Every finding on record at Lakeview Extended Care and Rehabilitation

This citation pertains to Intake Number 3008221.Based on observation, interview and record review, the facility failed to ensure the accurate dispensing of medication, as ordered, for one resident (Resident #1) of three residents reviewed for medication administration.Findings include: Resident #1 (R1):On 5/11/26 at 6:25 PM, an interview was conducted with Confidential Person (CP) B regarding allegation details of Resident 1 (R1) receiving extra amount of metoprolol succinate capsules. The CP reported the Resident was ordered to receive the metoprolol (Kapspargo) sprinkles 100 mg (milligrams) one capsule but was administered 4 capsules (four 100mg capsules equals 400mg). The Resident had to be transferred to the emergency room, given charcoal, stay overnight in the hospital for observation and had loose bowel movements as a reaction to the charcoal causing exhaustion for the Resident.The CP reported that the medication was labelled as 25mg in the packaging from the facility pharmacy. The order was for 100mg, to take one capsule. The packaging had read to take one capsule but was labeled as 25mg. The nurse had questioned the discrepancy with a pharmacist and was told to give 4 capsules. The nurse had given the 4 capsules, meanwhile the Pharmacist looked into the discrepancy and realized they were 100 mg capsules that were in the packaging, called the facility and the resident was taken to the emergency room since the 4 capsules had been administered. The CP reported that Poison Control had been contacted, the Resident had to drink charcoal and stayed for observation. The CP was concerned about how the error occurred and if it could happen again. A review of Resident 1's medical record revealed an admission into the facility on 2/12/25 with diagnoses that included Parkinson's Disease, and hypertensive heart disease. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed substantial/maximal assistance or was dependent on a helper with activities of daily living. A review of R1's medication orders revealed an order for Metoprolol Succinate Oral Capsule ER (extended release) 24 hour sprinkle 100mg, give 1 capsule by mouth one time a day for Hypertension with a start date on 5/1/26 to be administer at 8:00 AM. Prior to that the Resident had been on Metoprolol Succinate ER tablet extended Release 24 hour 50mg, give 1 tablet by mouth one time a day. Kapspargo Sprinkle-metoprolol succinate used for the treatment of high blood pressure, angina pectoris (chest pain) and heart failure. Common side effects include tiredness, dizziness, shortness of breath, [NAME] cardia (low heart rate), hypotension (low blood pressure) and diarrhea. On 5/12/26 at 9:55 AM, an interview was conducted with the Director of Nursing (DON) regarding medication errors. The DON reported one recent medication error involving Resident 1 receiving Metoprolol Succinate Capsules with the Resident receiving a total of 400mg when the order was for 100mg. The DON reported the label had said 25 mg, but what was in the packaging was 100mg capsules. The DON reported that the Resident had been increased to 100mg tablets but since that medication could not be crushed and the resident had issues with swallowing larger medication, it was changed to the sprinkles. The new medication had come in on Thursday afternoon to start on Friday morning. The Nurse had questioned the discrepancy with the Pharmacist on the unit and was told to give four of the capsules. The Pharmacist had checked with the retail store and discovered the medication packaging was labeled wrong, had immediately called the Nurse but the medication had been given. The Resident was immediately taken to the emergency room that was connected to the facility and treated with charcoal and Poison Control was notified. The DON reported that Poison Control had released her at 4:30 PM but the Resident stayed for continued monitoring overnight. The DON reported no critical drop in blood pressure or heart rate that needed to be treated. The Resident returned to the facility in the morning and had not had any adverse cardiac effects. The DON reported having meetings with the Pharmacists and the family. They reviewed their processes and with the pharmacy had changed the labels with bigger printing of descriptions of the medication and they started scanning the medication which puts another check into the system. Education was provided to the Nurses and Pharmacists were working diligently on identifying problems and corrective actions. The DON reported the Resident did not present with any low heart rate, blood pressure, or arrythmia concerns that had to be treated. The Resident was on IV (intravenous) fluids while in the ER. On 5/12/26 at 10:21 AM, an interview was conducted with Pharmacist C who reported she had looked at the card of medication that had capsules, the order was for 100mg but the sticker on the med card had Kapspargo 25mg and had directed the nurse to give the four capsules. The Pharmacist reported the label had said to give one capsule and that was what the Nurse had questioned. The Pharmacist reported she had left the unit and had called the technician and found out we only had the 100mg Kapspargo Sprinkle and stated, I called the nurse, but they had already given it to her. The Pharmacist reported the breakdown was the label. When the label was made, the wrong strength of 25mg was selected and stated, If I would have looked at the imprint, I would have seen the capsule did not match the description. The Pharmacist reported that the Pharmacist does a second check before it goes to the facility, but it had not been caught with that check and the card with the medication was delivered to the facility. The Pharmacist reported they had changed the labeling. On 5/12/26 at 11:00 AM, the DON reported the timeline as the medication given at 7:43 AM, Pharmacist C had called the Nurse approximately 8:05 AM, the Resident was transferred to ER. She was notified at 8:18 AM and the Resident was already in ER. The processes put in place were reviewed and when asked if they were in sustained compliance, the DON stated, No not yet, we are still working on the processes to ensure this does not happen again. The (name of computer program used) is new and we are still working to make sure everything is as accurate as possible, and expressed they will be following this in QA (quality assurance program). On 5/12/26 at 12:15 PM, an observation was made of Nurse A passing medication and reviewing the checks she does prior to giving medication. The Nurse explained that the label on the med card had said 25mg and on the computer it had 25mg also, but it had said give one capsule, she had questioned the Pharmacist C who was on the unit at the time and reported the Pharmacist had said to give the four capsules. An observation was made of a photo of the med card had one capsule crossed off and handwritten 4 that was signed by the Pharmacist C. The Nurse reported that the imprint description had been made bigger and she checks the description of the medication to make sure it is accurate. An observation was made of the Nurse passing medication to R1 at 12:46 PM, without any concerns with medication administration. The scanning process was new to the facility, and the card was scanned. The nurse verified the correct medication on the computer. On 5/12/26 at 1:41 PM, an interview was conducted with Pharmacist D who explained that they got the order in for the Kapspargo Sprinkle 100 mg, but the tech put it in as 25mg but was dispensed with the 100 mg. The Pharmacist reported that he did not catch the mistake when checking the medication and it was sent to the facility. The Pharmacist indicated that most of the time the medication was prepopulated, if not we have to put it in manually and the tech inadvertently put it in for the 25mg.

This citation pertains to intake Number 2701247.Based on observation, interview and record review, the facility failed to ensure that the medication storage room was locked and secured.Findings include: On 4/16/26 at 8:49am, the medication storage room behind the nurse's station was observed to be open. There were no staff present at the nurse's desk and no staff in sight of the open door. On 4/16/26 at 9:44am, an interview was conducted with Certified Nursing Assistant (CNA) A. CNA A was asked if the medication storage room is left open throughout the day? CNA A stated, yes, it is open throughout the day every once in a while. On 4/16/26 at 9:47am, an interview was conducted with CNA B. CNA B was asked if the medication storage room is left open during the day? Yes, it is. However, usually, when it is open there are people sitting at the desk. CNA B was asked if they have seen the door open before with no one at the desk? Yes, I saw it that way before, with no one at the desk. It happens sometimes.On 4/16/26 at 9:50am, an interview was conducted with Environmental Services (ES) C: ES C was asked if they have ever seen the medication storage room door left open during the day? Yes, but typically only when they use it. It is usually closed. ES C was asked if they have ever seen the medication storage room door open with no one at the desk and no one in the room? ES C stated, yes, sometimes I have seen it open with no one around.On 4/16/26 at 9:53am, an interview was conducted with ES D. ES D was asked if they have ever seen the medication storage room door left open during the day? ES D stated, yes, I have seen the door left open. ES D was asked if they have ever seen the medication storage room open with no one at the desk or in the room? ES D stated, yes, I have seen it like that. I would say it happens quite a bit. ES D was asked how many times a week the medication storage room is left open with no one around? ES D stated, I work five days a week and I would say 3-4 times a week it is like that.On 4/16/26 at 10:00am, an interview was conducted with Infection Control (IC) E. IC E was asked if they have ever seen the medication storage room left open during the day? IC E stated, yes, I have. IC E was asked if they have ever seen the medication storage door open with no one around or in sight? IC E stated, I can't say that I have seen it open with no one around. But I have seen it open with no nurses around and only the ward clerk there.On 4/16/26 at 10:03am, an interview was conducted with the Director of Nursing (DON). The DON was asked if the medication storage room is left open throughout the day? The DON stated, I wouldn't say it is left open a lot. Each nurse has a key, and it should be locked. If they are passing meds, I will pass through and if I see it open, I will close it. The DON was asked if they have ever observed the medication storage room being open with no one around? The DON stated, no, I can't say that I have seen it open without someone around. The DON was made aware that the medication storage room was open and not monitored this morning. The DON was asked if the medication storage room should be closed every time the nursing staff leaves the room? The DON stated, yes, it should be closed every time.On 4/16/26 at10:16am, an interview was conducted with LPN F: LPN F was the nurse that shut the medication storage room when it was observed open at the beginning of the survey. LPN F' was asked if the medication storage room should be closed when no one is around? LPN F stated, yes, it should be. LPN F was asked if the door gets left open throughout the day? LPN F stated, it gets left open once in a while if we are busy. LPN F was asked if they have ever observed the medication storage room open with no one around? LPN F stated, yes and then I go and shut it.Review of the policy titled, Oral Medication Administration, revealed:Procedure:I. Medication rooms in all units are to be kept locked at all times.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services for an indwelling catheter for three residents (R3, R4, R19) of three residents reviewed for indwelling catheters, resulting in leaky catheter tubing, catheter tubing touching the floor and urine collection bags being uncovered. Findings include: Resident #19: R19 is [AGE] years old and admitted to the facility on [DATE]. R19 has a brief interview for mental status (BIMS) score of 14, indicating that he is cognitively intact. On 01/27/2026 at 10:21AM, during observation and interview with R19, the urine collection bag is observed not covered, urine was present and it was visible from the hallway. On 01/29/2026 at 8:36AM, during follow up observation and interview with R19, the urine collection bag is observed not covered, urine was present and visible upon entering the room. On 01/29/2026 at 8:41AM, an interview was conducted with the infection control (IC) nurse A. IC nurse A was asked if the urine collection bags be covered with dignity bags. IC nurse A stated, yes, they should be covered and off the floor. Resident #3: On 1/27/2026, at 10:51 AM, Resident #3 was resting in bed. The bed was in a low position. Their urinary catheter bag was covered by a blue dignity bag which was resting on the fall matt on the floor. On 1/27/2026, at 2:13 PM, Resident up in their wheelchair. Their urinary catheter tubing was wrapped tight around their right leg towards the outside and hooked under their wheelchair. On 1/28/2026, at 10:00 AM, a record review of Resident #3's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, Parkinson's disease, Heart Failure and the need for an indwelling urinary catheter. Resident #3 had severely impaired cognition. Resident #4: On 1/28/2026, at 9:37 AM, Resident #4 was up in their wheelchair propelling themselves in the hallway using their feet on the floor. Their urinary catheter bag was hanging under their wheelchair. The urinary catheter tubing was dragging on the floor as Resident #4 propelled though the hallway. On 1/28/2026, at 9:40 AM, an observation along with Nurse B was conducted of Resident #4's catheter tubing on the floor and Nurse B offered, yes, that should be tucked up. On 1/28/2026, at 10:30 AM, a record review of Resident #4's electronic medical record revealed a readmission on [DATE] with diagnoses that included supra pubic urinary catheter surgical placement, Cerebral Palsy and Depression. Resident #4 had intact cognition. On 1/28/2026, at 1:35 PM, During Infection Control task, Infection Control (IC) Nurse A was alerted Resident #4's catheter tubing was dragging on the floor while they propelled in the hallway. IC Nurse A offered, Resident #4 was currently on antibiotics for a Urinary Tract Infection. IC Nurse A was also alerted Resident #3's urinary drainage bag was resting on the fall matt on the floor.

Based on observation, interview, and record review, the facility failed to ensure a sanitary and homelike environment in the residents' bathroom and communal shower room, for four residents (#9, #13, #15, #16), and residents that use the shower room), of five residents reviewed for homelike environment, resulting in the potential for embarrassment, dissatisfaction of living conditions, and spread of infection. ]Findings include: Resident #9: An observation was made on 11/18/24 at 9:55 AM in Resident #9's bathroom of a denture cup under the hot water faucet handle at the sink. The lid of the denture cup was positioned just under the faucet handle. On 11/18/24 at 1:24 PM, an observation was made in Resident #9's room of the denture cup that was positioned under the hot water faucet handle of the sink. The room was shared with two residents. Resident #13: An observation was made on 11/18/24 at 9:56 AM of a denture cup positioned under the hot water faucet handle of the sink. Can not wash hands without the potential to drip or come in contact with the top of the denture cup. The room was shared with two residents. An observation was made in the bathroom of a bedpan inside a bag and stored on top of toilet paper behind the toilet. On 11/18/24 a 12:37 PM, an observation was made in Resident #13's room of the denture cup stored under the hot water faucet handle of the sink. Resident #15: An observation was made on 11/18/24 at 9:52 AM of the Resident dressed and sitting up in their wheelchair. An observation was made in the Resident's bathroom of a denture cup under the hot water faucet handle where drips or hands can come in contact with the denture up when hands were washed. On 11/18/24 at 1:24 PM, an observation was made in Resident #15's room of a denture cup stored underneath the faucet handle of the sink. The room is shared by two residents. Resident #16: An observation was made on 11/18/14 at 9:50 AM in Resident #16's room of a denture cup stored under the cold-water faucet handle of the sink. In the bathroom a bed pan in a bag was stored in a bin under the sink with multiple bottles of shampoo and other bottles of personal items. Shower Room: On 11/18/24 at 1:48 PM, an observation was made of the shower room on the one end of the unit. The shower room had a shower chair positioned in the area of the shower stall. Positioned on the floor around the chair were buckets used in a commode chair or on the shower chair that had an opening on the seat for a bucket to be placed. One of the buckets was soiled with a brown substance that looked like bowel movement. Another bucket was turned over and on the floor. Under the sink in the shower room, two buckets were stacked together with the bucket on top with a lid on it. The two stacked buckets were positioned in a basin. There were no resident names on the buckets. On 11/18/24 at 2:00 PM, an observation was conducted with the Director of Nursing (DON) of the one shower room. The buckets stored under the sink were separated and appeared to have been used and not thoroughly cleaned. The buckets stored in the shower area had liquid in the bottom and was not thoroughly cleaned inside and on the outside. The bucket positioned upside down was wet inside and had not been thoroughly cleaned after being used with debris on the inside of the bucket. The DON indicated that was not the way to store the commode buckets and indicated they will be disposed and/or cleaned and stored off the floor. Observations were made, with the DON, of Resident rooms that had a denture cup stored under the faucet handles of the sinks. The DON indicated they should not be stored that way. An observation, of Resident #16's bathroom with the bed pan stored with personal bathing items, was made with the DON. The DON indicated the bedpan was to be stored in the wire rack and the shampoo bottles and lotions were not to be stored with the bedpan. The DON indicated the items might have been brought in by the Resident's family and due to volume of items, they were stored down in that wire rack and reported the lower rack was for the bedpan storage only and the other items can be stored at the Resident's bedside. On 11/18/24 at 2:32 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse A regarding the storage of the commode buckets in the bathroom. The ICP Nurse reported conversations with staff about storage of items and stated, last week, talked to staff about the same issue. The ICP Nurse indicated they should be cleaned, dried and put away, not stacked wet or on the floor and stacked together. A review of the denture cups stored under the faucet handles in multiple Resident rooms was reviewed. The ICP Nurse reported the denture cups should not be stored under the faucet handles but should be in the Resident's rack in the bathroom or by the nightstands. A review of facility policy titled, Resident Environmental Quality, revealed, Policy: It is the policy of (facility name) to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public . A review of facility policy titled, Safe and Homelike Environment, revealed, .Definitions: . Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living .

Based on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two residents (Resident #6 and Resident #25), of 12 residents reviewed for care planning, resulting in the potential for unmet care needs and a decline in overall health and wellbeing. Findings include: Resident #6: A review of Resident #6's medical record revealed an admission into the facility on [DATE] with diagnoses that included right femur fracture, diabetes, poly arthritis, chronic pain and dementia. The Resident had an order, dated 5/31/24, Left hand resting hand splint at night-monitor skin integrity. On 11/18/24 at 11:10 AM, an observation was made of Resident #6 sitting in their room. A hand splint was observed among the Resident belongings. The Resident was observed to have right hand finger contracture. The Resident was interviewed, answered questions and engaged in limited conversation. When asked if the Resident could open her fingers up on her right hand, the Resident indicated the fingers would not open on their own. When asked about the hand splint, the Resident indicated they would wear it when I want to. On 11/20/24 at 12:07 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding Resident #6's hand splint. The ADON indicated the Resident did not like to wear it and refused it a lot of times, and will hid the appliance in their drawer under clothing. The ADON was asked about care planning for the hand splint. On 11/20/24 at 1:17 PM, the ADON returned and was queried regarding Resident #6's care planning of the hand splint. A review of the care plan with the ADON revealed a care plan for skin integrity to address the potential for skin breakdown with the application of the hand splint. The care plan lacked a focus for the use of the hand splint, interventions or plan of care with the refusals. The Resident had a care plan for restorative therapy and the ADON indicated they should have it under both care plans. Resident #25: A review of Resident #25's medical record revealed an admission into the facility on [DATE] with diagnoses that included pneumonia left lower lobe, anxiety disorder and stroke. On 11/18/24 at 1:42 PM, an observation was made of Resident #25 in their room. The Resident was interviewed and answered questions. The Resident had an incentive spirometer (IS) and a smaller respiratory device. When asked about the items, the Resident reported he uses the incentive spirometer to suck the air up, and the other device the Resident reported it helps him breathe. The Resident reported he did not use the incentive spirometer very often. On 11/20/24 at 10:43 AM, an observation was made with the Assistant Director of Nursing (ADON) of Resident #25 in his room. The Resident was asked about the incentive spirometer and the Resident stated, I'm supposed to do it, don't do it much. The ADON indicated the other device was a flutter valve. The Resident used the flutter valve by blowing air out and the device made a fluttering sound. A review of Resident #25's care plan with the ADON revealed no care plan for the incentive spirometer or the flutter valve. The ADON indicated that there was not an order for the flutter valve or IS but indicated that they should be care planning for the items. On 11/20/24 at 11:36 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #25's lack of care planning for the IS and flutter valve. The DON reported Resident #25 had a history of pneumonia and reported for best practice, we want healthy lungs, and indicated a care plan would be implemented and will be included on the care guide as well. A review of facility policy titled, Comprehensive Resident Care Plans, revealed, C. The Interdisciplinary Team (IDT) in coordination with the resident/resident's responsible person will develop and maintain a comprehensive care plan that identifies the highest practicable level of physical, mental, and psychosocial well-being the resident may be expected to attain and/or maintain .

Based on interview and record review the facility failed to notify the physician of an unintended significant weight loss for one resident (Resident #17) of three residents reviewed for nutrition, resulting in a lack of physician oversight and potential interventions for weight loss. Findings include: Resident #17 (R17): R17 is [AGE] years old and readmitted to the facility on [DATE] with diagnoses that include atrial fibrillation, nausea/vomiting, generalized weakness and GERD (gastroesophageal reflux disease). R17 has a BIMS (brief interview for mental status) score of 10 indicating moderate cognitive impairment. On 11/18/24 at 10:19 AM, R17 was asked if they felt like they had lost some weight since being in the facility. R17 stated they think they have lost some weight in the facility and believes it is because of their poor appetite. R17 stated, I really like the food but just don't always have the appetite to eat it. On 11/20/24 at 09:10 AM, record review revealed R17 has experienced an unintended significant weight loss of 10% in the last 6 months. On 04/01/24 R17 weighed 152.5 lbs and on 10/07/24 R17 weighed 135.4 lbs. Record review revealed R17 has a care plan in place for alteration in nutrition status, it last reviewed on 11/04/24. On 11/20/24 at 09:15 AM, a review of a dietary noted dated 10/22/24, indicated that R17 had experienced a significant weight loss in the last six months. The dietary note does not indicate that the physician was notified of the weight loss. On 11/20/24 at 09:27 AM, interview was conducted with CDM (Certified Dietary Manager) C. CDM C indicated that R17 had been acutely ill during the early months of the weight loss. CDM C stated that R17 is currently on a supplement and the current weight loss is being attributed to an acute condition from months ago. CDM C stated R17 is getting 4 oz juice with beneprotein in it for additional protein. CDM C stated R17 receives snacks at 10 am, PM and at bedtime. CDM C stated R17 is receiving monthly weights and their appetite is improving. R17 averages about 40% intake for meals but sometimes will eat 75% or more, R17 was experiencing nausea and at one point was taking Zofran for that. CDM C stated they visit R17 weekly and review the food menu with them. CDM C stated that R17 is always satisfied with her meals, and she likes the food at the facility. On 11/20/24 at 11:04 AM, an interview was conducted with ADON (Assistant Director of Nursing) B and the DON (Director of Nursing) ADON B was asked what the procedure was for getting resident weights in the facility. ADONB stated the aides weigh the resident and that gets recorded in the chart and given to the dietary managers. ADON B stated the dietary managers review the weights and discuss any weight loss during the care conferences quarterly. ADON B was asked if the physician should be made aware of a weight loss. ADON B stated yes, the physician should be made aware so they can make orders as needed. The DON stated she was unable to locate any documentation that showed the physician was notified of the weight loss. The DON stated nurses can notify the physician via tiger text, but the record of tiger text goes away after a while. The DON stated the nurses should make a progress note that they notified the physician of any weight loss. Review of the policy titled, Weight Monitoring Program, last reviewed 03/20/24 revealed: IX. Suggested Interdisciplinary Nutrition Interventions for Unintended Weight Loss. A. Dietary Considerations -Certified Dietary Manager (CDM) or Registered Dietitian to notify nursing via recommendation form. Nursing will then notify physician of significant weight changes via tiger text or another approved form of communication.

Based on interview and record review the facility failed to ensure that physicians' orders for code status was present in the EMR (electronic medical record) for three residents (R15, R19 and R21) of four residents reviewed for advance directives, resulting in the absence of code status orders in the EMR and the potential for the resident's preference for life sustaining treatment to not be followed by the facility. Findings include: Resident #19: R19 is [AGE] years old and readmitted to the facility most recently on 03/19/2019 with diagnoses that include paraplegia, chronic pain, muscle wasting and contractures of the bilateral upper extremities. R19 has a BIMS (brief interview for mental status) score of 15 indicating they are cognitively intact. On 11/18/24 at 02:24 PM, record review revealed there was no physician order for code status in the EMR (electronic medical record). A signed DNR (do not resuscitate) form was in the paper chart at the nurse's station. On 11/20/24 at 11:13 AM, record review revealed a physician's order for DNR was entered in the EMR, the order was created and signed by the physician on 11/18/24 at 20:58 (8:50 PM). This was after it was brought to the attention of the staff by this surveyor. Resident #21: R21 is [AGE] years old and most recently readmitted to the facility on [DATE] with diagnoses that include hypertension, gout, urinary retention and chronic kidney disease. R21 has a BIMS score of 13 indicating they are cognitively intact. On 11/18/24 at 04:06 PM, record review revealed there was no physician's order for code status located in the EMR. A signed full code form was in the paper chart at the nurse's station. On 11/20/24 at 11:20 AM, record review revealed that a physician's order for full code status was entered in the EMR, the order was created and signed by the physician on 11/18/24 at 20:55 (8:55 PM). This was after it was brought to the attention of the staff by this surveyor. On 11/20/24 at 11:22 AM, an interview was conducted with the DON (director of nursing) The DON was asked how the staff members identify a resident's code status in an emergent situation. The DON replied that the outside binder on the paper charts has a sticker that says DNR and that is how staff would know what the code status is. The DON stated that if there is not a DNR sticker on the outside of the binder then the resident is a full code. The DON was asked if residents should have an order in the chart to identify their code status. The DON stated yes, they should have an active code status order in the EMR from the physician. Record review of the policy titled, Residents' Rights Regarding Treatment and Advance Directives, approved 6/04/2024, revealed: Policy: It is the policy of Lakeview Extended Care and Rehab to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Procedure: I. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. IX. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. 37771 Resident #15: A review of Resident #15's medical record revealed an admission into the facility on [DATE] with a readmission on 10/5/21 with diagnoses that included non-traumatic brain dysfunction, abnormalities of gait and mobility, and dementia. A review of the Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact and needed substantial/maximal assistance with most activities of daily living and needed supervision or touching assistance to partial/moderate assistance with most transfers and mobility. On 11/18/24 at 4:00 PM, a record review of Resident #15's medical records revealed the Resident had a Do Not Resuscitate (DNR) status for code status. Review of the medical record with the Director of Nursing revealed no physician order for the DNR code status. On 11/19/24 at 9:59 AM, a record review of Resident #15's medical records revealed the Resident had Do Not Resuscitate status and an order was obtained by the facility with an order entry for the DNR code status dated for 11/18/24 at 8:50 PM. On 11/20/24 at 11:40 AM, an interview was conducted with the Director of Nursing (DON) regarding physician order for Resident #15's code status. The DON reported that for whatever reason, when they have a change in the medical record number, it did not carry over and stated, They should have an active order for code status.

Based on interview and record review, the facility failed to ensure that licensed nurses (RN-Registered Nurses, and LPN-Licensed Practical Nurses) and Certified Nursing Assistants (CNA) received yearly competencies and/or education/in-services for 4 of 12 staff reviewed for education and yearly competencies/education, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of all residents residing at the facility and according to the facility assessment. Findings include: On 10/19/23 at 2:05 PM, an interview was conducted with Director of Operations, Human Resources (HR) N during the Sufficient and Competent Nurse Staffing task of the survey. The training, Nurse licenses, CNA registrations, competencies, and backgrounds of five CNA's and five Nurses were reviewed with HR N. When asked about regular in-services, training and/or competencies for specific resident needs that were indicated in the Facility Assessment, such as hospice, the HR N indicated that the Relias training did not include Hospice training and stated, They are all going to be delinquent in hospice (training) because we don't offer that. The staff that was reviewed with the records of training and competencies provided by HR N was not identified to be sufficient and HR N indicated that the Director of Nursing might have some of the information needed to determine adequate staff training and competencies. Multiple documents titled Scorecard: All Competencies, had not been dated with a date of completion. On 10/19/23 at 3:30 PM, an interview was conducted with the Director of Nursing (DON) regarding documentation of staff competencies, training, and in-services. The DON had a binder with recent competencies for the last year. When asked about the Facility Assessment and capturing education for the needs of Residents that were identified in the Facility Assessment, for example, Hospice services, the DON indicated that they do not have a section in Relias for hospice, but they had an in-service where a Hospice Nurse came into the facility. The DON did not have a list of who attended the in-service that was readily available. The DON indicated they would look into adding hospice into the on-line training. On 10/25/23 at 9:12 AM, an interview was conducted with the DON regarding the review of staff training and competency records. Staff training provided by the facility included on-line training hours, Scorecard: All competencies that the DON indicated was CMS based, and competencies/varies testing that was reviewed by a preceptor. The review of LPN R was reviewed with the lack of competencies reviewed with a preceptor that was completed for 2022. LPN R had an Infection Prevention and Control Hand Hygiene Skills Competency Assessment completed 5/18/22 but did not have that competency completed for 2023. The DON indicated that was to be done yearly. The DON stated, She missed it, she needs to make it up. She was not here for that. LPN R had varied competency testing completed 3/3/23. When the DON was asked for competencies completed for 2022, the DON indicated they did not have any to show for 2022 except for the Hand Hygiene Skills Competency completed 5/18/22. A review of RN I's competencies and training revealed the document Scorecard: All Competencies, one dated 2/16/22 and one dated 10/13/23. The DON indicated the date was when it had been reviewed. The competencies were greater than a 12-month period. The DON indicated they were to be completed annually. A review of CNA O revealed a Scorecard dated 2/16/22 and 10/13/23, that was greater than an annual 12-month period, infection prevention and control competency completed 5/18/22 and then not until 7/26/23 that was greater than the annual 12-month period. A review of LPN E revealed infection prevention and control competency for hand hygiene skills was completed 5/17/22 and 8/14/23 that was greater than the annual 12-month period. Further review of education and competencies revealed no competencies completed for 2022. A Scorecard dated 2/23/22 and 10/13/23. The DON was unsure when the Scorecard had been completed but the Scorecard competencies had not been checked timely and were dated on 10/13/23. The time period was greater then the annual 12-month period. The DON indicated the Scorecard competencies were to be competed annually. On 10/25/23 at 11:11 AM, an interview was conducted with the DON and Social Services Director B regarding in-services. The SSD indicated she competed in-service education that included topics regarding dementia, elder justice act, abuse, resident rights, staff communication, infection control and corporate compliance. The SSD reviewed the attendance for the in-service and indicated CNA N had not attended the in-service. CNA P had attended an in-service 2/2022 and indicated the staff should have had the October in-service but the SSD did not have the documentation that she had attended the required in-service since 2/2022. A review of the Hospice in-service that had been provided to the facility by a hospice service Nurse for Nurses revealed Nurses I and R had not attended. The DON indicated that Nurse I had been a hospice nurse. The DON reported that they had added hospice and end of life care communication to the on-line training for CNA's and Nurses. On 10/25/23 at 1:10 PM, an interview was conducted with SSD B regarding the difficulty in producing the needed documentation of education/training/competencies/in-services for the Competent Nurse Staffing task for the survey process and for the facility to have records of staff easily accessible and knowledgeable of the needed/required staffing competencies and education. The SSD reported they were going to list staff and education needs and stated, It's too hard to find everything that everyone is needing. We will have it all right here. The SSD indicated that CNA N had attended the in-service she had presented in August 2022, and CNA P had completed the in-service presentation information on 1/1/23. On 10/25/23 at 2:00 PM, an interview was conducted with the DON regarding the difficulty in producing the needed documentation of education/training/competencies/in-services for Competent Nurse Staffing task for the survey process and for the facility to have records of staff easily accessible. The DON was asked about keeping track of staffing education. The DON indicated that moving forward, they will have a spread sheet and will put all the education needs and training together. The DON indicated that she will be monitoring the spreadsheet for completeness. The DON indicated that the CMS Scorecard Competencies, education testing and in-service provided by the SSD, and competencies were to be done on an annual basis. A review of the facility policy titled, Training Requirements, effective date 2/2023, revealed, Policy Statement: It is the policy of (name of facility) to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles .II. The amount and types of training necessary are based on a facility assessment . V. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment . IX. The Director of Nursing or designee maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. X. Documentation of required training will be forwarded to the HR department to be placed into the individual's personnel file, in accordance with facility policy for retention of training records .

Based on interview and record review, the facility failed to ensure that drug regimen review recommendations were reviewed by the physician in a timely manner for one resident (Resident #21) of five residents reviewed for medications, resulting in the potential for the resident to receive unnecessary medications with potential adverse effects. Findings Include: Resident #21: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record Review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #21 was admitted to the facility on [DATE] with diagnoses: diabetes, diabetic wound right great toe non/healing, chronic kidney disease, hypertension, peripheral vascular disease, gout, arthritis, anemia, sepsis, osteomyelitis (bone infection). The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed some assist with all care. A review of the monthly pharmacy reviews of the resident's medications titled, Medication Regiment Reviews/MRR, for Resident #21 identified an August 10, 2023 MRR titled, Pharmacy Recommendations for Physician, with a heading titled, Potential side effects: A drug interaction between aspirin and Plavix has been noted. The use of these two medications together may cause increased risk of life-threatening bleeding . Carefully evaluate the increased risk of bleeding associated with coadministration of Aspirin-Low Oral and Plavix Oral with the potential therapeutic gain . The recommendations were signed by the pharmacist on 8/10/2023 and the Director of Nursing/DON on 8/17/2023, but not by the physician. The physician's choices for response were: I agree with Nursing response; I agree with Pharmacy, no order needed; I agree with Pharmacy, order written; I disagree with Pharmacy, comment needed. There was a space for comments, a physician signature and date, they were all blank. During an interview with the DON on 10/18/2023 at 1:30 PM, she confirmed the physician had not responded to the pharmacists recommendation from August 2023. A record review of the Medication Administration Record/MAR for Resident #21 dated 10/15/2023, indicated the resident was still receiving both medications: aspirin low dose (81 mg) and Plavix. A record review of the facility policy titled, Drug Regimen Review, dated effective December 2006 and revised 5/2023 provided, . the drug regime of each resident, must be reviewed at least monthly or more often as required . The report will address any irregularities and be forwarded to the Director of Nursing, the attending physician and Medical Director of Lakeview Extended Care and Rehab. Purpose of Policy: To prevent adverse outcomes . The attending physician will review by the end of each month . The Medical Director will be notified by the Pharmacist regarding any reports that have not been acted upon. The pharmacist will review physician response to recommendations at the next drug regimen review .

Based on observation, interview and record review, the facility failed to conduct inspection of bed assist bars to monitor securement, bed safety and risk for entrapment for one resident (Resident #2) of two residents reviewed for bed assist bar safety, resulting the potential of injury and entrapment. Findings include: Resident #2: A review of Resident #2's medical record revealed an admission into the facility on [DATE] with diagnoses that included peripheral vascular disease, cellulitis of lower extremities, cerebrovascular disease, osteoporosis, non-traumatic brain dysfunction, depression, and dementia. A review of the Minimum Data Set assessment, dated 9/14/23, revealed the Resident had severe cognitive impairment, was independent in bed mobility, needed limited assistance with transfer, and extensive assistance with locomotion on unit, dressing, toilet use and personal hygiene. On 10/17/23 at 10:26 AM, an observation was made of Resident #2 dressed and sitting in her wheelchair in her room. An interview was conducted with the Resident who engaged in conversation. The Resident had a bed with partial siderails/assist bars on either side of the bed positioned towards the head of the bed. A review of Resident #2's care plan lacked a care plan that addressed the use of side rails. On 10/18/23 at 1:35 PM, an interview was conducted with the Director of Nursing regarding inspection and monitoring of assist bars for Resident #2. A review of the facility measurements of the assist bars revealed the Resident had not had her measurements completed in October 2023. The DON was asked for monitoring of Resident #2's assist bars prior to October. The DON indicated that they did not have any measurements prior. The DON produced the facility document titled Assessment/evaluation for conformance to FDS's bed system entrapment zones that was dated 8/22/23 but did not have any assessment questions completed and the facility document titled, Side Rail Monitoring Assessment for Resident #2 was not completed. On 10/18/23 at 1:43 PM an interview was conducted with Plant Operations Facilities Director (POFD) C and the DON regarding Resident #2's side rail monitoring. The POFD reported that they started with assessments in August and was unsure why Resident #2 was not completed. The DON reported that moving forward, the assessments with measurements will be completed monthly. A review of facility policy titled Proper Use of Bed Rails, effective date August 2023, revealed, .IV Installation and Maintenance of Bed Rails. A. The facility will assure the correct installation and maintenance of bed rails, prior to use. This include: .2. Ensuring that the bed's dimensions are appropriate for the resident by: .c. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; e. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. F. Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time . 4. Conducting routine preventative maintenance of bed rails to ensure they meet current safety standards and are not in need of repair . V. Ongoing Monitoring and Supervision: A. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to the following information: 1. The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring . B. Responsibilities of ongoing monitoring and supervision are specified as follows: 1. Direct care staff will be responsible for care and treatment in accordance with the plan of care . 4. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails .

Based on interview and record review, the facility failed to follow evidence-based practices for Infection Control, including : 1) That Infection Prevention and Control Program (IPCP) policies were reviewed annually, and 2) That surveillance for infectious illnesses was analyzed for identification of infections, communicable diseases, trends, patterns, and reported routinely, resulting in the potential for a lack of guidance to ensure compliance with infection control standards and exposure to infectious organisms, which could lead to an unidentified outbreak. Findings Include: FACILITY Infection Control On 10/25/23 at 11:07 AM, during a review of the Infection Prevention and Control Program (IPCP) with Infection Preventionist/IP Q, the facilities Infection Control policies were reviewed. The Infection Prevention and Control Program, was dated effective December 1, 2018 and last reviewed 10/2021; the program plan had not been reviewed yearly to ensure it contained current information. The Legionella Policy titled, Reducing the Risk of Legionella, was last reviewed on 3/21/2022. The Hand Hygiene policy was last reviewed 3/1/2022. The Respiratory Protection Program, was effective September 2020 and last reviewed 1/2022. The IP said she began her role of IP at the facility in January 2023. During the review of the Infection Control Program on 10/25/2023 at 11:20 AM, Infection surveillance was reviewed for October 2022 to October 2023. Resident and employee infections were reviewed and identified the following: January 2023: There were 3 residents listed as having an infection. One resident was admitted with pneumonia. 2 employees had respiratory symptoms and 2 had GI (gastrointestinal) symptoms. February 2023: 4 residents were listed as having infections. 3 residents were admitted with pneumonia and 1 had a urinary tract infection. 3 employees had respiratory symptoms and 2 had GI symptoms. 2 of the employees with respiratory symptoms tested positive for Covid-19. March 2023: 2 residents were listed as having infections. 1 resident with GI symptoms was positive for C. difficile. 4 staff were listed as positive for Covid-19. 1 additional employee with respiratory symptoms was negative for Covid-19 and 1 employee had GI symptoms and was negative for Covid-19. Upon further interview with the IP on 10/25/2023 at 11:45 AM, it was identified that there was no summary report for 4th quarter 2022 infection surveillance data that should be reported at the Infection Control Committee meeting. The IP Q said the facility infection surveillance data was reported quarterly (January, April, July and October) with the hospital's Quality Assurance reporting. The IP was asked if the facility provided their own infection surveillance analysis, with comparisons to the facilities identified infections in the prior year or month to month. She said this was not done. With additional review, there was no Infection Surveillance summary report for January, February or March 2023 and the information was not reported for April 2023. The IP Q said the goal would be for the facility to meet monthly and report and compare their own infection surveillance findings to promote a decreased risk of the spread of infection. The IP also identified that the facility had an outbreak of Covid-19 beginning in February 2023 and continuing into March 2023. The facility was reporting data, but it was not analyzed to determine the facility's trends from month to month, quarter to quarter or year to year; to aid in identifying focus areas, and needed interventions to aid in decreasing the rates of infection. APIC Text: Long-Term Care- October 2, 2014, and 2023, Hospitals that participate in Medicare/Medicaid are required to use the National Healthcare Safety Network (NHSN) criteria for surveillance definitions. However, NHSN definitions do not address the unique issues of the LTCF (Long-term care facility) and therefore may not always be appropriate for meaningful surveillance in the LTCF. In 2012, the Society for Healthcare Epidemiology of America ([NAME]) and CEC released updated surveillance definitions for LTCF's (often referred to as the McGeer criteria). These definitions are widely used in LTCF's because they address common LTCF issues . APIC Text: Infection Prevention and Control Programs-, February 1, 2021, . dissemination of infection prevention information is a crucial component of an infection prevention and control program . Further review of the facility policy titled, Infection Prevention and Control Program, effective date December 1, 2018 and reviewed 10/2021 provided, . Purpose of Policy: To provide a guideline for establishing and maintaining an infection prevention and control program . Written standards, policies, and procedures for the program, which must include, but are not limited to: . When and whom possible incidents of communicable disease or infections should be reported . The facility will conduct an annual review of its infection prevention and control program and update their program, as necessary.

Based on observation, interview and record review, the facility failed to properly secure a medication cart with medical supplies and prescription medications for the Long Hall medication cart, resulting in the medication cart left unlocked and not under direct supervision of the Nurse with the potential for drug diversion and ingestion of prescription medications. Findings include: On 10/18/23 at 12:05 PM, an observation was made of the Long Hall medication cart not locked and without a Nurse within the vicinity of the medication cart. An observation was made of staff in and out of the Nurses' Station and Resident's in the hallway. While waiting for the Nurse to return, an observation was made of Nurse K coming from the short hallway and returned to the cart. The Nurse had a cup with medication in her hand. When asked about the unsecured medication cart, the Nurse reported that she was responding to a call for help with an altercation between the housekeeping staff and a resident, and reported she was just around the corner and had taken the medication with her which was the cup in her hand with medication in it. The observation was reviewed of the medication cart unlocked and not under supervision of the Nurse. The Nurse responded that she had responded to a call for help and had not locked her cart. The Nurse then left the medication cart area and delivered the medication to a Resident whose room was across the hall and down a short distance from where the medication cart was positioned. The Nurse walked into the Resident's room and was not able to be seen from where this surveyor stood by the unlocked medication cart. When the Nurse returned, the observation of the Nurse not within sight of the unsecured medication cart was reviewed with the Nurse. The explained that she had been right there and indicated the Resident's room where she had passed the medication. On 10/18/23 at 12:15 PM, an interview was conducted with Housekeeping Staff D regarding the altercation with a Resident. The Housekeeping staff was around the Nurses' Station in the shower room that was partially down the short hall of the unit. The Housekeeping Staff indicated she had a Resident that she needed help with, had called out for help and Nurse K came over and took care of the situation. When asked where the Resident and Nurse were at, the Housekeeping staff indicated in the hallway outside the door of the shower room. An observation was made of the medication cart in the long hall of the unit not within visual sight. On 10/25/23 at 3:30 PM, an interview was conducted with the Director of Nursing (DON) of the observation of the unsecured medication cart left unattended in the long hall of the unit. The DON indicated she was aware of the unsecured and unattended medication cart. A review of the facility policy titled Medication Administration General Guidelines, effective date March 2009, revealed, .Procedure: .XV. During routine administration of medications, the medication cart is kept locked with computer closed or under direct observation of authorized staff .

Based on interview and record review, the facility failed to ensure that a timely Preadmission Screening/Annual Resident Review (PASARR) for a comprehensive level II OBRA evaluation was completed for one resident (Resident #14) of one resident reviewed for PASARR review, resulting in the potential for delayed mental health services and unmet care needs. Findings include: Resident #14: A review of Resident #14's medical record revealed an admission into the facility on [DATE] with diagnoses that included weakness, altered mental status, Alzheimer's dementia, PTSD (post-traumatic stress disorder), and depression with anxiety. Review of the Minimum Data Set assessment, dated 7/19/23 revealed the Resident had moderately impaired cognition and needed extensive assistance with bed mobility, dressing, and personal hygiene and was dependent on staff for transfers and toilet use. Further review of Resident #14's medical record revealed PASARR form DCH-3877, dated 2/15/23, had in Section II-Screening Criteria, was marked Yes 1. The person has a current diagnoses of Mental Illness and Dementia were marked; Yes 2. The person has received treatment for Mental Illness was marked; and 4. Yes There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. The next portion of the form revealed, Explain any Yes and Resident has an Alzheimer Dementia diagnosis, PTSD, and depression. Resident is not on any psychotropic medications. The directions on the bottom indicated, Distribution: If any answer to items 1-6 in Section II is yes, send one copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. The same form was filled out with the same information dated 8/2/23. There was not a DCH-3878 in the medical records. On 10/18/23 at 1:02 PM, an interview was conducted with Social Services Director (SSD) B regarding Resident #14's PASARR documentation. The SSD reported that the DCH-3877 was completed in February 2023, and the Doctor was to fill out the DCH-3878 but had not done so and the Director of Nursing had filled out another DCH-3877 in August 2023 when they realized it was not completed back in February. The SSD indicated she would find out if it had been completed. The SSD indicated that the Resident had a diagnosis of Alzheimer's dementia diagnosis and the last one done in February of 2023 had a modified code in there and when the Social Worker was reviewing the PASARR's, they realized the 3878 was not completed. The SSD indicated that it should have been done back in February. On 10/18/23 at 2:38 PM, an interview was conducted with the SSD B. The SSD indicated that the last submitted annual review was in February of 2022. The SSD reported that the 3877 had gone to the Doctor and that it was still in their queue to be completed from August. The SSD indicated they had done a reminder, but it had not been followed through and stated, It's a fix that needed to be done. On 10/25/23 at 4:00 PM, the SSD was asked about facility policy for PASARR's. The SSD reported that their policy needed to be updated and she had the information from Leading Age to update the facility policy.

Based on observation, interview and record review, the facility failed to ensure that care plans were evaluated, revised and/or updated for two residents (Resident #15 and Resident #17), of 14 residents reviewed for care planning, resulting in the lack of care plan revision and implementation of appropriate interventions and the potential for unmet care needs. Findings include: Resident #17: A review of Resident #17's medical records revealed an admission into the facility on [DATE] and re-admission on 5/24/23 with diagnoses that included dementia, Alzheimer's disease with behavioral disturbance, Parkinson's disease, generalized weakness, emphysema, and major neurocognitive disorder. Review of the Minimum Data Set (MDS) assessment, dated 9/14/23, revealed the Resident had severely impaired cognition and was total dependent on staff for activities of daily living such as bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. The MDS indicated the activity of walk in room and walk in corridor did not occur-activity was not performed by resident or staff at all over the entire 7-day period. A review of Resident #17's care plan included the following: -Dated 7/12/21 with a readmitted date 5/24/23-Problem: Resident has a potential for decline in ambulation that will affect locomotion on and off unit. Expected Outcome: Resident will not have a decline in ambulation to the point that a wheelchair will be the main source of locomotion for resident within the next 90 days. Interventions included: Resident is in the walk to dine program, unit staff to ambulate resident to and from day room for meals; dated 7/21/21, To enhance restorative program and increase ambulation, unit CNA's to ambulate res. To day-room for meals, 2 assist FWW gait belt, w/c (wheelchair) to follow; 4/10/23 See ADL (activities of daily living) care plan. -There was not an ADL care plan. -Yellow highlighted areas throughout the care plan but did not indicate if the highlighted areas were discontinued and not dated as discontinued. -Multiple entries written in and not dated of with the entry was started. -Multiple entries were crossed off but did not indicate the date the entry was discontinued. -Dated 5/24/23 readmitted , Problem: Altered Cognition/Communication. Expected Outcome: New Goal-7/11/23. Resident will continue to exhibit no sign of pain for next MDS Pain assessment for next care conference meeting. The expected outcome did not address the Problem. -Dated 5/24/23 readmitted , Problem: Bowel and Bladder maintenance with an expected outcome dated 7/11/23, New Goal: Resident will not obtain any skin breakdown at peri-area through to next care conf meeting review. The expected outcome did not address the bowel and bladder maintenance. On 10/18/23 at 1:49 PM, an interview was conducted with the Director of Nursing (DON) regarding the care plan for Resident #17. The care plans were reviewed. When asked if Resident #17 continues to walk to the dining room, the DON indicated he no longer walks to the dining room and will check to see when he last accomplished that intervention. When asked about the ADL care plan the DON reviewed the care plans and indicated there was not an ADL care plan and that there should be one. The DON was asked what the yellow highlighted areas indicated and if that was facility policy when that documentation was discontinued. The DON indicated she was not sure what the highlighted areas meant and stated, I can't answer you, and reported that discontinued items would be crossed off and marked as d/c. The bowel and bladder maintenance problem was reviewed with the outcome of skin breakdown and the DON indicated it could be a goal due to incontinence causing skin breakdown but that the expected outcome did not address bowel and bladder maintenance. The Altered cognition/communication problem with expected outcome addressing pain was reviewed and the DON agreed that expected outcome would be for the pain care plan. When asked about dating the discontinued items and the written-in entries, the DON indicated they should be dated. On 10/18/23 at 2:06 PM, an interview was conducted with MDS Nurse F regarding Resident #17's care plan. The Nurse indicated that she had other Nurses helping with care plans, but she had not had the chance to go through any issues with care plans. A review of the concerns of Resident #17's care plan was reviewed with the MDS Nurse. The Nurse indicated that her goal was to take the care plans and update them on the computer. When asked about the yellow highlighted areas, the MDS Nurse indicated that those were discontinued and that they should have initials and d/c by the entry. The MDS Nurse indicated that problems, goals, and interventions should be dated when a new entry into the care plan was made. A review of facility policy titled, Comprehensive Resident Care Plans, effective date 2/2008, revealed, Procedure: 1. Guidelines: . C. Following Interdisciplinary Team conference the care plan is reviewed and updated . a. In each resident's Comprehensive Care Plan the Interdisciplinary Team will: Address identified problem areas; Incorporate risk factors associated with identified problems; Build on resident strengths; Reflect the resident/responsible person's whishes regarding care and treatment goals; Identify treatment goals, timetables and objectives in measurable outcomes . G. Discontinued care plans or portions of the care plan are yellowed out and dated with initials . IV. Planning and Setting Goals A. Planning and setting goals are whenever possible, a team effort by the interdisciplinary team, resident and family/responsible party. B. Goals are realistic. C. Goals must be stated in terms of behavior that is both specific and measurable within a given time . VI. Evaluation . B. When the goal is achieved, the problem and goal are yellowed out with date and initials of the person deleting the problem/goal. C. Establish a new time frame or other approaches to be taken to meet the resident's needs more adequately . 37666 Resident #15: Care Planning: On 10/17/23 at 12:12 PM, Resident #15 was observed sitting in a wheelchair in his room. A door alarm was positioned across the top of his door and alarmed loudly when anyone attempted to enter or exit the room. The resident was asked why he had a door alarm and he shrugged his shoulders and said, I don't know. Nurse I said it was there so the staff could monitor him when he exits the room. She said he had behaviors and was verbally too friendly with the ladies at times. The resident was observed while 2 staff assisted him while he ambulated from his room to the dining room. A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #15 indicated an admission to the facility on [DATE] with diagnoses: Hypertension, history of urinary urgency, benign prostatic hyperplasia, history of a stroke, depression, kidney disease, weakness and Dementia. The MDS assessment dated [DATE] identified the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and needed assistance with all care. The Section E- Behavior section revealed the following: A.) Physical behavioral symptoms directed towards others . Behavior not exhibited; Verbal behavioral symptoms directed toward others . Behavior not exhibited; Other behavioral symptoms not directed toward others . Behavior not exhibited. E0900. Wandering -Presence & Frequency- Behavior not exhibited. On 10/18/23 at 2:43 PM, the Social Worker B was interviewed about the alarm on Resident #15's door. She stated, It was after he had Covid and came back from another facility. He was going in and out of other resident's rooms, possibly related to Covid. He also used to blow kisses to other residents. He is Italian and that could be from his culture. I tried to explain to him that not everyone has the same beliefs I just did his quarterly note, and he has done really well, he has had no instances of issues. He no longer wanders. I think it could have been from Covid. Asked the Social Worker if the resident will always have the laser alarm, as it is loud, and the resident is not sure why he has it. The Social Worker B said the resident's care conference was planned for next week and she would have a discussion with the team and family to determine if it is the most appropriate intervention. A review of a provider progress note dated 9/5/2023 had no mention of the door alarm or reason that it might be needed. A review of the physician orders report revealed: 1:1 supervision while in dayroom, undated. There was no mention of the door alarm. A review of the Care Plans for Resident #15 identified the following: I am at risk for altered impulse control and judgement in terms of interpersonal reactions and connections related to history of CVA (cerebrovascular accident/stroke); I have greeted people with gestures of hand kissing and/or blowing kisses as a sign of respect and politeness; I may need reminders that other resident may not share my same culture and diversity . dated 2/14/2023. There was no mention of a door alarm and each of the interventions was not dated to indicate when they were enacted. A review of Resident #15's Care Plan titled, Resident is at Risk for Accidents . dated 3/5/2020 and reentry 10/5/2021 identified 4/22/21 Doorway laser alarm-chime dc'd (discontinued), 10/24/2021. A review of each of the Care Plans for Resident #15 did not identify a current intervention of a door alarm or why it would be used.

Based on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services were provided to one resident (Resident #25), of one resident reviewed for Hospice services and end-of-life care, resulting in a lack of coordination of comprehensive services and care provided to the resident and the potential for unmet care needs. Findings include: Resident #25: A review of Resident #25's medical record revealed an admission into the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction, anxiety, atrial fibrillation, mood disorder, and Alzheimer's dementia. A review of the Resident's Minimum Data Set assessment, dated 9/14/23, revealed the Resident had severely impaired cognition and needed limited assistance with bed mobility, transfer, walk in room, dressing, toilet use and personal hygiene. Further review of the medical record revealed the Resident was receiving Hospice services. On 10/17/23 at 2:14 PM, the Resident was seen sitting on the bench in the hallway. The Resident was dressed and clean. The Resident was asked some questions, but answers were not reliable, and the Resident did not engage in conversation but was pleasant in nature. Multiple observations were made earlier in the morning of the Resident sitting on the bench or walking unassisted near the Nurses' Station with staff interacting at times with the Resident. A review of Resident #25's medical record revealed no documentation of Hospice staff visits. A review of the binder for Resident #25's Hospice care was reviewed and lacked documentation of communication with the Hospice services and there was no calendar to indicate when Hospice services were to be conducted and who from the Hospice team had or will be seeing the Resident. There was no plan of care from the Hospice service. On 10/25/23 at 3:38 PM, an interview was conducted with the Director of Nursing (DON) of Resident #25's Hospice communication with the facility. When asked about the communication with the facility, the DON indicated that the binder should have the communication. When reviewing the binder with the DON and the paper chart, there was no documentation of the Hospice visits. The DON stated, They use to leave notes in the book. They should be in the notebook (binder). and made a call to have staff call the Hospice service for the visit notes to be sent to the facility. When asked when the Nurse was last in to see the Resident, the DON was unsure and stated, I think she was here last week. When asked what the CNA's (certified nursing assistants) accomplish when they come in, the DON indicated she did not think that a Hospice CNA comes in to work with the Resident. When asked for a calendar to indicate who was seeing the Resident and when, the DON indicated they did not have a calendar and that the Nurse usually comes in once a week. On 10/26/23 at 11:56 AM, an interview was conducted with the Assistant Director of Nursing (ADON) A regarding Resident #25's Hospice services. When asked about Hospice Nurse visits and when the Nurse was last in to visit the Resident, the ADON indicated the Hospice Nurse had been there last Friday. The ADON was asked for the communication of the visit, but the ADON indicated the facility did not have the communication of the Nurse visits. When asked about Hospice CNA visits, the ADON indicated that the facility CNA's shower the Resident and was unaware of CNA visits. A review of facility policy titled, Hospice Residents, effective date 8/2011, revealed, .D. Hospice Plan of Care-A written hospice plan of care must be established and maintained in consultation with a facility representative. All hospice care provided must be in accordance with this hospice plan of care. 1. The hospice plan of care will identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. 2. The hospice plan of care will reflect the participation of the hospice, the facility and the patient and family to the extent possible . E. Coordination of services. 1. The hospice will designate a member of each interdisciplinary group that is responsible for a resident of the facility. The designated interdisciplinary group member is responsible for: a. Providing overall coordination of the hospice care of the facility resident with the facility representatives; and b. Communicating with the facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family.

Based on observation, interview and record review, the facility failed to institute, implement, and operationalize systemic policies and procedures to ensure the provision of comprehensive and accurate pharmaceutical services pertaining to and including 1) The acquisition and verification of delivered medication; 2) The accurate recording and documentation of dispensed medications; 3) Accurate medication labeling; 4) The accurate documentation of controlled (narcotic) medication counts on a shift-by-shift basis; 5) The documentation, reconciliation, and ongoing monitoring of medication orders; 6) Dating of medications; 7) The disposal of expired medications, and 8) The accurate documentation of narcotic medication administration for 10 sampled residents (Resident #13, Resident #101, Resident #102, Resident #103, Resident #104, Resident #105, Resident #106, Resident #107, Resident #108, Resident #109) and three unsampled of 11 Residents reviewed for pharmaceutical services. This deficient practice resulted in documentation of Resident #101 receiving double the prescribed dose of a controlled, antianxiety medication seven times in a two month period, Resident #13 and 101's controlled medication labels having inaccurate order information, incomplete documentation of a missing and then administered narcotic for Resident #103, administration of an expired medication to Resident #13, and medication labels with administration instructions different than the health care provider order, and the likelihood of residents not receiving prescribed medications, administration of incorrect medication dosages and/or at incorrect frequencies, undetected narcotic diversion, and possible alterations in overall health and well-being. Immediate Jeopardy: The Immediate Jeopardy began on 01/24/2022. The Immediate Jeopardy was identified on on 01/24/2022. The Administrator was notified of the Immediate Jeopardy on 1/25/2022 at 12:15 PM. A plan to remove the immediacy was requested. The IJ was removed on 01/25/2022 based on the facility's implementation of the plan removal as verified onsite on 01/27/2022. Although the IJ was removed, the facility's deficient practice remained at a scope isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An interview was completed with Social Worker A on 1/24/21 at 1:45 PM. When queried regarding if any facility residents were currently receiving and/or had an order for as needed (PRN) psychoactive medications, Social Worker A replied, No. On 1/24/22 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). When queried, the DON revealed there were no residents in the facility who were receiving PRN psychotropic medications. Upon request for a report of facility residents with PRN medication orders, the DON revealed they were unable to generate a report from their Electronic Medical Record (EMR). When queried how the facility monitored PRN medications, including psychoactive medications, the DON replied staff talk about it. When queried regarding facility policy/procedure to ensure new PRN medication orders are not missed if ordered on a weekend and/or night shift and not passed in nurse-to-nurse report, the DON was unable to provide an explanation. The DON revealed Unit Secretary/Certified Nursing Assistant (CNA) F was the EMR superuser and may be able to help. The DON also indicated they would check with pharmacy as well. An interview was conducted with Unit Secretary/Certified Nursing Assistant (CNA) F on 1/24/22 at 2:25 PM. When queried regarding facility policy/procedure pertaining to medication order entry and if nursing staff enter Health Care Provider orders into the EMR, Unit Secretary/CNA F stated, No, I put in the orders and then the nurse verifies. Unit Secretary/CNA F was asked for clarification regarding what type of orders they were entering into the EMR and revealed the facility had two physicians and both physicians entered orders differently. Per Unit Secretary F, Physician E entered their own orders electronically and Physician G wrote all their orders. Unit Secretary/CNA F indicated they entered all of Physician G's written orders into the EMR. When queried concerning telephone orders received by nursing staff, Unit Secretary/CNA F stated they enter the orders the nurse tells me to. With further inquiry, Unit Secretary/CNA F clarified they enter orders for medications and treatments when told to do so by nursing staff without a written physician order. Unit Secretary/CNA F was then asked about the process/procedure for controlled drugs and psychoactive medication initiation/orders and replied, If they (psychiatric provider) orders something then our doctors order it. Unit Secretary/CNA F indicated they would made aware of the order at that time. When asked about orders initiated when they are not working such as at night and on weekends, Unit Secretary/CNA F revealed nursing staff enter the orders and then communicate to the next shift. Unit Secretary/CNA F was then asked if it is possible for nursing staff to forget to communicate the information regarding the medication order and replied, Yes. When queried how they would know about the order/order change if not communicated, Unit Secretary/CNA F revealed they did not have a process in place to ensure validation and accuracy of medication orders with pharmacy. On 1/24/22 at 2:35 PM, the DON provided a list titled, Rx's for (facility) and revealed the facility pharmacy was able to print a report. Review of the report revealed the following for Resident #101, Lorazepam (controlled psychoactive antianxiety medication) 0.5 mg (milligrams): Take ½ tablet by mouth twice a day as needed . (Physician E) . Next Fill Due: 2/5/22 . An interview was conducted with Pharmacist C on 1/24/22 at 2:40 PM. When queried regarding the list of Resident medication orders they provided to the facility, Pharmacist C indicated the list provided was reflective of all the PRN medication orders for facility residents. Pharmacist C was then queried regarding Resident #101's PRN Lorazepam order including the date the medication was ordered and stated, That is the most recent script number. With further inquiry, Pharmacist C revealed Resident #101's original order was on 11/19/21 for Lorazepam 0.5 mg ½ tab PRN TID (three times a day) then got a clarification (order) for PRN BID (twice a day). Pharmacist C was queried regarding the process/procedure in which medications are ordered and how the pharmacy receives and fills medication orders and replied, For (Physician E) scripts are electronically sent though ChartLink (system). When queried regarding the end date for orders, Pharmacist C replied, (Physician E) reviews and approves the orders. When asked why facility staff had stated no residents had PRN psychotropic medications, Pharmacist C was unable to explain the discrepancies and reiterated that was the most recent order they had for (Resident #101's) Ativan (Lorazepam). Resident #101's medications, including controlled medications, within the medication cart was completed on 1/24/22 at 3:00 PM with Licensed Practical Nurse (LPN B). The label on the front of Resident #101's narcotic medication package detailed, Lorazepam 0.5 mg . Take ½ tablet by mouth twice a day as needed . The corresponding Receipt and Disposition of Scheduled Drugs form did not include the medication order. When queried regarding the label on Resident #101's Lorazepam indicating the medication was for PRN administration, LPN B replied, It is scheduled. When asked why the label did not indicate the medication was scheduled, LPN B was unable to provide an explanation. LPN B proceeded to open Resident #101's Medication Administration Record (MAR) in the EMR. The MAR indicated the medication was scheduled BID. When queried regarding facility policy/procedure regarding medication administration, including implementation of the Five Rights of medication administration, when the label did not match the order, LPN B replied, We scan the med. No further explanation was provided. An interview was conducted with the DON on 1/24/22 at 3:15 PM. The DON was asked about pharmacological services for the facility and revealed the facility had a contract with a local pharmacy. When queried regarding why the provided Rx's for (facility) list indicated Resident #101 had an order for PRN Lorazepam when they had stated no facility residents had PRN psychotropic medication orders, the DON stated, Pharmacy probably entered it (order) wrong. When asked why the label on Resident #101's Lorazepam medication container also specified the medication was PRN, the DON did not provide an explanation. On 1/24/22 at 4:30 PM, an interview was completed with Pharmacist D. When queried regarding the provided Rx's for (facility) list and Resident #101's Lorazepam medication container card both reflecting the Resident received the medication on a PRN basis, Pharmacist D replied, It does say that. Pharmacist D was queried regarding the facility/pharmacy procedures related to the acquisition, receipt, dispensing, and accounting for medications including controlled medications and replied, Whatever (order) is in CPSI (EMR system) is what is ordered. Pharmacist D indicated what medication ordered is then filled and sent to the facility. When asked about the discrepancy in Resident #101's Lorazepam medication order between the pharmacy, facility, and label, Pharmacist D stated, The PRN is based on the pharmacy. If it was PRN previously then possible that is correct. Pharmacist D was then asked where the problem occurred with the medication and stated, I would say it is with checking the order. When queried how to identify the cause of the error with the order, Pharmacist D stated, If (staff) are not double checking (order and label) here, then we wouldn't know. Resident #101 Record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (abnormal heart rhythm), weakness, anxiety disorder, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS section titled, Medications Received revealed Resident #101 received an Antianxiety medication six out of the previous seven days. Review of Resident #101's Health Care Provider orders for Lorazepam revealed the following: - Lorazepam Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: PRN TID (three times a day) . Start Date: 11/19/21; Stop Date: 11/26/21 . Ordered: 11/19/21 (Physician E) . Entered 11/19/21 (Physician E) . Nursing Verified: 11/26/21 Pharmacy Verified: 11/20/21 . - Lorazepam Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: PRN TID . Start Date: 11/26/21; Stop Date: 12/1/21 . Ordered: 11/26/21: (Physician E) . Entered: 11/26/21: (Unit Secretary/CNA F) . Nursing Verified: 12/1/21 (Registered Nurse [RN] I) . Pharmacy Verified 11/26/21 . - Lorazepam Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: BID . Start Date: 12/1/21; Stop Date: 12/25/21 . Ordered: 12/1/21 (Physician E) . Entered: 12/1/21 (RN I) . Nursing Verified: (Blank); Pharmacy Verified: 12/25/21 . Further review of Resident #101's Receipt and Disposition of Scheduled Drugs forms included sections for date, drug name, strength, quantity, pharmacist, unit, who received the drug, date received, and prescription number. The form detailed, Nurse signing for drugs must fax this form to (Pharmacy) . and included the following sections for documentation of the controlled medication: Date . Time . Dose . Dosage Given . Dosage Wasted . Administered by . In-depth analysis of Resident #101's of Receipt and Disposition of Scheduled Drugs forms dated 12/3/21 and 12/21/21 revealed the following: -12/17/21 at 9:15 AM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/24/21 at 8:19 AM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/25/21: Unable to read Lorazepam dosage given amount -12/26/21 at 8:23 AM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/27/21 at 8:16 AM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/28/21 at 9:31 AM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/29/21 at 9:06 PM: Lorazepam dosage given: 0.5 mg, Wasted: None -12/30/21 at 7:32 AM: Lorazepam dosage given: 0.5 mg, Wasted: None Additionally, there were noted discrepancies in the method of documentation of the Lorazepam dosage given for Resident #101's Receipt and Disposition of Scheduled Drugs forms dated 11/2/21, 12/3/21, 12/21/21, and 1/4/22. The actual milligrams administered was documented by some staff, others were documenting the number 1 or 1/2 tab in the Dosage Given category. Review of Resident #101's care plan revealed a care plan entitled, Resident is unable to function at previous ADL ability Medical status compromised by acute COPD . Xanax (Alprazolam- controlled, anti-anxiety medication) is a home med . Xanax being very effective for SOB (Shortness of Breath) . No psychiatric DX (diagnosis) . (Dated: 11/30/21). The care plan included the Expected Outcome . Resident will continue to verbalize Xanax being effective for SOB related to COPD by next review . Review of Resident #101's medication orders since admission revealed the Resident had never had an order for Xanax while a resident at the facility. On 1/24/22 at 5:09 PM, Pharmacist D indicated they had additional information related to Resident #101's Lorazepam. Pharmacist D stated, (Pharmacist C) was aware of the discrepancies and potential for errors. Pharmacist D continued, (Physician E) wants to be the one to enter orders. When queried when they identified the potential, Pharmacist D replied, Well, in December (2021) (Pharmacist H) did not catch the order change. When queried regarding policies and procedures related to double checking medications and orders, Pharmacist D indicated facility staff are responsible to check the medications. Pharmacist D was then asked if they were saying that facility staff are not checking resident medications/orders and stated, I would say that's probable. When queried regarding the process for Receipt and Disposition of Scheduled Drugs forms, Pharmacist D stated, Don't look at them. When queried how verbal orders for medications are received by the pharmacy to be filled, Pharmacist D replied, Prints to a printer at the pharmacy. When queried if pharmacy staff play a role in verification of a stop date on PRN psychoactive medications, Pharmacist D stated, I don't think so. An interview was conducted with the DON on 1/24/22 at 5:25 PM. When asked about facility policy/procedures regarding review of Receipt and Disposition of Scheduled Drugs forms to ensure accurate reconciliation and accounting for controlled medications, the DON revealed they do not review the forms. When queried how they account for the controlled medications to identify, evaluate, and resolve potential concerns, the DON did not provide further explanation. When queried regarding documentation for Resident #101 indicating they had received the incorrect dosage of Lorazepam seven times, the DON replied, I don't know. They got the right dose. We scan it. The DON was asked if staff are able to bypass scanning and still administer medications and indicated they were not aware that was possible. The process for bypassing medication scanning in CPSI EMR system was discussed with the DON at this time and a report of medications administered without being scanned for Resident #101 was requested. An interview was conducted with the DON and Assistant Director of Nursing (ADON) on 1/25/22 at 9:45 AM. When queried regarding facility policy/procedure for medication orders and communication with pharmacy, the DON indicated all orders are entered in CPSI and electronically transmitted to pharmacy. When queried regarding both them and the Pharmacist D stating they do not review the Receipt and Disposition of Scheduled Drugs forms and how the facility is able to ensure a system is in place to ensure accountability and prevent diversion of controlled medications, the DON indicated they look at the forms. When asked why they stated they did not look at the forms on 1/24/22, an explanation was not provided. When queried why they were not aware of nor had they addressed the administration dosage documentation discrepancies for Resident #101 if they were reviewing the forms, the DON did not provide an explanation. When queried regarding incorrect administration instructions and labels on narcotic medication, the DON stated, There are two labels (on controlled medication bubble packs). One on the front and one on the back. The back label is from CPSI and the front is from pharmacy. When asked why the labels would be different, the DON reiterated they were either printed from the pharmacy or from CPSI. When queried why the medication labels do not always match and how safe medication administration is completed with incorrect and/or contradictory medication labels, the DON did not provide an explanation. On 1/25/22 at 10:35 AM, an interview was conducted with RN I. When queried regarding facility policy/procedure for medication order entry, RN I revealed nurses, unit secretaries, and (Physician E) all enter orders into the EMR. When asked if nursing staff are supposed to verify medication orders prior to administrator, RN I indicated they were. Resident #101's Lorazepam orders were reviewed with RN I at this time. When asked why Resident #101's Lorazepam order (start date: 11/26/21) was ordered by Unit Secretary/CNA F on 11/26/21 and administered 14 times prior to being verified by nursing staff, RN I was unable to provide an explanation. With further inquiry, RN I revealed the Resident's Lorazepam order was changed to scheduled on 12/1/21 following a care conference and they had entered the order. When queried regarding other staff indicating Physician E always entered their own orders but had not entered the orders for Resident #101's Lorazepam, RN I revealed the Physician entered most of the orders. When queried regarding documentation of contacting the Physician, RN I stated, I contacted them via tiger text. When asked if tiger texts are part of the medical record, RN I revealed they would have to check. Review of Resident #101's Progress Note documentation in the EMR revealed a Social Services note dated 12/1/21. The note detailed, Psychiatric Diagnosis: Resident is on Ativan for anxiety related to COPD . (Physician E) ordered Ativan 0.25 mg PRN TID on 11/19/21 . Resident's use of PRN Ativan was discussed . at care conference . Resident had been taking Ativan at home . twice daily . According to MAR, Resident is taking Ativan 1-2 times daily . Resident would prefer it be scheduled for twice daily . Nursing will send a communication to (Physician E) . An interview was completed with the ADON on 1/25/22 at 11:00 AM. When queried regarding the rationale for Unit Secretaries entering verbal orders for medications in the EMR, the ADON stated, I don't know. Someone told them to. The ADON was then asked where there is documentation and/or proof showing that the medication was ordered. The ADON replied, I see what you are saying. When queried regarding facility policy/procedure related to verbal orders including what staff are allowed to take and/or enter orders, the ADON stated, Maybe we will not have the ward clerk enter orders anymore. An interview was completed with Unit Secretary/CNA F on 1/25/22 at 11:30 AM. When queried regarding medication order entry, Unit Secretary/CNA F revealed they entered orders received verbally from nursing staff when asked in order to assist nursing staff. At 4:00 PM on 1/25/22, an interview was conducted with Resident #101 in their room. When queried if they knew what medications they take, Resident #101 replied, I did but I probably couldn't say. I know I take Eliquis (anti-coagulation medication). Resident #101 was then asked if facility nursing staff tell them what their medications are when they administer their medications and stated, No, but I know I take a heart pill too. When queried if they took any medications for their nerves or anxiety, Resident #101 stated, No, I don't think so. A tour and count of the long hall facility medication cart, including the controlled substances, was completed with RN I on 1/25/22 at 15:15 PM. The following expired medications were noted in the medication cart: - Antidiarrheal, Loperamide 2 mg tablets; Expired 1/22. Quantity: 24 tablet container - Iron 324 mg tablets; 1000 count bottle; Expired 1/22. When queried regarding the date of the month medications expire when only a month is listed, RN I replied, The first and indicated they would dispose of the medications. Resident daily, non-controlled medications, were noted to be in plastic, reusable box containers with clear plastic, pop-open tops to access the medication. Labels with the resident name and medication were present on the container. The printing on the labels was dull, as though done with a printer with low ink. When queried regarding the process in which the medications are received/filled from pharmacy, RN I revealed the medication containers are filled at the local pharmacy and delivered to the facility. When asked if they had ever encountered any concerns with the process, RN I revealed they had received medications for resident that looked different than normal and had to verify the medications. RN I stated, It was the wrong meds. When asked how often that had happened, RN I replied, More than it should. RN I was asked what they did when that happened and replied, Contact the pharmacy and not give the med. When queried if they completed a variance report or Incident and Accident report, RN I indicated they did not and were just supposed to contact pharmacy. When asked, RN I was unable to recall a specific resident. The following controlled substances were noted in the medication cart: - Resident #13: Lorazepam 0.5 mg medication package. Directions: Take 1 tablet by mouth every four hours as needed. The corresponding Receipt and Disposition of Scheduled Drugs form revealed the medication was received by the facility on 10/25/21. - Resident #102: Norco (narcotic pain medication) 5/325 mg medication package. Directions: Take 1 tablet by mouth every six hours as needed for pain. The number 14 pill bubble was noted to be circled on the package in ink. Clear, office tape was present on the back of the number 14 pill bubble and there was no pill present in the bubble. The corresponding Receipt and Disposition of Scheduled Drugs form revealed Missing was written on the number 14 tablet line with a line drawn through it. The med was then documented as administered on 10/26/21 at 5:07 AM. When queried regarding Resident #13's Lorazepam order, RN I revealed the medication was ordered daily. When asked about Resident #102's Norco, RN I was unable to provide an explanation. An interview and review of medications was completed with the ADON on 1/25/22 at 4:50 PM. When queried regarding observation of Resident #102's Norco and how the medication was able to be administered if it was missing, the ADON was unable to provide an explanation. Upon review of the medication package, label, and narcotic sign out sheet, the ADON revealed the nurse signature who had administered the number 14 Norco was RN K. When queried by Resident #13's Lorazepam label indicated the Resident was to receive the medication on a PRN basis when the medication was ordered as scheduled daily, the ADON indicated they were unaware it was. A photocopy of Resident #13's medication bubble pack with label was reviewed with the ADON at this time. The ADON pointed out a small, unremarkable sticker, which was previously not noticed with the phase Directions Changed Refer to Chart was present below the label. The ADON revealed pharmacy would place the stickers instead of replacing the label. When asked why the pharmacy did not replace the label and/or why the sticker was not more noticeable, the ADON revealed that is just how pharmacy has always done it. The ADON did not elaborate further regarding pharmacy practices. The ADON then stated, They (pharmacy) should just replace it (label). The ADON then stated they had been informed by the DON that pharmacy already came to the facility updated the labels and stickers to ensure all the meds were correct and would scan. An interview was conducted with RN K on 1/25/22 at 7:55 PM. When queried regarding Resident #102's Norco including Controlled Substance sheet, RN K stated, I don't remember. RN K then stated, Maybe someone pulled it from the wrong pack, and it was missing but then we found it. RN K continued, I don't remember crossing off missing. I think it had to have been found before I gave it. With further inquiry, RN K stated, Someone may have pulled out (Resident #102's) card and scanned it. When queried how that could happen, RN K explained that the medication scanning is specific to the medication, not the Resident. RN K provided an example, Patient A and patient B are both on Norco. Someone could have pulled the Norco from patient B's card, scanned it, and given it to patient A. The scanner for the meds will scan and work no matter which patient is getting it. Then they replaced it. When asked if they were saying the medication was then removed from patient A's card and placed in patient B's card, RN K replied, Yes. RN K was queried hour the medication was able to be put back in the bubble pack after the seal was broken, RN K replied, Tape it. When queried if that happened frequently, RN K did not directly respond but revealed it does happen. RN K was then asked what nursing staff are supposed to do, per facility policy/procedure, if that situation were to happen and replied, Probably waste it (medication). An interview was conducted with the DON on 1/26/22 at 9:00 AM. When queried regarding accurate reconciliation and monitoring of controlled medications related to Resident #102's Norco, the DON stated, It was documented as given. Not missing. With further inquiry regarding how a narcotic medication be marked as missing and then administered without any documentation, waste, double staff signature, and/or administrative involvement to ensure prevention of diversion, the DON did not provide an explanation. When queried regarding Resident #13's Lorazepam continuing to be labeled as PRN on 1/25/22, the DON restated that the medication packs contain two labels. When queried if they were saying that it is acceptable for one label to be incorrect, the DON replied, No. No further explanation was provided. The DON then revealed all medications in the facility had been checked by pharmacy and were corrected. When queried how many Resident medication labels were incorrect and needed to be corrected the DON replied, None. When asked about the label on Resident #13's Lorazepam indicating the medication was PRN and not scheduled, the DON stated, I don't know. When queried if the label stating the Lorazepam was PRN was incorrect, the DON replied, Yes. The DON then stated, (It) was corrected. On 1/26/22 at 9:30 AM, a tour of the long hall medication/treatment cart was completed with RN I. The following were noted: - Flonase Nasal Spray for Resident #107. The open dates 12/15/21 and 12/28/21 were both written on the container. -Latanoprost 0.005% Ophthalmic Solution (prescription eye medication) for Unsampled Resident #1. The medication was opened and undated. -Carbamide Peroxide 6.5% solution for Unsampled Resident #1. The medication labeled indicated it was to be used BID. -Nystop Powder (prescription anti-fungal medication) 60 grams (gm) for Resident #109. The label detailed, Apply three times daily. RN I stated, No, this is PRN. -Brimonidine 0.2 % Ophthalmic Solution for Resident #13. The dated written on the medication included, Open: 12/14/21; Expire: 1/11/22. When queried if Resident #13 had an order and/or was receiving the Brimonidine 0.2% Ophthalmic Solution, RN I replied, Yes, I gave it last night. RN I revealed they had not seen the expiration date and that Resident #13 had been receiving the same eye drops at each administration past the expiration date. When queried regarding the dates on Resident #107's Flonase, RN I revealed a staff member must not have seen the date and then dated it. When asked if it was facility policy/procedure to date an open medication with an open date when they did not open the med and did not know the date the medication was actually opened, RN I indicated it was not. When queried regarding Unsampled Resident #1's Latanoprost 0.005% eye drops being opened and undated, RN I specified the medication should be dated when opened. When queried how long the medication can be used for after opening, RN I indicated most eye drops are good for 30 days but they would need to look up the specific medication. When queried regarding Unsampled Resident #1's Carbamide Peroxide 6.5% solution, RN I revealed the medication had been discontinued. When queried regarding Resident #109's Nystop powder, RN I revealed the label was incorrect and stated, (Resident #109's) powder is PRN. A tour of the short hall medication/treatment cart was completed with RN L on 1/26/22 at 10:10 AM. A Calmoseptine ointment, four-ounce container for Resident #103 with the label Apply to Butt twice daily until healed&quo[TRUNCATED]

Based on observation, interview and record review, the facility failed to institute, implement, and operationalize systemic policies and procedures to ensure the provision of comprehensive and accurate pharmaceutical services pertaining to and including 1) The acquisition and verification of delivered medication; 2) The accurate recording and documentation of dispensed medications; 3) Accurate medication labeling; 4) The accurate documentation of controlled (narcotic) medication counts on a shift-by-shift basis; 5) The documentation, reconciliation, and ongoing monitoring of medication orders; 6) Dating of medications; 7) The disposal of expired medications, and 8) The accurate documentation of narcotic medication administration for 10 sampled residents (Resident #13, Resident #101, Resident #102, Resident #103, Resident #104, Resident #105, Resident #106, Resident #107, Resident #108, Resident #109) and three unsampled of 11 Residents reviewed for pharmaceutical services. This deficient practice resulted in documentation of Resident #101 receiving double the prescribed dose of a controlled, antianxiety medication seven times in a two month period, Resident #13 and 101's controlled medication labels having inaccurate order information, incomplete documentation of a missing and then administered narcotic for Resident #103, administration of an expired medication to Resident #13, and medication labels with administration instructions different than the health care provider order, and the likelihood of residents not receiving prescribed medications, administration of incorrect medication dosages and/or at incorrect frequencies, undetected narcotic diversion, and possible alterations in overall health and well-being. Immediate Jeopardy: The Immediate Jeopardy began on 01/24/2022. The Immediate Jeopardy was identified on on 01/24/2022. The Administrator was notified of the Immediate Jeopardy on 1/25/2022 at 12:15 PM. A plan to remove the immediacy was requested. The IJ was removed on 01/25/2022 based on the facility's implementation of the plan removal as verified onsite on 01/27/2022. Although the IJ was removed, the facility's deficient practice remained at a scope isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An interview was completed with Social Worker A on 1/24/21 at 1:45 PM. When queried regarding if any facility residents were currently receiving and/or had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/22 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). When queried, the DON revealed there were no residents in the facility who were receiving PRN [CONDITION(S)] medications. Upon request for a report of facility residents with PRN medication orders, the DON revealed they were unable to generate a report from their Electronic Medical Record (EMR). When queried how the facility monitored PRN medications, including psychoactive medications, the DON replied staff talk about it. When queried regarding facility policy/procedure to ensure new PRN medication orders are not missed if ordered on a weekend and/or night shift and not passed in nurse-to-nurse report, the DON was unable to provide an explanation. The DON revealed Unit Secretary/Certified Nursing Assistant (CNA) F was the EMR superuser and may be able to help. The DON also indicated they would check with pharmacy as well. An interview was conducted with Unit Secretary/Certified Nursing Assistant (CNA) F on 1/24/22 at 2:25 PM. When queried regarding facility policy/procedure pertaining to medication order entry and if nursing staff enter Health Care Provider orders into the EMR, Unit Secretary/CNA F stated, No, I put in the orders and then the nurse verifies. Unit Secretary/CNA F was asked for clarification regarding what type of orders they were entering into the EMR and revealed the facility had two physicians and both physicians entered orders differently. Per Unit Secretary F, Physician E entered their own orders electronically and Physician G wrote all their orders. Unit Secretary/CNA F indicated they entered all of Physician G's written orders into the EMR. When queried concerning telephone orders received by nursing staff, Unit Secretary/CNA F stated they enter the orders the nurse tells me to. With further inquiry, Unit Secretary/CNA F clarified they enter orders for medications and treatments when told to do so by nursing staff without a written physician order. Unit Secretary/CNA F was then asked about the process/procedure for controlled drugs and psychoactive medication initiation/orders and replied, If they (psychiatric provider) orders something then our doctors order it. Unit Secretary/CNA F indicated they would made aware of the order at that time. When asked about orders initiated when they are not working such as at night and on weekends, Unit Secretary/CNA F revealed nursing staff enter the orders and then communicate to the next shift. Unit Secretary/CNA F was then asked if it is possible for nursing staff to forget to communicate the information regarding the medication order and replied, Yes. When queried how they would know about the order/order change if not communicated, Unit Secretary/CNA F revealed they did not have a process in place to ensure validation and accuracy of medication orders with pharmacy. On 1/24/22 at 2:35 PM, the DON provided a list titled, Rx's for (facility) and revealed the facility pharmacy was able to print a report. Review of the report revealed the following for Resident #101, [MEDICATION(S)] (controlled psychoactive antianxiety medication) 0.5 mg (milligrams): Take ½ tablet by mouth twice a day as needed . (Physician E) . Next Fill Due: 2/5/22 . An interview was conducted with Pharmacist C on 1/24/22 at 2:40 PM. When queried regarding the list of Resident medication orders they provided to the facility, Pharmacist C indicated the list provided was reflective of all the PRN MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . With further inquiry, Pharmacist C revealed Resident #101's original order was on 11/19/21 for [MEDICATION(S)] 0.5 mg ½ tab PRN TID (three times a day) then got a clarification (order) for PRN BID (twice a day). Pharmacist C was queried regarding the process/procedure in which medications are ordered and how the pharmacy receives and fills medication orders and replied, For (Physician E) scripts are electronically sent though ChartLink (system). When queried regarding the end date for orders, Pharmacist C replied, (Physician E) reviews and approves the orders. When asked why facility staff had stated no residents had PRN [CONDITION(S)] medications, Pharmacist C was unable to explain the discrepancies and reiterated that was the most recent order they had for (Resident #101's) [MEDICATION(S)] ([MEDICATION(S)]). Resident #101's medications, including controlled medications, within the medication cart was completed on 1/24/22 at 3:00 PM with Licensed Practical Nurse (LPN B). The label on the front of Resident #101's narcotic medication package detailed, [MEDICATION(S)] 0.5 mg . Take ½ tablet by mouth twice a day as needed . The corresponding Receipt and Disposition of Scheduled Drugs form did not include the medication order. When queried regarding the label on Resident #101's [MEDICATION(S)] indicating the medication was for PRN administration, LPN B replied, It is scheduled. When asked why the label did not indicate the medication was scheduled, LPN B was unable to provide an explanation. LPN B proceeded to open Resident #101's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No further explanation was provided. An interview was conducted with the DON on 1/24/22 at 3:15 PM. The DON was asked about pharmacological services for the facility and revealed the facility had a contract with a local pharmacy. When queried regarding why the provided Rx's for (facility) list indicated Resident #101 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why the label on Resident #101's [MEDICATION(S)] medication container also specified the medication was PRN, the DON did not provide an explanation. On 1/24/22 at 4:30 PM, an interview was completed with Pharmacist D. When queried regarding the provided Rx's for (facility) list and Resident #101's [MEDICATION(S)] medication container card both reflecting the Resident received the medication on a PRN basis, Pharmacist D replied, It does say that. Pharmacist D was queried regarding the facility/pharmacy procedures related to the acquisition, receipt, dispensing, and accounting for medications including controlled medications and replied, Whatever (order) is in CPSI (EMR system) is what is ordered. Pharmacist D indicated what medication ordered is then filled and sent to the facility. When asked about the discrepancy in Resident #101's [MEDICATION(S)] medication order between the pharmacy, facility, and label, Pharmacist D stated, The PRN is based on the pharmacy. If it was PRN previously then possible that is correct. Pharmacist D was then asked where the problem occurred with the medication and stated, I would say it is with checking the order. When queried how to identify the cause of the error with the order, Pharmacist D stated, If (staff) are not double checking (order and label) here, then we wouldn't know. Resident #101 Record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS section titled, Medications Received revealed Resident #101 received an Antianxiety medication six out of the previous seven days. Review of Resident #101's Health Care Provider orders for [MEDICATION(S)] revealed the following: - [MEDICATION(S)] Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: PRN TID (three times a day) . Start Date: 11/19/21; Stop Date: 11/26/21 . Ordered: 11/19/21 (Physician E) . Entered 11/19/21 (Physician E) . Nursing Verified: 11/26/21 Pharmacy Verified: 11/20/21 . - [MEDICATION(S)] Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: PRN TID . Start Date: 11/26/21; Stop Date: 12/1/21 . Ordered: 11/26/21: (Physician E) . Entered: 11/26/21: (Unit Secretary/CNA F) . Nursing Verified: 12/1/21 (Registered Nurse [RN] I) . Pharmacy Verified 11/26/21 . - [MEDICATION(S)] Dose: 0.25 mg; Administer Amount: 0.5 tablet . Frequency: BID . Start Date: 12/1/21; Stop Date: 12/25/21 . Ordered: 12/1/21 (Physician E) . Entered: 12/1/21 (RN I) . Nursing Verified: (Blank); Pharmacy Verified: 12/25/21 . Further review of Resident #101's Receipt and Disposition of Scheduled Drugs forms included sections for date, drug name, strength, quantity, pharmacist, unit, who received the drug, date received, and prescription number. The form detailed, Nurse signing for drugs must fax this form to (Pharmacy) . and included the following sections for documentation of the controlled medication: Date . Time . Dose . Dosage Given . Dosage Wasted . Administered by . In-depth analysis of Resident #101's of Receipt and Disposition of Scheduled Drugs forms dated 12/3/21 and 12/21/21 revealed the following: -12/17/21 at 9:15 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/24/21 at 8:19 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/25/21: Unable to read [MEDICATION(S)] dosage given amount -12/26/21 at 8:23 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/27/21 at 8:16 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/28/21 at 9:31 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/29/21 at 9:06 PM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None -12/30/21 at 7:32 AM: [MEDICATION(S)] dosage given: 0.5 mg, Wasted: None Additionally, there were noted discrepancies in the method of documentation of the [MEDICATION(S)] dosage given for Resident #101's Receipt and Disposition of Scheduled Drugs forms dated 11/2/21, 12/3/21, 12/21/21, and 1/4/22. The actual milligrams administered was documented by some staff, others were documenting the number 1 or 1/2 tab in the Dosage Given category. Review of Resident #101's care plan revealed a care plan entitled, Resident is unable to function at previous ADL ability Medical status compromised by acute [CONDITION(S)] . [MEDICATION(S)] ([MEDICATION(S)]- controlled, anti-anxiety medication) is a home med . [MEDICATION(S)] being very effective for SOB (Shortness of Breath) . No psychiatric DX (diagnosis) . (Dated: 11/30/21). The care plan included the Expected Outcome . Resident will continue to verbalize [MEDICATION(S)] being effective for SOB related to [CONDITION(S)] by next review . Review of Resident #101's medication orders since admission revealed the Resident had never had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/22 at 5:09 PM, Pharmacist D indicated they had additional information related to Resident #101's [MEDICATION(S)]. Pharmacist D stated, (Pharmacist C) was aware of the discrepancies and potential for errors. Pharmacist D continued, (Physician E) wants to be the one to enter orders. When queried when they identified the potential, Pharmacist D replied, Well, in December (2021) (Pharmacist H) did not catch the order change. When queried regarding policies and procedures related to double checking medications and orders, Pharmacist D indicated facility staff are responsible to check the medications. Pharmacist D was then asked if they were saying that facility staff are not checking resident medications/orders and stated, I would say that's probable. When queried regarding the process for Receipt and Disposition of Scheduled Drugs forms, Pharmacist D stated, Don't look at them. When queried how verbal orders for medications are received by the pharmacy to be filled, Pharmacist D replied, Prints to a printer at the pharmacy. When queried if pharmacy staff play a role in verification of a stop date on PRN psychoactive medications, Pharmacist D stated, I don't think so. An interview was conducted with the DON on 1/24/22 at 5:25 PM. When asked about facility policy/procedures regarding review of Receipt and Disposition of Scheduled Drugs forms to ensure accurate reconciliation and accounting for controlled medications, the DON revealed they do not review the forms. When queried how they account for the controlled medications to identify, evaluate, and resolve potential concerns, the DON did not provide further explanation. When queried regarding documentation for Resident #101 indicating they had received the incorrect dosage of [MEDICATION(S)] seven times, the DON replied, I don't know. They got the right dose. We scan it. The DON was asked if staff are able to bypass scanning and still administer medications and indicated they were not aware that was possible. The process for bypassing medication scanning in CPSI EMR system was discussed with the DON at this time and a report of medications administered without being scanned for Resident #101 was requested. An interview was conducted with the DON and Assistant Director of Nursing (ADON) on 1/25/22 at 9:45 AM. When queried regarding facility policy/procedure for medication orders and communication with pharmacy, the DON indicated all orders are entered in CPSI and electronically transmitted to pharmacy. When queried regarding both them and the Pharmacist D stating they do not review the Receipt and Disposition of Scheduled Drugs forms and how the facility is able to ensure a system is in place to ensure accountability and prevent diversion of controlled medications, the DON indicated they look at the forms. When asked why they stated they did not look at the forms on 1/24/22, an explanation was not provided. When queried why they were not aware of nor had they addressed the administration dosage documentation discrepancies for Resident #101 if they were reviewing the forms, the DON did not provide an explanation. When queried regarding incorrect administration instructions and labels on narcotic medication, the DON stated, There are two labels (on controlled medication bubble packs). One on the front and one on the back. The back label is from CPSI and the front is from pharmacy. When asked why the labels would be different, the DON reiterated they were either printed from the pharmacy or from CPSI. When queried why the medication labels do not always match and how safe medication administration is completed with incorrect and/or contradictory medication labels, the DON did not provide an explanation. On 1/25/22 at 10:35 AM, an interview was conducted with RN I. When queried regarding facility policy/procedure for medication order entry, RN I revealed nurses, unit secretaries, and (Physician E) all enter orders into the EMR. When asked if nursing staff are supposed to verify medication orders prior to administrator, RN I indicated they were. Resident #101's [MEDICATION(S)] orders were reviewed with RN I at this time. When asked why Resident #101's [MEDICATION(S)] order (start date: 11/26/21) was ordered by Unit Secretary/CNA F on 11/26/21 and administered 14 times prior to being verified by nursing staff, RN I was unable to provide an explanation. With further inquiry, RN I revealed the Resident's [MEDICATION(S)] order was changed to scheduled on 12/1/21 following a care conference and they had entered the order. When queried regarding other staff indicating Physician E always entered their own orders but had not entered the orders for Resident #101's [MEDICATION(S)], RN I revealed the Physician entered most of the orders. When queried regarding documentation of contacting the Physician, RN I stated, I contacted them via tiger text. When asked if tiger texts are part of the medical record, RN I revealed they would have to check. Review of Resident #101's Progress Note documentation in the EMR revealed a Social Services note dated 12/1/21. The note detailed, Psychiatric Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . (Physician E) ordered [MEDICATION(S)] 0.25 mg PRN TID on 11/19/21 . Resident's use of PRN [MEDICATION(S)] was discussed . at care conference . Resident had been taking [MEDICATION(S)] at home . twice daily . According to MAR, Resident is taking [MEDICATION(S)] 1-2 times daily . Resident would prefer it be scheduled for twice daily . Nursing will send a communication to (Physician E) . An interview was completed with the ADON on 1/25/22 at 11:00 AM. When queried regarding the rationale for Unit Secretaries entering verbal orders for medications in the EMR, the ADON stated, I don't know. Someone told them to. The ADON was then asked where there is documentation and/or proof showing that the medication was ordered. The ADON replied, I see what you are saying. When queried regarding facility policy/procedure related to verbal orders including what staff are allowed to take and/or enter orders, the ADON stated, Maybe we will not have the ward clerk enter orders anymore. An interview was completed with Unit Secretary/CNA F on 1/25/22 at 11:30 AM. When queried regarding medication order entry, Unit Secretary/CNA F revealed they entered orders received verbally from nursing staff when asked in order to assist nursing staff. At 4:00 PM on 1/25/22, an interview was conducted with Resident #101 in their room. When queried if they knew what medications they take, Resident #101 replied, I did but I probably couldn't say. I know I take [MEDICATION(S)] (anti-coagulation medication). Resident #101 was then asked if facility nursing staff tell them what their medications are when they administer their medications and stated, No, but I know I take a heart pill too. When queried if they took any medications for their nerves or anxiety, Resident #101 stated, No, I don't think so. A tour and count of the long hall facility medication cart, including the controlled substances, was completed with RN I on 1/25/22 at 15:15 PM. The following expired medications were noted in the medication cart: - Antidiarrheal, Loperamide 2 mg tablets; Expired 1/22. Quantity: 24 tablet container - Iron 324 mg tablets; 1000 count bottle; Expired 1/22. When queried regarding the date of the month medications expire when only a month is listed, RN I replied, The first and indicated they would dispose of the medications. Resident daily, non-controlled medications, were noted to be in plastic, reusable box containers with clear plastic, pop-open tops to access the medication. Labels with the resident name and medication were present on the container. The printing on the labels was dull, as though done with a printer with low ink. When queried regarding the process in which the medications are received/filled from pharmacy, RN I revealed the medication containers are filled at the local pharmacy and delivered to the facility. When asked if they had ever encountered any concerns with the process, RN I revealed they had received medications for resident that looked different than normal and had to verify the medications. RN I stated, It was the wrong meds. When asked how often that had happened, RN I replied, More than it should. RN I was asked what they did when that happened and replied, Contact the pharmacy and not give the med. When queried if they completed a variance report or Incident and Accident report, RN I indicated they did not and were just supposed to contact pharmacy. When asked, RN I was unable to recall a specific resident. The following controlled substances were noted in the medication cart: - Resident #13: [MEDICATION(S)] 0.5 mg medication package. Directions: Take 1 tablet by mouth every four hours as needed. The corresponding Receipt and Disposition of Scheduled Drugs form revealed the medication was received by the facility on 10/25/21. - Resident #102: [MEDICATION(S)] (narcotic pain medication) 5/325 mg medication package. Directions: Take 1 tablet by mouth every six hours as needed for pain. The number 14 pill bubble was noted to be circled on the package in ink. Clear, office tape was present on the back of the number 14 pill bubble and there was no pill present in the bubble. The corresponding Receipt and Disposition of Scheduled Drugs form revealed Missing was written on the number 14 tablet line with a line drawn through it. The med was then documented as administered on 10/26/21 at 5:07 AM. When queried regarding Resident #13's [MEDICATION(S)] order, RN I revealed the medication was ordered daily. When asked about Resident #102's [MEDICATION(S)], RN I was unable to provide an explanation. An interview and review of medications was completed with the ADON on 1/25/22 at 4:50 PM. When queried regarding observation of Resident #102's [MEDICATION(S)] and how the medication was able to be administered if it was missing, the ADON was unable to provide an explanation. Upon review of the medication package, label, and narcotic sign out sheet, the ADON revealed the nurse signature who had administered the number 14 [MEDICATION(S)] was RN K. When queried by Resident #13's [MEDICATION(S)] label indicated the Resident was to receive the medication on a PRN basis when the medication was ordered as scheduled daily, the ADON indicated they were unaware it was. A photocopy of Resident #13's medication bubble pack with label was reviewed with the ADON at this time. The ADON pointed out a small, unremarkable sticker, which was previously not noticed with the phase Directions Changed Refer to Chart was present below the label. The ADON revealed pharmacy would place the stickers instead of replacing the label. When asked why the pharmacy did not replace the label and/or why the sticker was not more noticeable, the ADON revealed that is just how pharmacy has always done it. The ADON did not elaborate further regarding pharmacy practices. The ADON then stated, They (pharmacy) should just replace it (label). The ADON then stated they had been informed by the DON that pharmacy already came to the facility updated the labels and stickers to ensure all the meds were correct and would scan. An interview was conducted with RN K on 1/25/22 at 7:55 PM. When queried regarding Resident #102's [MEDICATION(S)] including Controlled Substance sheet, RN K stated, I don't remember. RN K then stated, Maybe someone pulled it from the wrong pack, and it was missing but then we found it. RN K continued, I don't remember crossing off missing. I think it had to have been found before I gave it. With further inquiry, RN K stated, Someone may have pulled out (Resident #102's) card and scanned it. When queried how that could happen, RN K explained that the medication scanning is specific to the medication, not the Resident. RN K provided an example, Patient A and patient B are both on [MEDICATION(S)]. Someone could have pulled the [MEDICATION(S)] from patient B's card, scanned it, and given it to patient A. The scanner for the meds will scan and work no matter which patient is getting it. Then they replaced it. When asked if they were saying the medication was then removed from patient A's card and placed in patient B's card, RN K replied, Yes. RN K was queried hour the medication was able to be put back in the bubble pack after the seal was broken, RN K replied, Tape it. When queried if that happened frequently, RN K did not directly respond but revealed it does happen. RN K was then asked what nursing staff are supposed to do, per facility policy/procedure, if that situation were to happen and replied, Probably waste it (medication). An interview was conducted with the DON on 1/26/22 at 9:00 AM. When queried regarding accurate reconciliation and monitoring of controlled medications related to Resident #102's [MEDICATION(S)], the DON stated, It was documented as given. Not missing. With further inquiry regarding how a narcotic medication be marked as missing and then administered without any documentation, waste, double staff signature, and/or administrative involvement to ensure prevention of diversion, the DON did not provide an explanation. When queried regarding Resident #13's [MEDICATION(S)] continuing to be labeled as PRN on 1/25/22, the DON restated that the medication packs contain two labels. When queried if they were saying that it is acceptable for one label to be incorrect, the DON replied, No. No further explanation was provided. The DON then revealed all medications in the facility had been checked by pharmacy and were corrected. When queried how many Resident medication labels were incorrect and needed to be corrected the DON replied, None. When asked about the label on Resident #13's [MEDICATION(S)] indicating the medication was PRN and not scheduled, the DON stated, I don't know. When queried if the label stating the [MEDICATION(S)] was PRN was incorrect, the DON replied, Yes. The DON then stated, (It) was corrected. On 1/26/22 at 9:30 AM, a tour of the long hall medication/treatment cart was completed with RN I. The following were noted: - [MEDICATION(S)] Nasal Spray for Resident #107. The open dates 12/15/21 and 12/28/21 were both written on the container. -[MEDICATION(S)] 0.005% Ophthalmic Solution (prescription eye medication) for Unsampled Resident #1. The medication was opened and undated. -[MEDICATION(S)] Peroxide 6.5% solution for Unsampled Resident #1. The medication labeled indicated it was to be used BID. -[MEDICATION(S)] Powder (prescription anti-fungal medication) 60 grams (gm) for Resident #109. The label detailed, Apply three times daily. RN I stated, No, this is PRN. -[MEDICATION(S)] 0.2 % Ophthalmic Solution for Resident #13. The dated written on the medication included, Open: 12/14/21; Expire: 1/11/22. When queried if Resident #13 had an order and/or was receiving the [MEDICATION(S)] 0.2% Ophthalmic Solution, RN I replied, Yes, I gave it last night. RN I revealed they had not seen the expiration date and that Resident #13 had been receiving the same eye drops at each administration past the expiration date. When queried regarding the dates on Resident #107's [MEDICATION(S)], RN I revealed a staff member must not have seen the date and then dated it. When asked if it was facility policy/procedure to date an open medication with an open date when they did not open the med and did not know the date the medication was actually opened, RN I indicated it was not. When queried regarding Unsampled Resident #1's [MEDICATION(S)] 0.005% eye drops being opened and undated, RN I specified the medication should be dated when opened. When queried how long the medication can be used for after opening, RN I indicated most eye drops are good for 30 days but they would need to look up the specific medication. When queried regarding Unsampled Resident #1's [MEDICATION(S)] Peroxide 6.5% solution, RN I revealed the medication had been discontinued. When queried regarding Resident #109's [MEDICATION(S)] powder, RN I revealed the label was incorrect and stated, (Resident #109's) powder is PRN. A tour of the short hall medication/treatment cart was completed with RN L on 1/26/22 at 10:10 AM. A [MEDICATION(S)] ointment, four-ounce container for Resident #103 with the label Apply to Butt twice daily until healed (Ordered: 4/2/21) and dated as opened: 8/10/21 was present in the cart. When queried regarding [MEDICATION(S)] ointment for Resident #103, RN L stated, It isn't in the MAR. When asked if the Resident was receiving a treatment with the ointment, RN L indicated they were not. RN L was then queried if the [MEDICATION(S)] should be in the cart if the Resident was not receiving it and replied, No. A review of Resident #103's orders was completed with RN L was completed at this time. RN L stated, Not there. On 1/26/22 at 10:32 AM, RN L approached this surveyor and revealed they had found more information regarding Resident #103's [MEDICATION(S)] order. RN L stated, It is ordered. RN L continued, Ordered 3/19/19 as BID (twice daily) PRN. When asked why it had not been on the Resident's MAR, RN L was unable to provide an explanation. Review of Resident #13's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's CPSI Medication Record documentation revealed the Resident had active orders for [MEDICATION(S)] 0.5 mg daily and [MEDICATION(S)] 0.2% ophthalmic solution BID in both eyes. At 12:05 PM on 1/26/22, the DON was unavailable, and an interview was conducted with the ADON. When queried regarding observations of medications/medications labels in the facility medication/treatment carts on 1/26/22, the ADON revealed they could not believe the issues were not corrected and would ensure it was taken care of. When asked how many Resident medication labels had been incorrect and relabeled, the ADON replied, Several. The ADON provided documentation showing the following Residents had active orders in place at the facility pharmacy but did not have active orders for the medications/treatments in the EMR system including: - Resident #106: [MEDICATION(S)] Ointment: A [TRUNCATED]

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services out of the facility's total census of 22 residents. Findings include: 1. On 10/21/21 at 10:46 AM and at 10:52 AM, Cook staff B was observed rinsing out a cloth towel at the one compartment sink and then wiping off counter tops. Upon observation the surveyor inquired with staff B on the purpose of the cloth towel to which they replied, cleaning up messes on the counters. On 10/21/21 at 10:54 AM, the surveyor asked the Certified Dietary Manager, staff A, how the facility cleans and sanitizes its work surfaces to which they stated, we have our red and green buckets. One has soapy water in it, and one has our Quat sanitizer. At this time the surveyor asked staff A if they could test the sanitizer bucket to verify its concentration to which they replied, of course we just changed it out a little bit ago. We try and make sure it is swapped out at least every two hours. On 10/21/21 at 10:57 AM, testing of the sanitizer concentration by staff A via a test strip revealed a concentration of zero. Upon observation staff A placed their hand in the solution and stated, oh this is cold. We will remake it now. At On 10/21/21 at 10:57 AM, testing of the sanitizer concentration by staff A via a test strip revealed a concentration of 300 ppm to which they stated, much better with warm water. We try to keep always keep it between 200 ppm - 400 ppm. At this time the surveyor asked staff A if the facility allowed cloth towels wet with water to be used to wipe down work surfaces for cleaning or sanitizing purposes to which they stated, just water? No, we would use our green and red buckets. Review of 2013 U.S. Public Health Service Food Code, Chapter 7-204.11 Sanitizers, Criteria, directs that: Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobial's applied to FOOD-CONTACT SURFACES shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P

Based on interview and record review, the facility failed to ensure that the Medical Director attended quarterly QAPI meetings, was composed of the appropriate staff, and met at the appropriate intervals, resulting in, the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 22 residents residing at the facility. Findings include: On 10/26/21 at 2:30 PM, an interview was conducted with DON (Director of Nursing), ADON (Assistant Director of Nursing) and Risk Management I regarding the facility's QAPI (Quality Assurance and Performance Improvement) Program. The DON and ADON explained their QAPI is in conjunction with the acute care hospital and is held monthly. They explained there are LTC (long term care) and acute care representatives and LTC disciplines do not report out at each monthly meeting, but rather quarterly, on their designated month. At the conclusion of each meeting the facilitator will indicate which department reports they will review at the next QAPI meeting. The DON and ADON were asked if their Medical Director L attended the QAPI meetings quarterly. The ADON stated he does not attend any of the meetings as he has clinics during the scheduled meeting times. The ADON added they do provide him with a summary of what was discussed at the meetings. The DON and ADON were queried about a designee for Medical Director L at the meetings and they stated he does not have one. The Chief of Staff (over acute care) K attended the QAPI meetings but he has nothing to do with LTC and the inner workings. A review was completed of their QAPI sign in sheets since January 2020, the following meetings were held with minimum attendance from LTC representatives: January 14,2020 - DON, Infection Control, Therapy and Social Services were present February 11, 2020 - Therapy was the only LTC representative present June 9, 2020 - DON, Therapy, Social Services, and Infection Control attended September 8, 2020 - DON and Infection Control attended March 9, 2021 - DON and Therapy attended April 27, 2021 - The DON attended May 11, 2021 - DON, ADON and Social Services attended June 8, 2021 - Dietary, DON, ADON, Therapy and Social Services attended September 14, 2021 - ADON, Infection Control and Therapy attended the meeting October 12, 2021 - Dietary, DON, Social Services and Therapy attended The DON, ADON and Risk Management were queried as to the multiple gaps in the QAPI meetings. Risk Management explained in 2020 they only met four times due to COVID and in 2021 they did not meet in January or February due to COVID as well. There was a gap of five months when there were no QAPI meetings. July and August 2021 meetings were not held as their QAPI facilitator was on medical leave and they were transitioning to a new facilitator. Conversation was held with the DON and ADON that while COVID did present challenges there were many avenues that could be utilized to hold the QAPI meetings per the regulations. The DON and ADON were also queried regarding the LTC departments and their attendance. It was pointed out that not all the required members were present monthly as required. They expressed their understanding of the concerns with their QAPI Program. According to the SOM (State Operations Manual) Appendix PP, .The committee should be composed of staff who understand the characteristics and complexities of the care and services delivered by each unit, and/or department. The QAA Committee must be composed of, at a minimum: o The director of nursing (DON), o The Medical Director or his/her designee, and o At least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems . the Medical Director is a required member of the QAA committee. This requirement stems from the Medical Director's responsibility for the overall medical care provided and the implementation of all resident care policies in the facility. There should be evidence of meaningful participation by the Medical Director in the QAPI program . QAA committee meetings must be held at least quarterly or more often as necessary to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively .

Based on observation, interview and record review, the facility failed to care plan, store and clean a Continuous Positive Airway Pressure ([CONDITION(S)]) mask/machine and supplies for one resident (Resident #10) of one resident reviewed for [CONDITION(S)] care and use, resulting in the [CONDITION(S)] mask being left out on the nightstand, the distilled water not being dated with an open date and with the likelihood of contamination/respiratory infection from a dirty [CONDITION(S)] mask. Findings include: Resident #10: On 10/21/21, at 10:30 AM, Resident #10 was lying in their bed. Their [CONDITION(S)] mask was lying on their nightstand. There was an open half-gallon of distilled water on the nightstand with no open date. On 10/22/21, at 9:31 AM, Resident #10 was sitting in their wheelchair. Their [CONDITION(S)] mask was lying on the nightstand. The open undated distilled water also remained. Nurse M entered the room and was asked if the [CONDITION(S)] mask was normally stored open on the nightstand and Nurse M stated, No. Normally it's in a plastic bag. Nurse M was asked if the distilled water was normally dated with an open date and Nurse M stated, yes, and discarded the distilled water. On 10/22/21, at 11:00 AM, a record review of Resident #10's medical record revealed an admission 8/26/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident Required assistance with Activities of Daily Living and had intact cognition. A review of the physician Order Chronology report provided by the facility revealed no order to clean or store the [CONDITION(S)] mask. A review of the care plans revealed no care plan for the [CONDITION(S)] mask. A review of the baseline care plan revealed no mention of the [CONDITION(S)] mask. On 10/26/21, at 11:00 AM, a further record review of Resident #10's medical record revealed the following: Order Chronology . 10/25/2021 10:34 [CONDITION(S)] @ NOC per home instructions . A further review of the care plans revealed Problem . 10/25/2021 Oxygen use via [CONDITION(S)] use at night Expected Outcome Will be able to tolerate [CONDITION(S)] use every night . Ensure mask and equipment are maintained . Monitor Application of [CONDITION(S)] mask at night and that machine is turned on correctly every night per home instructions . The care plan was signed 10/26/21 On 10/26/21, at 11:15 AM, the Director of Nursing (DON) was asked who is responsible for cleaning the [CONDITION(S)] mask and machine and the DON stated, that they haven't had a [CONDITION(S)] in a while and offered a document on how to care for a [CONDITION(S)]. On 10/26/21, at 2:00 PM, a record review of the facility provided Res Med Air Curve 10 . policy revealed Effective Date: October 2021 Policy Statement: It is the policy of (the facility) to provide cleaning of [CONDITION(S)] machines . Caring for the device A. It is important to regularly clean the AirCurve 10 device to make sure you receive optimal therapy. The following sections will help the with disassembling, cleaning, checking and reassembling the device. WARNING Regularly clean the tubing assembly, water tub and mask to receive optimal therapy and to prevent the growth of germs that an adversely affect the health . On 10/26/21, at 3:30 PM, the DON stated that the facility did not have a policy for dating or storing the open distilled water.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 175 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS FOR ONE (#501) OF THREE SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF SAMPLED OF 3, RESULTING IN A FALL WITH MULTIPLE FACIAL FRACTURES. FINDINGS INCLUDE: ON 7/18/12 AT 12:25 P.M., DURING A TOUR OF THE FACILITY, RESIDENT #501 WAS OBSERVED SEATED IN THE DINING ROOM EATING HER LUNCH MEAL. RESIDENT #502 WAS SEATED IN A HIGH BACK WHEEL CHAIR WITH AN ALARM ATTACHED. RESIDENT #502 WAS FURTHER OBSERVED WEARING A SEAT BELT. A REVIEW OF THE FACILITY'S "RECORD OF ADMISSION" REVEALED THAT RESIDENT #501 WAS AN [AGE] year OLD FEMALE WHO WAS PREVIOUSLY admitted to the facility on [DATE] AND REadmitted on [DATE], AFTER A FALL AT THE FACILITY. THE FACILITY'S "[DIAGNOSES REDACTED]. A REVIEW OF #501'S PHYSICIAN'S "HISTORY AND PHYSICAL (H&P)" DATED 4/7/12 REVEALED, "...SHE HAS BEEN A RESIDENT FOR A LONG TIME. MOST OF THE INFORMATION OBTAINED FROM REVIEWING NURSING NOTES AND DISCUSSION WITH NURSING STAFF AS PATIENT DOES NOT COMMUNICATE AT ALL BECAUSE OF SEVERE IMPAIRED COGNITIVE FUNCTION FROM DEMENTIA. EXTREMITIES SEVERE DEFORMITY OF THE MAJOR JOINTS INCLUDING SMALL JOINT SECONDARY UNDERLYING RHEUMATOID ARTHRITIS OF THE SMALLER JOINT. CNS (CENTRAL NERVOUS SYSTEM) CONFUSED TO TIME, PLACE AND PERSON DUE TO UNDERLYING DEMENTIA, VASCULAR ORIGIN..." THE H&P FURTHER NOTED THAT #501 HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 2/29/12 DOCUMENTED THAT #501 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE FROM STAFF WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, LOCOMOTION ON THE UNIT, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. THE MDS FURTHER DOCUMENTED THAT #501'S "BALANCE DURING TRANSITIONS AND WALKING" WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE..." IN AREAS OF MOVING FROM SEATED TO STANDING POSITION, WALKING, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS. A REVIEW OF THE FACILITY'S "FACILITY INCIDENT REPORT-24 HOURS" DATED 6/22/12 REVEALED THAT ON 6/22/12 AT 5:15 A.M., "...RESIDENT WAS USING HER FEET TO MOVE AROUND IN HER WHEELCHAIR WITH THE SEATBELT ALARM ON. SHE WAS IN THE HALLWAY CLOSE TO THE NURSE'S STATION. CNA (CERTIFIED NURSING ASSISTANT) (#2) WAS AT THE NURSE'S STATION WHEN SHE HEARD THE SEATBELT ALARM GO OFF. SHE (CNA #2) WENT IMMEDIATELY TOWARDS RESIDENT BUT SHE (#501) STOOD UP AND fell TO THE FLOOR SO FAST THAT SHE (CNA #2) COULD NOT REACH HER (#501) IN TIME. RESIDENT WAS TAKEN TO THE emergency room . X-RAYS OF THE HIPS, PELVIS, CHEST AND RIGHT KNEE WERE NEGATIVE OF ACUTE ABNORMALITY. CT (COMPUTED TOMOGRAPHY/CAT SCAN) OF HEAD, FACIAL BONE AND CERVICAL SPINE SHOWED FRACTURE OF NASAL BONE AND FRACTURE OF RIGHT MAXILLARY ANTRUM. RESIDENT THEN RETURNED BACK TO OUR UNIT..." A NURSE'S NOTE DATED 6/22/12 AT 2:14 P.M., REPORTED, "...RESIDENT (#501) BACK FROM ACUTE CARE UNIT, FACIAL FRACTURES PRESENT, DURING ASSESSMENT, RESIDENT COMPLAINED OF RIGHT RIB PAIN, RIGHT EYE AND RIGHT MAXILLARY EDEMATOUS BLACK AND BLUE, LUNG SOUNDS DIM WITH SLIGHT EXPIRATORY WHEEZE..." A NURSE'S NOTE DATED 6/22/12 AT 4:08 P.M., DOCUMENTED, "...GRIPS (HAND STRENGTH) WERE NOT EQUAL ON COMMAND BUT ABLE TO GRAB BED SHEET, UNABLE TO ASSESS RIGHT PUPIL AT THIS TIME DUE TO SWELLING. RIGHT PUPIL 6 MM (MILLIMETERS) TO 4 MM WITH SLUGGISH REACTION..." A NURSE'S NOTE DATED 6/22/14 AT 8:11 P.M., DOCUMENTED, "...UPSET AND IRRITABLE AT THIS TIME, WHEN ASKED IF SHE IS IN PAIN SHE CONFIRMS THAT YES, SHE IS. UNABLE TO OPEN RIGHT EYE FOR PUPIL CHECK RELATED TO SWELLING..." A REVIEW OF THE HOSPITAL CAT SCAN REPORT, DATED 6/22/12 REVEALED, "...IMPRESSION: FRACTURE OF THE NASAL BONE WITH NO DISPLACEMENT. FRACTURE POSTERIOR WALL RIGHT MAXILLARY ANTRUM. THERE IS AN UNDISPLACED AND SEPARATED FRACTURE IN THE LATERAL WALL OF THE RIGHT MAXILLARY ANTRUM. AIR FLUID LEVEL IN THE RIGHT ANTRUM IS LIKELY FROM A HEMATOMA. THERE IS AN S-SHAPED CONFIGURATION TO THE NASAL SEPTUM, ALTHOUGH UNCLEAR IF THERE IS A FRACTURE AT THIS LEVEL. THERE ARE MUCOSAL CHANGES OF CHRONIC SINUSITIS IN THE ETHMOIDS, SPHENOID AND BASE OF THE LEFT FRONTAL SINUS. THERE IS LESSER AREA OF EDEMA WITH A SMALLER AREA OF HEMATOMA IN THE RIGHT FACE..." THE FACILITY'S "FALL INVESTIGATION SHEET" DATED 6/22/12 REVEALED, "...STOOD UP WITHOUT ASSISTANCE; RECENT CHANGES IN MOOD STATUS: YES, AGITATED; INJURY SUSTAINED: YES, BRUISE, FACE AND RIGHT KNEE; ORDER RESTRAINT OR SIDE RAIL, DEVICE IN PLACE WITH SIGNED CONSENT: YES..." A REVIEW OF THE FACILITY'S "SUMMARY OF INVESTIGATION" DATED 6/27/12 REVEALED, "...HER (#501) URINE CULTURE SHOWED 20,000 CFU/ML (COLONY FORMING UNITS/MILLILITER) ESCHERICHIA COLI (INTESTINAL BACTERIA) THE DIRECTOR OF NURSING WAS UNABLE TO CLARIFY WHETHER RESIDENT #501 HAD BEEN diagnosed with [REDACTED].#501 HAD RECEIVED treatment for [REDACTED]. FURTHER REVIEW OF #501'S CLINICAL RECORD REVEALED THE PRESENCE OF A URINARY TRACT INFECTION. A REVIEW OF #501'S "FALLS" CARE PLAN INITIATED 1/20/10 REVEALED, "...ACCIDENTS, FALLS INJURY RELATED TO CONFUSION..." THE FALLS CARE PLAN DOCUMENTED THAT #501 HAD PREVIOUS FALLS ON 6/7/12 WHEN RESIDENT #501 fell FROM HER BED, NO INJURY, ORDERED TO HAVE "30 MINUTE MONITORING CHECKS"; ON 6/8/12, RESIDENT #501 fell FROM HER BED AND HIT HER HEAD, IN ADDITION TO THE LATEST FALL ON 6/22/12 WITH RESULTANT FRACTURES. RESIDENT #501'S FALLS CARE PLAN INDICATED THAT RESIDENT #501 WOULD BE FREE OF FALLS AND WILL BE FREE FROM FRACTURE/SPRAIN/DISLOCATIONS AND BURNS. ADDITIONALLY, THE FALLS CARE PLAN, UPDATED ON 6/25/12, ADDED, "...1:1 (ONE TO ONE) SUPERVISION DURING PERIODS OF AGITATION FOR SAFETY REASONS..." THE FALLS CARE PLAN FURTHER REVEALED THAT ON 6/29/12, ADDITIONAL INTERVENTIONS WERE ADDED WHICH INCLUDED: "...1:1 SUPERVISION WHEN SITTING IN ROOM, 1:1 SUPERVISION WHEN IN WHEELCHAIR IN THE HALLWAY OR AT THE NURSE'S STATION, LINE OF SIGHT SUPERVISION WHILE SITTING AT TABLE IN DAY ROOM OR RESTING IN RECLINER IN DAYROOM..." THERE WAS NO DOCUMENTED EVIDENCE THAT 1:1 SUPERVISION OR ADDITIONAL 30 MINUTES CHECKS HAD BEEN ordered on [DATE] DURING RESIDENT #501'S REPORTED EPISODES OF AGITATION AND COMBATIVE BEHAVIOR JUST PRIOR TO HER FALL. UPON FURTHER REVIEW OF THE CLINICAL RECORD, IT WAS REVEALED THAT RESIDENT #501 WAS OFTEN ABLE TO REMOVE HER SEATBELT AND AT OTHER TIMES, WAS UNABLE TO DO SO UPON REQUEST. ON 7/18/12 AT 2:40 P.M., DURING AN INTERVIEW, CERTIFIED NURSING ASSISTANT (CNA) #1 REPORTED, "...WE DON'T LIKE TO WAKE HER UP BECAUSE SHE GETS LOUD SO WE DO HER LAST. SHE WOKE UP IRRITATED AND VERY COMBATIVE. SHE WAS YELLING OUT AND ANGRY AND WANTED TO GET UP. SO WE GOT HER UP IN HER WHEELCHAIR AND PUT HER SEATBELT ON. SHE WAS SO FUSSY AND COMBATIVE SO WE DECIDED TO LEAVE AND COME BACK TO DO HER CARE. (CNA #2) STAYED WITH HER AND I WENT TO TAKE MY GARBAGE AND LINEN OUT. WHEN I CAME BACK, I PUT LINEN IN THE SOILED UTILITY ROOM. (RESIDENT #501) WAS AT THE NURSE'S STATION SO WE COULD WATCH HER AND (CNA #2) WAS AT THE NURSE'S STATION WITH (RESIDENT #501)..." WHEN ASKED IF THEY (CNA #1 AND CNA #2) WERE ASSIGNED TO PROVIDE ONE ONE-TO-ONE (1:1) SUPERVISION IN LIGHT OF RESIDENT #501'S AGITATED AND COMBATIVE STATE, CNA #1 SAID, "...THE PATIENTS ARE ALWAYS 1:1 SUPERVISION WHEN WE GET THEM UP ON THE MIDNIGHT SHIFT..." CNA #1 FURTHER REPORTED THAT THE NURSE (LICENSED PRACTICAL NURSE/LPN #1) WAS DOWN THE HALL PASSING HER MORNING MEDICATIONS. CNA #1 FURTHER REPORTED THAT "I PUSHED MY LINEN CART INTO THE SOILED UTILITY ROOM AND THAT'S WHEN I HEARD AN ALARM SO I IMMEDIATELY RAND TO (RESIDENT #501) BUT I COULDN'T GET THERE FAST ENOUGH. SHE WAS STANDING AND SHE JUST fell ." ON 7/19/12 AT 10:35 A.M., DURING AN INTERVIEW, LPN #1 REPORTED, "...I WAS (RESIDENT #501'S) ASSIGNED NURSE ON THE MORNING OF HER FALL. SHE WAS VERY AGITATED AT THE TIME WHEN SHE fell . I GAVE HER HER 6:00 A.M. PILLS AROUND 5:00 A.M. AND SHE SEEMED OKAY AT THAT TIME BEFORE THE CNAS GOT HER UP SO I WENT ON TO PASS MY MEDS. AFTER THEY (CNA #1 AND CNA #2) GOT HER UP, I HEARD HER YELLING REALLY LOUD DOWN THE HALL SO I WENT TO HER AND OFFERED HER PAIN PILLS AND SHE DECLINED, SO I LEFT TO CONTINUE MY MEDS..." WHEN ASKED IF SHE PERFORMED AN ASSESSMENT IN LIGHT OF #501'S BEHAVIOR, LPN #1 SAID, "NO". A REVIEW OF THE "MEDICATION RECORD" FOR 6/22/12 REVEALED THAT LPN #1 HAD ADMINISTERED #501'S 6:00 A.M. MEDICATIONS AT 4:27 A.M. LPN #1 FURTHER REPORTED, "...WHEN I WAS IN A RESIDENT'S ROOM GIVING MEDS, I HEARD THE CNAS CALL FOR ME. I WALKED OUT INTO THE HALLWAY AND I SAW (RESIDENT #501) ON THE FLOOR. HER NOSE WAS BLEEDING AND (CNA #1) WAS NEXT TO HER. I DON'T KNOW WHERE (CNA #2) WAS. IT ALL HAPPENED SO FAST. (RESIDENT #501) had a history of [REDACTED]. WHEN ASKED IF SHE (LPN #1) HAD INSTRUCTED THE CNAS TO KEEP #501 IN LINE OF SIGHT OR TO PROVIDE 1:1 SUPERVISION ONCE IT WAS OBSERVED THAT SHE WAS AGITATED, YELLING OUT AND COMBATIVE, LPN #1 SAID, "...NO. I DID NOT..." WHEN ASKED IF #501'S PHYSICIAN HAD BEEN NOTIFIED, LPN #1 REPORTED, "...NO, BECAUSE SHE ALWAYS DOES IT..." LPN #1 THEN STATED, "...I SHOULD HAVE TOLD THE STAFF TO STAY WITH HER 1:1..." ON 7/19/12 AT 11:15 A.M., DURING AN INTERVIEW, CNA #2 REPORTED, "...(CNA #1) ASKED ME TO HELP HER WITH (RESIDENT #501). (RESIDENT #501) WAS VERY LOUD AND KEPT TRYING TO SCRATCH US. SHE WAS REALLY BOISTEROUS. THAT WASN'T NORMAL FOR HER. SHE USUALLY SLEEPS FOR US. I DIDN'T REPORT IT TO THE NURSE BECAUSE WHEN (RESIDENT #501) YELLED OUT A REALLY LONG AND LOUD SCREECH, I ASSUMED THE NURSE HEARD HER..." CNA #2 FURTHER REPORTED, "...WE GOT HER UP IN A WHEELCHAIR AND PUT HER IN FRONT OF THE NURSE'S DESK. I WAS BEHIND THE DESK AND (CNA #1) WAS TAKING HER LAUNDRY AND TRASH OUTSIDE AND THEN CAME BACK. (RESIDENT #501) WAS DOWN A WAYS BY THE MEDICATION ROOM AND WAS PUSHING HERSELF ALONG WITH THE HANDRAILS. SHE (#501) GOT OUT OF MY SIGHT AND (CNA #1) WENT INTO THE SOILED UTILITY ROOM. I HEARD HER (#501) ALARM SO I CAME AROUND FROM BEHIND THE NURSE'S DESK/STATION AND #501 WAS ALREADY STANDING UP AND THEN SHE JUST fell ..." WHEN ASKED IF RESIDENT #501 WAS IN LINE OF SIGHT PRIOR TO HER FALL, CNA #2 SAID, "...AT THE TIME OF THE FALL, SHE WASN'T IN ANYONE'S SIGHT. I SHOULD HAVE FOLLOWED HER..." WHEN ASKED WHAT SHE (CNA #2) WAS DOING WHILE SEATED BEHIND THE NURSE'S STATION JUST PRIOR TO #501'S FALL, CNA #2 REPORTED, "...I WAS SITTING BEHIND THE NURSE'S DESK EATING A CANDY BAR THAT A FAMILY MEMBER HAD BROUGHT IN FOR THE STAFF. I'LL BE HONEST, THAT'S WHAT I WAS DOING. THERE IS NO EXCUSE..." ON 7/19/12 AT 12:00 P.M., DURING AN INTERVIEW, WHEN QUERIED ABOUT FACILITY STAFF'S LACK OF SUPERVISION OF #501 WHO WAS REPORTEDLY AGITATED, YELLING OUT AND COMBATIVE, THE DIRECTOR OF NURSING (DON) REPORTED, "...(CNA #2) TOLD ME SHE DIDN'T KNOW THAT (RESIDENT #501) COULD MOVE THAT FAST. HOWEVER, I DON'T FIND IT APPROPRIATE THAT SHE (CNA #2) WAS BEHIND THE NURSE'S STATION EATING A CANDY BAR INSTEAD OF SUPERVISING THE RESIDENT (#501)..." A REVIEW OF THE FACILITY'S "FALL PREVENTION PROGRAM PROTOCOL" POLICY REVISED 5/2009; REVIEWED 3/2012 REVEALED: "...IT IS THE POLICY TO DETERMINE FALL RISK AND PROVIDE PROMPT MANAGEMENT TO PREVENT FALLS AND INJURY..." "...PURPOSE: PREVENT FALLS FOLLOWING BASIC CARE PROCESS OF ASSESSMENT, CARE PLANNING AND ONGOING EVALUATION. THIS WILL ALERT STAFF TO RESIDENTS WHO ARE AT RISK AND MAY HELP PREVENT FALLS..." THE FACILITY'S FALL PREVENTION POLICY DID NOT ADDRESS PROVIDING INCREASED SUPERVISION AND 1:1 MONITORING OF THE RESIDENT EXHIBITING UNTOWARD BEHAVIORS.

THIS CITATION PERTAINS TO INTAKE MI 346 BASED ON OBSERVATION, INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 4 RESIDENTS (#101) SAMPLED FOR SAFETY, FROM A TOTAL SAMPLE OF 6 RESIDENTS REMAINED FREE OF ACCIDENT HAZARDS AND RECEIVED ADEQUATE SUPERVISION TO PREVENT ACCIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHO WITH A HISTORY OF CONFUSION, DEMENTIA AND FORGETFULNESS, LEFT THE FACILITY'S PREMISES WITHOUT PERMISSION OR SUPERVISION, AND WAS FOUND WANDERING STREETS IN THE COMMUNITY, PLACING HIM AT HIGH RISK FOR SUBSEQUENT HARM AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #101 WAS AN [AGE] year-old-MALE WHO HAS LIVED AT THE FACILITY SINCE 6/08/2010. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD MODERATELY IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. HIS [DIAGNOSES REDACTED]. THE FACILITY REPORTED THAT HIS MOOD HAD DETERIORATED IN THE LAST NINETY DAYS AND HE REQUIRED REORIENTATION FOR HIS DAILY WANDERING BEHAVIORS. RESIDENT #101 had a history of [REDACTED]. HE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE LIMITED ASSISTANCE WITH WALKING AND LOCOMOTION ON THE UNIT. ACCORDING TO THE RESIDENT ASSESSMENT PROTOCOL DEVELOPED FROM THE MINIMUM DATA SET, RESIDENT #101 TRIGGERED THE NEED EVALUATE HIS COGNITIVE LOSS/DEMENTIA AND BEHAVIORAL SYMPTOMS. THESE ASSESSMENTS REVEALED THAT THE RESIDENT HAD RECENTLY EXPERIENCED A " DETERIORATION " AND " INCREASED CONFUSION " . STAFF IDENTIFIED THAT RESIDENT #101 WANDERED BUT DID NOT HAVE THE " ABILITY TO RETAIN INFORMATION " AND NEEDED " CONSTANT CUES AND SUPERVISION " . THE ASSESSMENT REVEALED THAT RESIDENT #101 HAD " NO INSIGHT INTO SAFETY " AND " IS VERY DISORIENTED " . " DESPITE REORIENTATION " THE RESIDENT FELT " HE NEEDS TO WALK TO HARBOR BEACH " . ACCORDING TO A PATIENT/RESIDENT OCCURRENCE REPORT DATED 06/26/2010 AT " APPROXIMATELY " 7:00 P.M., STAFF COULD NOT FIND RESIDENT #101 ON THE UNIT, IN THE FACILITY OR ON ITS PREMISES. ON 09/10/2010 AT 2:30 P.M., EMPLOYEE " E " , A CERTIFIED NURSING ASSISTANT, STATED THAT RESIDENT #101 DID ELOPE FROM THE FACILITY AFTER SUPPER AND PRIOR TO 7:00 P.M. SHE THEN STATED THAT THE WATCHMATE ALARM FOR WANDER PREVENTION DID NOT SOUND ON 06/26/2010 WHEN RESIDENT #101 LEFT THE FACILITY. ON 09/10/2010 AT 2:45 P.M., EMPLOYEE " F " STATED WHILE PASSING MEDICATIONS AROUND 7:00 P.M., SHE BECAME ALARMED WHEN SHE DID NOT SEE RESIDENT #101 WANDERING IN THE HALLWAYS. THE MEDICATION ADMINISTRATION RECORD CONFIRMED THAT SHE HAD SEEN HIM AT 6:44 P.M., WHILE ADMINISTERING HIM ATIVAN. IMMEDIATELY STAFF INITIATED A DOOR-BY-DOOR UNIT SEARCH, THEN HOSPITAL WIDE SEARCH AND FACILITY GROUNDS SEARCH THAT WAS UNSUCCESSFUL IN LOCATING RESIDENT #101. EMPLOYEE " F " STATED THAT STAFF DID NOT KNOW THAT RESIDENT #101 left the faciity on [DATE] BECAUSE THE WATCHMATE ALARM FOR WANDER PREVENTION DID NOT SOUND. EMPLOYEE " F " STATED THAT AFTER COMPLETING THIS UNSUCCESSFUL SEARCH, A COMMUNITY MEMBER CONTACTED THE FACILITY BY PHONE AND REPORTED LOCATING RESIDENT #101, WALKING UNSUPERVISED IN THE COMMUNITY, APPROXIMATELY HALF A MILE AWAY FROM THE FACILITY. ACCORDING TO THE PATIENT/RESIDENT OCCURRENCE REPORT DATED 06/26/2010 AT " APPROXIMATELY " 7:00 P.M., RESIDENT #101 WAS TRANSPORTED IN A PRIVATE CAR BACK TO THE FACILITY AT 7:15 P.M. AN OBSERVATION ON 09/10/2010 REVEALED THIS BEACH OR BODY OF WATER (LAKE HURON), IS ONLY TWO BLOCKS AWAY FROM THE FACILITY. ACCORDING TO THE FACILITY'S " ELOPEMENT POLICY AND PROCEDURE " DATED 10/06/2004, " SAFETY RELATED MEASURES " ARE IN PLACE TO PREVENT RESIDENTS FROM " LEAVING THE HOSPITAL/EXTENDED CARE AREAS WITHOUT SUPERVISION OR STAFF KNOWLEDGE" . THESE SAFETY RELATED MEASURE INCLUDE " ALARMS " WHICH ARE PRESENT ON THE " ENTRY DOOR TO THE EXTENDED CARE UNIT". THIS POLICY ESTABLISHES THAT " RESIDENTS IN THE EXTENDED CARE UNIT WITH ELOPEMENT POTENTIAL WILL BE ISSUED AN ALARM BRACELET (WATCHLET PLUS) WHICH TRIGGERS THE ALARM" WHEN IN CLOSE PROXIMITY TO AN OPEN EXIT DOOR. ACCORDING TO THE UNDATED CARE PLAN DEVELOPED PRIOR TO 06/23/2010, STAFF IDENTIFIED RESIDENT #101 TO BE AT RISK FOR ACCIDENTS AND INJURY RELATED TO HIS WANDERING. ACCORDING TO A FALL HISTORY AND INTERVENTION, SUMMARY STAFF APPLIED TWO WATCHLET PLUS BRACELETS TO RESIDENT #101 ' S ANKLES ON 06/17/2010. ACCORDING TO NURSING NOTES DATED 06/20/2010 AT 1:09 P.M., RESIDENT #101 WAS " VERY RESTLESS AND BECOMING AGITATED WANTING TO LEAVE FOR HARBOR BEACH " . ON 06/20/2010 AT 6:01 P.M., RESIDENT #101 WAS " DIFFICULT TO DIRECT " AFTER " AMBULATING NON-STOP SINCE 2 P.M. " . ON 06/21/2010 AT 12:28 P.M., RESIDENT #101 WAS " WANDERING UP/DOWN HALLS, RESTLESS " , REQUIRING ATIVAN (A SEDATING MEDICATION) TO MODIFY THESE BEHAVIORS. ON 06/22/2010 AT 3:09 P.M., RESIDENT #101 WANDERED " UP/DOWN HALLWAYS WHILE APPEARING EXHAUSTED AND STUMBLING. ON 06/26/2010 AT 3:09 P.M., THERE WAS " NO CHANGES IN BEHAVIOR/GESTURE " FOR RESIDENT #101. ACCORDING TO THE BEHAVIOR AND MOOD SHEET FOR 06/2010, STAFF DOCUMENTED THAT RESIDENT #101 HAD WANDERING BEHAVIORS ON 06/18/2010, 06/20/2010, 60/21/2010/ 60/22/2010, 60/24/2010 AND 06/26/2010. ACCORDING TO ALARM MONITORING DOCUMENTATION, STAFF DID NOT ROUTINELY TEST THE FUNCTION OF EITHER WATCHLET PLUS ATTACHED TO RESIDENT #101 PRIOR TO 06/28/2010. DURING ROUTINE TESTING OF THE EXIT DOORS FOR THE WATCHMATE SYSTEM ON 06/26/2010 AT 8:15 A.M., STAFF IDENTIFIED THAT THE ALARM DID NOT SOUND AND THE SYSTEMS FUNCTION TO ENSURE RESIDENT SAFETY FAILED. ACCORDING TO AN IMPORTANT MESSAGE FORM 4009, DATED 6/26/2010 AT 10:00 A.M., STAFF CONTACTED EMPLOYEE " G " IN PLANT OPERATIONS FOR TROUBLESHOOTING THE FAILED DOOR ALARM. ON THIS FORM STAFF WROTE " DOOR ALARM NOT WORKING " . ON 9/16/2010 AT 10:00 A.M., EMPLOYEE " G" STATED THAT HE CAME to the facility on [DATE] TO TROUBLESHOOT WHY THE WATCHMATE ALARM SYSTEM FAILED TO ALARM ON THE UNIT ' S EXIT DOORS, WHEN tested AT 8:15 A.M. HE STATED THAT HE DID NOT FOLLOW THE MANUFACTURERS GUIDELINES FOR TROUBLESHOOTING THE SYSTEMS BECAUSE HE, NOR THE FACILITY, HAD A MANUAL FOR THE SYSTEM. HE STATED HE REVIEWED THE ASPECTS OF THE SYSTEM THAT HE KNEW ABOUT AND THEN COMPLETED THE SAME TEST DONE AT 8:15 A.M. EMPLOYEE "G" STATED THE ALARM WORKED FOR HIS TEST " SO I LEFT " . EMPLOYEE "G" DENIED FIXING IT, OR MAKING ANY CHANGES/ADJUSTMENTS TO THE WATCHMATE WANDER PREVENTION SYSTEM. HE STATED HE DID NOT EVEN LOOK AT THE SENSOR BAR FOR POSITIONING WHILE TROUBLESHOOTING THE SYSTEM DURING THE MORNING HOURS OF 06/26/2010. ON 09/10/2010 AT 12:00 P.M., THE DIRECTOR OF NURSING STATED THAT THE LOCAL POLICE DEPARTMENT HAD BEEN GIVEN RESIDENT #101 ' S PHOTOGRAPH BECAUSE HE WAS SUCH A HIGH RISK FOR ELOPEMENT. SHE COULD NOT EXPLAIN WHY THE SYSTEM DID NOT WORK WHEN tested on [DATE] AT 8:15 A.M. THE DIRECTOR OF NURSING COULD NOT VERIFY THAT STAFF tested THE WATCHMATE SYSTEM BASED ON THE MANUFACTURERS GUIDELINES BEFORE 09/10/2010. FURTHER, SHE COULD NOT VERIFY THAT EMPLOYEE " G " COMPLETED THE TROUBLESHOOTING ON 06/26/2010, ACCORDING TO THE MANUFACTURERS GUIDELINES. SHE CONFIRMED THAT THE FACILITY DID NOT REFERENCE THE AUTHORIZED DEALER OR MANUFACTURERS MANUAL FOR TESTING REQUIREMENTS OR TROUBLESHOOTING GUIDELINES. ON 09/16/2010 AT 10:30 A.M., THE DIRECTOR OF ACTIVITIES STATED THAT HER STAFF WERE RESPONSIBLE FOR TESTING THE WATCHMATE ALARM SYSTEM TWICE A DAY AND THEN DOCUMENTING THE FUNCTIONALITY OF THESE TESTS. SHE REPORTED THAT ACTIVITY STAFF TESTING THE FUNCTIONALITY OF THE WATCHMATE PRODUCT HAD NO FORMAL TRAINING. THE ACTIVITIES DIRECTOR THEN CONFIRMED THAT THE TESTING BEFORE 09/13/2010 DID NOT MEET THE MANUFACTURERS GUIDELINES. SHE STATED " WE ALL KNOW WHAT WATCHMATES DO " AND TEST THEM BASED ON THAT KNOWLEDGE". SHE COULD NOT EXPLAIN WHY STAFF FAILED TO TEST THE ALARM SYSTEM AT LEAST ONCE DAILY ON 6/15/2010, 6/22/2010 , 7/13/2010, 7/19/2010, 8/10/2010, 8/24/2010, 8/30/2010 OR 8/31/2010 . ON 09/10/2010 AT 2:45 P.M., EMPLOYEE "F" , A REGISTERED NURSE, STATED THAT IN SHIFT CHANGE ON 06/26/2010 AT 2:00 P.M., SHE RECEIVED NOTIFICATION THAT THE EXIT DOOR ALARM DID NOT FUNCTION WITH ROUTINE TESTING AT 8:15 A.M., BUT THAT MAINTENANCE HAD ALREADY FIXED IT. SHE DENIED THE PROVISION OF ANY INCREASED MONITORING OR SUPERVISION FOR THE EXIT DOOR ON 06/26/2010 BETWEEN 2:00 P.M. AND 7:20 P.M. ACCORDING TO AN IMPORTANT MESSAGE FORM 4009, DATED 06/26/2010 AT 9:00 P.M., EMPLOYEE " G" RETURNED TO THE FACILITY TO TROUBLESHOOT AND RESOLVE WHY THE EXIT " DOOR (WAS) NOT GOING OFF WHEN (THE) WATCHMATE (BRACELETS WERE) CLOSE " . ACCORDING TO THE DIRECTOR OF NURSING ON 09/16/2010, STAFF NOTIFIED HER OF THE FAILURES AFTER RESIDENT #101 RETURNED FROM HIS ELOPEMENT ON 06/26/2010. SHE STATED SHE HAD CONCERN THAT THE INITIAL MAINTENANCE CHECK ON 06/26/2010 HAD NOT IDENTIFIED OR RESOLVED WHY THE SYSTEM FAILED AND REQUIRED FURTHER TESTING AND TROUBLESHOOTING TO RESOLVE THIS FAILURE. ON 09/16/2010 AT 10:00 A.M., EMPLOYEE " G " STATED THAT FOLLOWING RESIDENT #101 ' S ELOPEMENT ON 06/26/2010, HE RETURNED AGAIN FOR FURTHER TROUBLESHOOTING OF THE SYSTEM FAILURE. EMPLOYEE " G " STATED THAT DURING THIS INSPECTION HE DID LOOK AT THE SENSOR BAR LOCATED ABOVE THE EXIT DOOR. HE FOUND THE SENSOR BAR DISPLACED AND FELT ITS ADJUSTMENT " COULD " , CORRECT THE FAILURE. EMPLOYEE " G " REVIEWED THE MANUFACTURERS MANUAL OBTAINED BY THE FACILITY ON 09/10/2010. EMPLOYEE " G " STATED THAT HE FAILED TO FOLLOW THE MANUFACTURERS GUIDELINES FOR TROUBLESHOOTING THE MONITORS FAILURE TO DETECT A WATCHLET. HE CONFIRMED THAT THE FACILITY WAS REQUIRED TO CONTACT THE AUTHORIZED DEALER ABOUT THE FAILURE, WHICH OCCURRED AT 8:15 A.M. ON 06/26/2010. EMPLOYEE " G " STATED THAT IF HE HAD MADE THE REQUIRED CALL TO THE AUTHORIZED DEALER, THEY " WOULD HAVE HAD US TROUBLESHOOT THE SENSOR AND REMOVE THE PROBLEM " BEFORE RESIDENT #101 ELOPED FROM THE FACILITY, UNSUPERVISED ON 06/26/2010. THE ADMINISTRATOR RECEIVED NOTIFICATION OF THE IMMEDIATE JEOPARDY ON 09/17/2010 AT 12:10 P.M., THAT BEGAN ON 06/26/2010 WHEN RESIDENT #101 ELOPED, UNSUPERVISED FROM THE FACILITY ' S PREMISES, RESULTING IN HIS POTENTIAL IMMINENT HARM. ON 09/22/2010, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101 REMAINS A RESIDENT AT THE FACILITY. STAFF IDENTIFIED HIM TO BE AT RISK FOR ELOPEMENT ON 06/11/2010. HE REMAINED AT RISK WHEN REASSESSED BY TWO NURSES, A SOCIAL WORKER AND THE ACTIVITIES DIRECTOR ON 06/20/2010. 2. RESIDENT #101 DID NOT HAVE ANY EVIDENCE OF INJURY OBSERVED, DOCUMENTED OR REPORTED FROM BECAUSE OF THE ELOPEMENT ON 06/26/2010. 3. ON 09/17/2010, THE DIRECTOR OF NURSING REVIEWED ALL CARE PLANS FOR RESIDENT #101 AND DEEMED THEM APPROPRIATE TO MEET HIS SAFETY NEEDS. SHE DOCUMENTED THIS REVIEW AS A LATE ENTRY IN THE NURSING NOTES ON 9/22/2010. 4. ON 09/17/2010, THE DIRECTOR OF NURSING REVIEWED ALL PHYSICIAN ORDERS [REDACTED]. SHE DOCUMENTED THIS REVIEW AS A LATE ENTRY IN THE NURSING NOTES ON 9/22/2010. 5. BEGINNING 06/28/2010, STAFF DOCUMENT AT LEAST WEEKLY THAT RESIDENT #101 HAS A FUNCTIONAL WATCHLET AND MONITORING SYSTEM, AFTER PHYSICALLY TESTING HIS SPECIFIC DEVICE. 6. RESIDENT #101 REMAINS ON THE FACILITY ' S BEHAVIOR MODIFICATION PROGRAM SINCE 06/11/2010. 7. ON 06/20/2010, TWO NURSES, A SOCIAL WORKER AND THE DIRECTOR OF ACTIVITIES ASSESSED 32 OF 32 RESIDENTS LIVING AT THE FACILITY. THE ASSESSMENT TEAM IDENTIFIED 3 OF THESE 32 RESIDENTS TO BE POTENTIAL RISKS FOR ELOPEMENT. STAFF DEVELOPED A CARE PLAN FOR ALL THREE RESIDENTS AND APPLIED A FUNCTIONAL WATCHLET TO THEIR PERSON. 8. ON 06/26/2010 AT 9:00 P.M., MAINTENANCE DOCUMENTED ADJUSTMENT OF THE WATCHMATE SENSOR BAR. 9. ON 09/10/2010, THE FACILITY OBTAINED COPIES OF THE WATCHMATE MANUFACTURERS MANUAL AND PLACED A COPY IN THE OPERATIONS PLANT, DIRECTOR OF NURSES OFFICE AND ON THE EXTENDED CARE UNIT. 10. AS OF 09/10/2010, STAFF IS TESTING THE WATCHMATE SYSTEM TWICE DAILY WITH NO REPORT OR DOCUMENTATION OF ANY FAILED TESTS. 11. ON 06/18/2010, 8 OF 10 LICENSED NURSING STAFF EMPLOYED BY THE FACILITY RECEIVED EDUCATION ON THE WATCHMATE SYSTEM. EDUCATION IS ONGOING WITH NO STAFF RETURNING TO WORK WITHOUT THE REQUIRED EDUCATION. BY 09/18/2010, 9 OF 11 STAFF (ONE NEW HIRE) HAD RECEIVED THIS REQUIRED EDUCATION. 12. ON 06/18/2010, 22 OF 24 CERTIFIED NURSING ASSISTANTS EMPLOYED BY THE FACILITY RECEIVED EDUCATION ON THE WATCHMATE SYSTEM. BY 09/18/2010, 24 OF 24 CERTIFIED NURSING ASSISTANTS HAD RECEIVED THE EDUCATION. 13. ON 07/01/2010, 7 OF 7 ENVIRONMENTAL STAFF RECEIVED EDUCATION ON ENSURING THE WATCHMATES SENSOR BAR PLACEMENT WHILE COMPLETING THEIR CUSTODIAL DUTIES. 14. ON 9/15/2010, 5 OF 5 ACTIVITY STAFF RECEIVED TRAINING ON TESTING THE WATCHMATE MONITORING SYSTEM, SPECIFIC TO THE MANUFACTURERS GUIDELINES. 15. ON 09/17/2010, 3 OF 3 PLANT OPERATION EMPLOYEES RECEIVED EDUCATION ON THE WATCHMATE MONITORING SYSTEM FROM THE MANUFACTURERS MANUAL/GUIDELINES. 16. ON 09/18/2010, THE DIRECTOR OF NURSING AND ADMINISTRATOR REVIEWED THE FOLLOWING POLICIES: a. ELOPEMENT POLICY AND PROCEDURE b. ALARM SYSTEMS FOR PATIENT/RESIDENT SAFETY c. EMERGENCY treatment for [REDACTED]. d. DEDICATED EMERGENCY DEPARTMENT e. AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION f. EQUIPMENT AND ELECTRICAL SAFETY g. BEHAVIOR MANAGEMENT OR ADAPTATION IN REGARDS TO OUTBURST BY A RESIDENT h. STAFFING PLAN i. ALARM WATCH PROCEDURE FOR MAINTENANCE AND REPAIR UPON REVIEW, ADMINISTRATION DEEMED THESE POLICIES APPROPRIATE, REQUIRING NO REVISIONS. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 09/18/2010, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THEN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY AS SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY.