the hospital. Reading the progress notes, the DON said Staff B alerted Staff A. Staff A walked into the room and saw the resident was bleeding. Staff A called EMS (Emergency Medical Services) because the resident was bleeding from his head. The DON confirmed she was in the building, but she was not immediately aware of the incident. The DON confirmed she was told that the nurses could not tell where the bleeding came from, and the doctor said to send him out to the hospital. The DON said she would have expected to be informed when a resident was being sent out to the hospital. The DON said the hospital called the facility the next day and informed the Unit Manager the resident had a neck fracture. The DON confirmed she did not interview the CNA nor obtain a written statement from her, stating, the nurse got a statement from her. Additionally, she confirmed the facility did not file an adverse report. The DON confirmed she talked with Staff B, CNA on [DATE] (during the survey) and confirmed she was not aware of the circumstances related to the mechanism of the fall prior to this date. The DON restated prior to [DATE], her knowledge of the incident was just that the resident fell out of bed and had been sent to the hospital. On [DATE] at 10:52 a.m., an interview was conducted with Staff A, LPN who confirmed that she was working the 7:00 a.m. to 3:00 p.m. shift on the day the resident fell . She stated when she walked into the room the resident was on the floor, near the left side of the bed, facing toward the bed. The resident's forehead was bleeding, and he denied being in pain. Staff A confirmed she assessed the resident at that time, and he was assisted back into bed using the mechanical lift. Staff A said she called the doctor, the resident's wife, and EMS. Staff A confirmed the DON was in the building and said she was notified at the time she called EMS. Staff A confirmed Resident #2 was sent to the local hospital, and she was notified later that he had a broken neck. Staff A said an incident report was filled out in the computer (EMR). She could not recall if any in-services were provided following the incident. On [DATE] at 11:12 a.m., a telephone interview was conducted with Resident #2's family member. She stated, her family member died because of a broken neck that he received at the facility. She confirmed Resident #2 passed away under the care of Hospice on [DATE]. On [DATE] at 11:18 a.m., a telephone interview was conducted with the facility Medical Director (MD), who was also listed as the resident's physician. He confirmed the resident was his patient and the facility communicated with him following the incident. The MD confirmed the resident sustained a vertebral fracture but stated he had not reviewed the hospital records to determine the cause. He stated the resident was sent out to the hospital as the nurses could not stop the bleeding. On [DATE] at 1:16 p.m., an interview was conducted with the NHA and DON. The NHA and the DON confirmed The Department of Children and Families Adult Protective Services came into the facility to investigate the incident; they were both unsure of the date. The DON confirmed the facility did not file an adverse report after the The Department of Children and Families Adult Protective Services visit. The DON and the NHA confirmed an allegation of neglect, and an incident resulting in a transfer to a higher level of care, a fracture, or death was reportable. The DON said the facility did investigate the incident; however, they realized it was not an unwitnessed fall after re-interviewing Staff B on [DATE] (during the survey). On [DATE] at 6:15 pm, an interview was conducted with the Regional Director of Clinical Reimbursement, Registered Nurse (RN). She confirmed she had provided in-servicing and training to the NHA, and DON related to Conducting investigations related to accidents. A review of the facility policy titled Accidents and Supervision with no date specified revealed: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives supervision and assistive devices to prevent accidents. Fundamental Information: Definitions Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. 2. Evaluation and Analysis: The process of examining data to identify specific hazards and risks to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. 3. Implementation of Interventions: Using specific interventions to try to reduce a resident's risks from hazards in the environment. 4. Monitoring for effectiveness and modifying interventions when necessary. 5. Supervision. A review of the facility policy titled Fall Risk Assessment with no date specified revealed: Policy: It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the facility designee upon admission, quarterly, or when a significant change is identified. 2. The risk assessment will contain the following components: a) Identify environmental hazards and individual risks, including the need for supervision. b) Evaluate and analyze hazards and risks. 3. An At Risk for Fall care plan will be completed for each resident to address each item identified on the risk assessment and will update accordingly. 4. The At Risk for Fall care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with the current standards of practice. A review of the facility policy titled Risk Management Process dated ,d+[DATE] revealed: 1. Assess the resident for incident related injury and initiate Falling Star: all available staff attend fall to assist with moving the resident, preparing chart if transfer is to occur, review of site of incident. 2. New intervention must be implemented as a preventative measure and placed on the care plan following the investigation to reduce risk of future occurrence ex. [DATE] fall mats to bedside when in bed. i.e., Wing tip mattress to define parameter, pad wheelchair, maintenance to evaluate for sharp edges, fall mats to bedside when in bed, bed in low position when in bed. 3. Complete fall assessment for all falls. 4. Witness statements are taken by the charge nurse and placed directly in incident note. 5. If route [root]cause for occurrence can be determined than the post occurrence evaluation is complete. If a route [root] cause cannot be determined, then complete the post occurrence tool. We should never have an unknown. If you feel unknown is the answer, you must call administrative staff. 6. MD made aware, and family made aware should be documented in [Electronic Medical Record (EMR] action tab of incident. Care plan must be checked to ensure new interventions in action tab of incident. Progress note should be entered in action tab. 10. Interdisciplinary team (IDT) will review fall at next clinical meeting: Care plan, progress note, incident, witness statements, and sign off in [EMR] and enter the IDT note such as IDT met and discussed fall, current fall intervention in place and functioning or IDT met and discussed fall intervention and initiated _____________ intervention for fall on _____________. Facility actions to remove Immediate Jeopardy were submitted by the NHA on [DATE] at 6:15 p.m. 1. On [DATE] The Director of Nursing with Nursing Management have reviewed by [DATE], all falls on the incident log for major injury and found one other issue with correction. 2. On [DATE] The Regional Director of Clinical Reimbursement provided education for the facility Administrator and the facility Director of Nursing on: 1) What is to be reported, 2) Conducting Investigations as related to incidents, accidents, falls, and adverse events. 3. Staff B, CNA was provided the policy for completing peri care and one to one education by the Director of Nursing for process and procedure for completing peri care on [DATE]. 4. Education provided on ,d+[DATE] and [DATE], by the Director of Nursing and nursing management to all clinical caregivers, CNAs, and Licensed Nurses related to: 1. Resident Safety in the Abundance of Caution when patients have been identified/care planned for aggressive behaviors. Residents with behaviors will have two staff members assist when performing ADL care. 2. Abuse, Neglect, Exploitation. 3. Demonstration of proper peri care and return demonstration/video was shown on peri care with return demonstration. 4. Policy on peri care. 5. When providing peri care to residents always maintaining safety, gathering all supplies and equipment needed prior to starting resident's care. Any clinical staff not on site was provided the education by telephone. Return demonstration will be completed upon return to work. Any staff member unable to attend in person or by telephone will receive the complete education when returning to work, prior to taking a resident assignment. Education will continue each shift until 100% of the staff are educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. 5. Beginning [DATE], all incidents will be reviewed in the morning clinical meeting by the IDT for any injury, focusing on major injury. The clinical team consist of the DON, Unit Manager, Minimum Data Set Coordinator, Social Services Director (SSD), Dietary manager, and other clinical staff as needed. As the incident is reviewed, education and reeducation will be provided to clinical staff applicable to the incident. 6. Audits will be completed to observe direct care of all care givers, by the Director of Nursing and her designated clinical staff. Audits will be completed daily for 4 weeks, then 3 times a week for 4 weeks, then weekly for 4 weeks. Results of the audits will be taken to the Quality Assurance and Performance Improvement (QAPI) for review and recommendations and will continue until 100% compliance has been reached. The QAPI Committee is compiled of the Medical Director, The NHA, DON, MDS, SS Director, Unit Managers, Dietary Director, Maintenance Director, Activities Director, and other staff as deemed necessary. The facility removal plan included that by [DATE]: 82% CNAs; 100% RNs, 60% LPNs had completed the education. On [DATE] from 9:38 a.m. to 10:00 a.m., interviews were conducted with five CNAs and one RN. All verified they had received and understood the education. Immediate Jeopardy was determined to be removed on [DATE] at 6:15 p.m. and reduced to a scope and severity of D.