Every finding on record at Langdon Place of Dover

Based on observation, interview, and record review, the facility failed to ensure that medication was removed from use in accordance with the manufacturer's instructions for 1 of 1 medication carts observed. (Resident identifier is #8.)Findings include:Observation on 5/13/26 at 8:35 a.m. of the Medication Cart with Staff A (Licensed Practical Nurse) revealed a Lispro Insulin KwikPen for Resident #8. Further observation revealed that on the pen was documented opened 4/13/26 and expires 5/10/26. Review on 5/13/26 of Resident #8's May 2026 Medication Administration Record with Staff A revealed that it was documented that Resident #8 had received Lispro Insulin on 5/11/26 at 11:30 a.m. and 4:30 p.m. and on 5/12/26 at 11:30 a.m. Interview on 5/13/26 at 8:35 a.m. with Staff A confirmed the Lispro Insulin KwikPen for Resident #8 had a discard date of 5/10/26. Review on 5/13/26 of the facility's policy titled Insulin Pen revised 1/22/26 revealed . Policy Explanation and Compliance Guidelines . 8. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation . Review on 5/14/26 of the manufacturer's Instructions For Use for Insulin Lispro KwikPen provided by the facility, revealed, .Preparing your Pen . Do not use your Pen past the expiration date printed on the Label or for more that 28 days after you first start using the Pen . Storing you Pen In-use Pen . Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it .

Based on interview and record review, the facility failed to follow physician's order for 2 of 2 residents reviewed for nutrition and notify the physician of weekly weights not being taken in a final sample of 8 residents. (Resident identifiers are #8 and #21.)Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Page 994 Daily Weights and Fluid Intake and Output Measurement revealed, .Daily weights are an important indicator of fluid status (Flever, 2019c). Each kilogram (2.2.lb [pound]) of weight gained or losses indicate changes in the amount of total body fluid, usually ECF (extracellular fluid), but do not indicate shift between body compartments.Compare the weight of each day with that of the previous day to determine fluid gain or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care . [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021, Chapter 19, page 267 revealed the following Communication with other health providers needs to be timely, accurate, and relevant to the patient's clinical situation. Resident #21 Review on 5/12/26 of Resident #21's provider progress note dated 5/1/26 revealed, Assessment and Plan . Heart Failure . Daily weights ordered . Review on 5/12/26 of Resident #21's physician's orders dated 5/1/26 revealed an order for daily weight. Please call provider for weight gain greater than 2 pounds in 24 hours or 5 pounds in 7 days. Review on 5/12/26 of Resident #21's Care Plan revealed, Focus [name omitted] exhibits or is at risk for fluid volume excess as evidenced by anasarca, cirrhosis, CHF [Congestive Heart Failure], AKI [Acute Kidney Injury] . Interventions . Monitor weight as ordered and report to physician per MD [Medical Doctor] order . Review on 5/12/26 of Resident #21's medical record, including weights and progress notes, revealed the following; On 5/1/26: 271.8 pounds. On 5/2/26: 259.6 pounds (a 12.2 weight loss). There was no documentation that the provider was notified of the weight loss. On 5/3/26: There was documentation that the resident refused to be weighed. There was no documentation the provider was notified of the refusal or attempted to reweigh. On 5/4/26: 261.4 pounds. On 5/5/26: There was no documented weight, and the resident was transported to the emergency room and returned late afternoon for an elbow infection. On 5/6/26: There was no documented weight. On 5/7/26: 262.3 pounds. On 5/8/26: No documented weight. On 5/9/26: 269.4 pounds (a weight gain of 7.1 pounds). There was no documentation the provider was notified. On 5/10/26: 276.8 pounds. On 5/11/26: 275.8 pounds. On 5/12/26: 267.2 pounds. On 5/13/26: There was documentation that the resident refused to be weighed, but there was no documentation the provider was notified of the refusal or attempted to reweigh. Interview on 5/14/26 at 1:06 p.m. with Staff G (Unit Manager) confirmed that daily weights should have been done on Resident #21 and were not. Staff G confirmed that the provider should have been notified of weight changes as per the above order. Interview on 5/14/26 at 2:08 p.m. with Staff H (Nurse Practitioner) confirmed the provider should have been notified with weight changes and that they should have attempted to get a reweight if the resident refused. Resident #8 Review on 5/14/26 of Resident #8's April 2026 Medication Administration Record (MAR) revealed the following physician's orders: Weekly shower/skin check and weight, complete UDA (user-Defined Assessment) every night shift every Wed, start date 4/15/2026, discontinued (D/C) date 5/6/26. Review on 5/14/26 of Resident #8's medical record revealed that on 4/9/26, Resident #8's weight was 153.4 pounds (lbs) and on 5/6/26, Resident #8's weight was 146 lbs. There were no documented weekly weights for Resident #8 on 4/15/26, 4/22/26, or 4/29/26. Review on 5/14/26 of Resident #8's nutrition note dated 4/28/26, revealed the following: admission weight 4/9/26 was 153.4 lbs. No updated weight available at this time; nursing notified to obtain current weight for monitoring. Goal is to maintain adequate nutritional intake to support healing and rehabilitation, with stable weight and improved glycemic control. Interview on 5/14/26 at approximately 12:45 p.m. with Staff G confirmed that there was no documentation of weights for Resident #8 between 4/10 and 5/6/26. Staff G stated that newly admitted residents were to have weekly weights taken for the first four weeks unless otherwise indicated by the provider. Interview further revealed that there was no documentation that a provider was notified that Resident #8's weekly weights weren't taken. Interview on 5/14/26 at approximately 1:00 p.m. with Staff H confirmed that he/she was not notified that Resident #8's weekly weights were not being taken until 5/6/26. Review on 5/14/26 of the facility's policy titled Weight Monitoring revised 1/22/26 revealed, A weight monitoring schedule will be developed upon admission for all residents . b Newly admitted residents - monitor weight weekly for 4 weeks .

Based on interview and record review, the facility failed to ensure that the resident's care plan was reviewed after the comprehensive assessment was completed for 1 of 1 residents reviewed for care planning in a final sample of 8 residents. (Resident identifier is #5). Findings include: Interview on 5/12/2026 at 12:36 p.m. with Resident #5's family member revealed that they had not attended a care plan meeting for Resident #5 and did not know when Resident #5 would be returning home with the family member. Review on 5/12/26 of Resident #5's provider progress note dated 4/20/26 revealed, . I do not feel [pronoun omitted] has the capacity for medical decision making at this time . will activate [pronoun omitted] DPOA [Durable Power of Attorney] according to his advanced directives . Review on 5/12/26 of Resident #5's medical record revealed that there was no documentation that a care plan meeting had been held after the admission Comprehensive Assessment had been completed on 4/27/26. Further review revealed that there was no documentation that Resident #5's responsible party and/or DPOA had been invited to a care plan meeting. Interview on 5/13/26 at 2:23 p.m. with Staff F (Registered Nurse) confirmed that there was no documentation that a care plan meeting had been held or that Resident #5's responsible party had been invited to a care plan meeting. Review on 5/14/26 of the facility's policy titled Care Planning-Resident Participation revised 1/22/26 revealed, Policy: This facility supports the resident's right to be informed of, and participate in their care planning and treatment (implementation of care) . 10. The facility will discuss the plan of care with the resient and/or representative at regularly scheduled care plan conferences. The facility will make an effort to schedule the conferences at the best time of the day for the resident/resident's representative. 11. If the participation of the resident and/or resident representative is determined tnt practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record.

Based on observation, interview, and record review, it was determined that the facility failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness, to measure the parts per million (PPM) for the low temperature dishwasher to ensure proper sanitization, and to maintain a clean environment for 1 of 1 kitchens observed. Findings include: Interview on 2/5/25 at approximately 8:25 a.m. with Staff J (Food Services Manager) revealed that the facility utitlized a low temperature chemical sanatizing dishwasher. Staff J stated they don't perform PPM testing as long as the temperatures were within range. Review on 2/5/25 of the Monthly Dish Machine Logs for January 2025 and February 2025 revealed that the PPM testing was not documented. The Machine Dish Log had spaced to record PPM testing 3 times a day. The Machine Dish Log contained the following statement: If temperatures or chemical concentration does not meet parameters, stop washing and alert a manager or designee. Review on 2/5/25 of the Product Specification Document copyright 2023 Ecolab USA Inc. revealed .Use a chlorine test kit and increase dosage, as necessary, to obtain the required level of available chlorine Set sanitizer concentrations at 50 parts per million. (Notice: Do not exceed 100 PPM's) . Interview on 2/6/25 at approximately 8:10 a.m. with Staff H (Regional Dietary Manager) confirmed the above findings. Observation on 2/5/25 at approximately 8:20 a.m. in the kitchen revealed the presence of dried cooked eggs, egg shells, pasta, and food debris on the floor in the food preparation area. Observation on 2/5/25 at approximately 8:25 a.m. in the walk-in refrigerator revealed a purple dried substance under the shelving. There were sdried onion skins and other miscellaneous unidentified debris. Interview on 2/5/25 at approximately 8:26 a.m. with Staff I (Cook) confirmed the above findings.

Based on interview and policy review, it was determined that the facility failed to implement a water management program for the prevention of waterborne pathogens for a facility with a census of 24 residents. Findings include: Review on 2/6/25 of the facility's policy, Legionella Water Management, dated 2016, revealed the following: .III. Areas Where Legionella Could Grow and Spread: Everywhere the water temp is between 77 and 108. Which is between the mixing valve and the end use. Unoccupied rooms and apartments, more than 7 days, Storage tanks . .IV. Control Measures and Monitoring: Assure re-circulator pumps are working each week. Know where the unoccupied room and apartments are located. Do not use the water downstream of a plumbing repair. Take the water storage tank temperatures weekly . .V. Ways to Intervene When Control Limits Are Not Met: If re-circulation pumps fail, fix within 24 hours. Run the hot water in rooms and apartments that are unoccupied for more than 7 days. If water storage tank temps fall below 120 degrees, make adjustments . Review on 2/6/24 of the facility's list of unoccupied rooms for more than 6 days from October 1, 2024 to February 6, 2025 revealed the following: room [ROOM NUMBER] was unoccupied on 11/1/2024 until 11/10/2024; room [ROOM NUMBER] was unoccupied on 12/1/2024 until 12/12/2024; room [ROOM NUMBER] was unoccupied on 12/11/2024 until 12/27/2024; room [ROOM NUMBER] was unoccupied on 10/5/2024 until 10/19/2024; room [ROOM NUMBER] was unoccupied on 10/11/2024 until 1/6/2025. Interview on 2/6/25 at 11:39 a.m. with Staff K (Director of Maintenance) revealed the hot water was not run in room [ROOM NUMBER], 502, 508, 513, and 514 when the above rooms were unoccupied for more than 7 days. Interview further revealed that the facility was not taking weekly temperatures at the storage tank.

Based on observation and interview, it was determined that the facility failed to follow professional principles for the storage of medications for 1 of 2 medication carts observed. Findings include: Observation on 2/6/25 at 12:03 p.m. of the high side medication cart in a common area was left unlocked and unattended. Further observation revealed that there were two residents in the area of the medication cart. Interview on 2/6/25 at 12:08 p.m. with Staff C (Clinical Corporate Nurse) confirmed the above findings. Staff C stated it was the facility policy to lock the medication cart when not attended by nursing staff. Review on 2/10/25 of the facility's policy titled Medication Storage, not dated, revealed the following .Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biological's will be stored in locked compartments (i.e., Medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperatures controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on interview and record review, it was determined that the facility failed to implement policies and procedures for providing COVID-19 vaccines for 2 of 5 residents reviewed for COVID-19 immunizations (Resident identifiers are #1 and #10). Findings include: Resident #1 Review on 3/12/24 of Resident #1's COVID-19 vaccine consent form, dated 2/1/24, revealed that Resident #1 had given consent to be vaccinated with the COVID-19 vaccine. Review on 3/12/24 of Resident #1's medical record revealed no documentation that Resident #1 received the COVID-19 vaccine after giving consent on 2/1/24. Resident #10 Review on 3/12/24 of Resident #10's COVID-19 vaccine consent form, dated 11/12/23, revealed that Resident #10 had given consent to be vaccinated with the COVID-19 vaccine. Review on 3/12/24 of Resident #10's immunization record revealed no documentation that Resident #10 received the COVID-19 vaccine giving consent on 11/12/23. Interview on 3/13/24 at approximately 10:15 a.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that the pharmacy had available single doses of COVID-19 vaccines since October 2023. Review on 3/13/24 of the facility policy titled, COVID-19 Vaccination, revision date of 2/7/24, revealed .Centers will provide the opportunity to received COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendations subject to availability, to patient/residents .1. Obtain COVID-19 vaccination history .3 Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule .5. Obtain consent .8. Obtain physician order for COVID-19 vaccination. 8.1 Use the Medical Director Authorization. 9. Administer the vaccine . Review on 3/13/24 of the facility's Updated (2023-2024 Formula) COVID-19 vaccine information from CDC, dated 9/22/23, revealed .Interim 2023-2024 COVID-19 Immunizations Schedule for Persons 6 months of Age and Older .Table 1a. For people who are NOT moderately or severely immunocompromised .2023-24 Moderna COVID-19 Vaccine .Age [AGE] years and older .unvaccinated (0 doses) Give 1 dose now .Any number of previous doses COVID-19 vaccines, NOT including at least 1 dose of 203-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 1b. For people who are NOT moderately or severely immunocompromised .2023-24 Pfizer-BioNTech COVID-19 Vaccine .Age [AGE] years and older .unvaccinated (0 doses) Give 1 dose now .Any number of previous doses COVID-19 vaccines, NOT including at least 1 dose of 203-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 2a. For people who ARE moderately or severely immunocompromised .2023-24 Moderna COVID-19 Vaccine .Age [AGE] years and older .unvaccinated (0 doses) Give a 3-dose initial series. Administer: Dose 1 now, Dose 2 at least 4 weeks after Dose 1 Dose 3 at least 4 weeks after Dose 2 .3 or more doses of Moderna COVID-19 Vaccine, NOT including at least 1 dose of 2023-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 2b. For people who ARE moderately or severely immunocompromised .2023-24 Pfizer-BIoNTech COVID-19 Vaccine .Age [AGE] years and older .unvaccinated give a 3-dose initial series. Administer: Dose 1 now, Dose 2 at least 3 weeks after Dose 1 Dose 3 at least 4 weeks after Dose 2 .3 or more doses of Pfizer-BioNTech COVID-19 Vaccine, NOT including at least 1 dose of 2023-24 COVID-19 vaccine .Give 1 dose at least 8 weeks (2 months) after the previous dose .

Based on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order and that an account of all controlled drugs is maintained for 2 of 2 narcotic books reviewed. Findings include: Review on 1/11/23 at 8:45 a.m. of the Transitional Care Unit low end medication cart with Staff A (Licensed Practical Nurse (LPN)) revealed that the controlled drug receipt and removal index/inventory page (inventory page used for receipt and tracking of the narcotics that are in the medication cart) in a binder did not have the two nurse receipt signatures required that log into the index/inventory page verifying that the narcotic was received and accounted for, nor did it have indication of removal from the count on the inventory page. Further investigation revealed that the controlled medication utilization record (record from pharmacy) in the alphabetical section of the narcotic count binder did not have the date received or the two nurse signatures. Interview on 1/11/23 at 8:50 a.m. with Staff A revealed that he/she usually does count with another nurse by using the binder that has the Controlled Medication Utilization record by alphabetical last name and has not used the index for logging or doing narcotic count. Staff A confirmed that he/she would not be able to confirm if a narcotic drug and controlled medication utilization record was removed from the count or from the alphabetical list of resident narcotics. Interview on 1/11/23 at 10:30 a.m. with Staff B (Interim Director of Nursing) revealed that their facility policy was for two nurses to log in narcotics and to be utilizing the index page for count. Staff B confirmed the above findings. Review on 1/12/23 at 12:20 p.m. of the facilities policy titled NSG300 Controlled Substances: Management of Revision date 04/01/22 .Policy Storage: Two Licensed nurses and/or authorized nursing personnel, per state regulations are required to document placement of controlled substances into inventory. Review on 1/20/23 at 9:00 a.m. of the facilities Omnicare 5.1 policy titled Delivery and Receipt of Routine deliveries. revised date 01/01/22 section 2.4 Immediately log accepted controlled substances into facility's controlled medication inventory system per facility policy. Standard Patricia A. Potter and Anne Griffin Perry Fundamentals of Nursing 7th edition page 688 .Medication Regulation and Nursing Practice .The nurse is responsible for following legal provisions when administering controlled substances or narcotics which are carefully controlled through federal and state guidelines

Based on observation, record review, and interview it was determined that the facility failed to follow professional standards for following physician's orders for residents 1 of 2 narcotic books reviewed (Resident Identifier #11) and 2 out of 25 medication administration observed ( Resident Identifiers are #11, #70 and #71). Findings include: Standard: Potter, Patricia A. and Anne Griffin Perry. Fundamentals of Nursing . 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #11 Review on 1/12/23 at 8:45 a.m. of the medication storage and disposition of controlled drugs log on the Transitional Care Unit with Staff A (Licensed Practical Nurse (LPN)) revealed that Resident #11 has an order for morphine sulfate 10 milligrams [mg] in 5 milliliters [ml] solution (medication for pain management) give 2.5 ml by mouth every 3 hours as needed for moderate to severe pain. On 12/10/22 at 22:56 [10:56 p.m.] Resident #11 was administered 0.5 mg instead of the ordered 2.5 mg. Interview 1/12/23 at approximately 9:30 a.m. with Staff B (Interim Director of Nursing Services) confirmed the above findings. 40522 Resident #70 Observation on 1/12/23 at approximately 8:27 a.m. with Staff D (Registered Nurse (RN)) revealed that Staff D popped 1 tablet of Resident #70's Calcium 500 Plus D3 [Vitamin D] (500-5 mg) medication from Resident #70's Calcium 500 plus D3 (500-5 mg) bingo card into a medication cup. Review on 1/12/23 with Staff D during Resident #70's medication administration revealed that Resident #70's Calcium 500 plus D3 (500-5 mg) bingo card and electronic medication administration record stated to give 2 tablets of Calcium 500 plus D3 (500-5 mg). Observation on 1/12/23 at approximately 8:30 a.m. with Staff D revealed that Staff D gave Resident #70's 1 tablet of the Calcium 500 plus D3 (500 mg-5 mg) medication. Interview on 1/12/23 at approximately 9:00 a.m. with Staff D stated that he/she completed his/her administration of medications with Resident #70. Staff D confirmed above findings. Resident #71 Observation on 1/12/23 at approximately 8:27 a.m. with Staff D revealed that 1 tablet of an over the counter medication of ferrous sulfate 325 mg was put into a medication cup by Staff D. Review on 1/12/23 with Staff D during Resident #71's medication administration revealed that Resident #71's electronic medication administration record stated to give 1 tablet of ferrous sulfate 324 mg. Observation on 1/12/23 at approximately 8:30 a.m. with Staff D revealed that Staff D gave Resident #71's 1 tablet of the ferrous sulfate 325 mg. Interview on 1/12/23 at approximately 9:00 a.m. with Staff D stated that he/she completed his/her medication pass with Resident #71. Staff D confirmed above findings with Resident #71. Staff D stated that there were no other supply of ferrous sulfate besides the 325 mg dose.

1. Based on observation, interview, and record review, it was determined that the facility failed to ensure that services provided met professional standards for securing medications for 1 of 2 medication carts observed. Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pg. 721; 'Administering Oral Medications'; Step 7; item o. Do not leave medications unattended Findings include: Observation on 12/6/21 between 9: 30 a.m. until 9:45 a.m. of Staff A (Registered Nurse) revealed an intravenous [MEDICATION(S)] was left unattended on the AOU (Admission Observation Unit ) medication cart. Interview with Staff A on 12/6/21 at 9:45 a.m. confirmed that he/she left the [MEDICATION(S)] warming up on the medication cart unattended during his/her medication pass prior to administering the medication to the resident. 2. Based on observation, interview, and record review, it was determined that the facility failed to ensure that services provided met professional standards for medication administration for 1 resident out 6 residents observed. (Resident identifier is #171.) Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. pg. 720; 'Administering Oral Medications'; Step 7; item h.Do not touch medication with fingers.Break prescored medications if needed by using a gloved hand or a clean pillating device. Findings include: Observation on 12/6/21 at approximately 9:45 a.m. of Staff A administering medications to Resident #171, during the medication pass, revealed Staff A placed the following medications in the the medication cup: aspirin 81 mg (milligram), [MEDICATION(S)] 1000 mg, [MEDICATION(S)] 100 mg, acidophilus, [MEDICATION(S)] 25 mg, [MEDICATION(S)] 300 mg Bid (twice a day), and pantrazole 40 mg. Observation further revealed Staff A picked out the [MEDICATION(S)] with his/her bare hands to split them in half. Interview on 12/6/21 at approximately 9:45 a.m. revealed Staff A indicated the resident liked them split so he/she can swallow them better. Staff A indicated he/she normally would not touch medication without gloves.

Based on interview and record review, it was determined that the facility failed to ensure that residents who use [CONDITION(S)] drugs received behavioral interventions unless clinically contraindicated and based on resident's comprehensive assessment for 2 residents out of 6 residents reviewed for unnecessary medications (Resident #13 and #14); and the facility also failed to ensure that residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat specific condition as diagnosed and documented in the clinical record for 1 resident out of 6 residents reviewed for unnecessary medications (Resident #13) in a final sample size of 11 residents. (Resident identifiers are #13 and #14.) Findings include: Resident #13 Review on 12/7/21 of Resident #13's physician orders revealed an order for [MEDICATION(S)] (anti-psychotic) 25 mg (milligram) by mouth at bedtime for sleep with a start date of 11/21/21. Review on 12/7/21 of Resident #13's medical diagnosis revealed diagnosis of [CONDITION(S)] (loss of coordination of voluntary muscle movements), anxiety disorder, unspecified depression among other diagnosis. Further review revealed no other psychiatric, cognitive nor behavioral diagnosis. Review on 12/7/21 of Resident #13's [CONDITION(S)] drug care plan dated 11/22/21 revealed that Resident #13 is at risk for complications related to the use of [CONDITION(S)] drugs with interventions to monitor for continued need of medications as related to behavior and mood. No target behaviors documented in the care plan. Review on 12/7/21 of Resident #13's November and December 2021's Electronic Medication Administration Record (EMAR) revealed that Resident #13 had no behaviors. Further review revealed no target behaviors documented for monitoring. Review on 12/7/21 of Resident #13's physician notes dated 11/22/21 and 11/30/21 revealed no documentation in regards to Resident #13's indication of use of [MEDICATION(S)] 25 mg nor target behaviors to be monitored. Further review revealed past medical history of anxiety, depression and no other past medical history of psychiatric, cognitive nor behavioral diagnoses. Review also revealed that Resident #13 is alert and oriented in time, place, and person. Further review also revealed Resident #13's affect, mood, judgement and insight are appropriate. Review on 12/7/21 of Resident #13's pharmacy Medication Regimen Review (MRR) dated 11/23/21 revealed that Resident #13 receives an antipsychotic, [MEDICATION(S)], without documentation of diagnoses and adequate indication for use in the medical record. Further review revealed recommendations were to update the medical records to include the specific diagnoses requiring treatment that is based upon an assessment of the resident's condition and therapeutic goal; and list of symptoms or target behaviors (e.g. hallucinations scratching) including their impact on the resident. Further review also revealed that the physician's response documented was that Resident #13 has depression which was signed and dated on 11/30/21. Interview on 12/7/21 at approximately 2:00 p.m. with Staff B (Unit manager) revealed that Resident #13 started [MEDICATION(S)] started prior to admission to facility. Staff B stated that sleep is not an appropriate indication of use for [MEDICATION(S)]. Staff B was not able to provided explanation on why Resident #13 was on [MEDICATION(S)]. Interview on 12/7/21 at approximately 3:00 p.m. with Staff E (regional nurse) confirmed the above findings of Resident #13's EMAR, physician notes, and pharmacy MRR. Staff E stated that they will have the physician clarify Resident #13's indication of use of [MEDICATION(S)]. Review on 12/7/21 of the FDA (Food Drug and Administration) website for [MEDICATION(S)] (i.e.[MEDICATION(S)]) prescribing information, retrieved from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/ 9s061lbl.pdf, revealed indication of use for the treatment of [CONDITION(S)], [CONDITION(S)] disorder manic and depressive episodes. Resident #14 Review on 12/7/21 of Resident #14's November and December 2021 EMAR revealed a physician order for [MEDICATION(S)] 5 mg by mouth one time a day for psychotic disorder with a start date of 11/19/21. Further review revealed no documentation that target behaviors were being monitored for Resident #14. Review on 12/7/21 of Resident #14's current care plan revealed that Resident #14 is at risk for complication related to the use of antipsychotic with a revision date of 11/19/21. Further review revealed interventions to complete behavior monitoring flow sheet and monitor for continued need of medications as related to behavior and mood. Further review also revealed no documentation of target behaviors being monitored. Interview on 12/7/21 at 1:37 p.m. with Staff B confirmed the above findings for Resident #14. Staff B stated that a behavior monitoring flowsheet is completed for residents receiving antipsychotic medication and it is documented in the EMAR. Review on 12/7/21 of facility's policy titled, [CONDITION(S)] Medication Use, with revision date 11/28/16, revealed that .[CONDITION(S)] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavior assessment records for residents receiving [CONDITION(S)] medication .Facility staff should monitor behavioral triggers, episode and symptoms

Based on interview and medical record review, it was determinted that the facility failed to fully report the results of an elopement investigation to the State Agency for 1 of 5 residents reviewed for elopment risk. (Resident identifier is Resident #1.) Findings include: Review on 4/6/21 of the facility's final report dated 3/26/21 that was sent to the State Agency read, in part, . It was reported to the [Administrator] that last nite (sic) at approximately 12:45 a.m., [Resident #1] exited the unit without notifying staff and exited the building the patient found (sic) walking with her walker outside. Patient returned to the facility with a staff member . Review on 4/6/221 of Resident #1's progress noted dated 3/23/21 at 8:04 a.m. read, in part, . 12:15 a.m. [Resident] noted to be missing from [pronoun omitted] room .grounds searched .[Staff I] MNA (Medication Nursing Assistant) used [pronoun omitted] car and located [resident] down [name of road], at [house number] where the homeowner had brought [Resident] inside Review on 4/6/21 of the facility's Risk Management Summary Report for Resident #1 for an elopement event dated 3/23/21 at 12:45 a.m. read, in part, . Event Location: Outdoors - non-facility property .Describe the circumstances of the event and immediate actions taken: .outside property searched, pt [patient] was found at the house closest to [name of facility] Summary of interview with witnesses: .Pt [patient] found at neighbors, no shoes on but fully dressed . Review on 4/6/21 of Staff A (Director of Nursing) undated notes of his/her investigation of the elopement read, in part, . Patient was found at a neighbors (sic) house where they had brought [pronoun omitted] in and were in the process of calling the building. Review on 4/6/21 of an undated written statement by Staff I (Medication Nursing Assistant) read, in part, I was working on .Monday 3/22/21 11-7 [11 p.m. to 7 a.m. shift]. I was alerted that the TCU [Transitional Care Unit] had a missing resident about 2430 [12:30 a.m.] .did an outside parameter check. At this point resident still not found. I decided to take a slow drive up the road .just in case [pronoun omitted] went that way. While driving back toward the facility I saw a [person] waving [pronoun omitted] hands on a porch I asked if she had seen an old [person] with a walker? [Pronoun omitted] stated we have [pronoun omitted] here. At this point I assisted resident back to my car . Interview on 4/6/21 at 10:30 a.m. with Staff C (Licensed Nursing Assistant) confirmed that he/she had been involved with the search of the facility for Resident #1 on 3/23/21, including outside of the facility. Staff C confirmed that Staff I drove his/her car off the facility's grounds to search for Resident #1. Interview on 4/6/21 at 12:30 p.m. with Staff A confirmed that the final report sent to the State Agency for Resident #1's elopement did not contain documentation that the resident was located at a neighbor's home and only reported that the resident was found walking outside. Interview on 4/6/21 at 12:48 p.m. with Staff B (Administrator) confirmed that the final report sent to the State Agency for Resident #1's elopement did not contain documentation the resident was off facility property and found at neighbor's home.

Based on observation, interview, record review, the facility failed to ensure that staff wore face masks in accordance with the Centers for Disease Control and Infection recommnendations during COVID-19 pandemic and transmission-based precaution for 2 out of 2 staff observed. (Resident identifiers are #117, #119, and # 217.) Findings include: Interview on 11/18/20 at 9:00 a.m. with Staff E (Unit Manager) revealed that Resident #119's and #117's were on contact and airborne precaution (transmission-based precaution) for the residents that were on a 14-day quarantine as new admits. Observation on 11/18/20 at 12:10 p.m. in Resident #117 and Resident #119's room, which had a transmission-based precaution sign outside of the door for contact and airborne precaution. Staff D (Licensed Nursing Assistant) was observed pulling down his/her N95 mask down his/her chin, Staff D then spoke to Resident #119 the pulled his/her N95 mask back up to the bridge of his/her nose then left the room. Interview on 11/18/20 at 12:10 p.m. with Resident #117 confirmed the above findings. Observation on 11/19/20 at approximately 11:46 p.m. in the hallway revealed that Staff D did not have a surgical mask nor a N95 mask on and only had a face shield covering his/her face. Interview on 11/19/20 at approximately 11:46 p.m. with Staff D confirmed the above findings on 11/19/20. Staff D stated that he/she just got out of a resident room and was unable to provide explanation why he/she did not have a surgical mask on. Staff D also stated that he/she should have a surgical mask at all times when on the unit. Observation on 11/19/20 at approximately 9:30 a.m. revealed that Staff H (Laundry aide) entering Resident #217's room where a sign that stated STOP please see the Nurse before entering the Patient's room! PATIENT-SPECIFIC CONTACT PLUS AIRBORNE PRECAUTIONS Sign .Wear an N95/approved KN95 Respirator, Gown, Face Shield and Gloves upon entering this room. Staff H was wearing a gown, gloves and a face mask. Observation on 11/19/20 at approximately 9:30 a.m. revealed two netted bags inside a wired laundry cart touching each other. Staff H revealed that one netted bag was the dirty bags that come out of the rooms and then Staff H takes the clean bags out of the out of the netted bag and hangs one up in the closets. Interview on 11/19/20 at approximately 9:35 a.m. with Staff H revealed that staff need to wear personal protective equipment when entering Resident #217's room, Staff H stated that gown, gloves and mask needed to be worn, but they do not need to wear a N95. Interview on 11/19/20 at approximately 9:30 a.m. with Staff H revealed that Staff H stated that it This room is different then the other end, on the other end then I put on everything. Staff H stated that Staff H was only going to the bathroom right next to the door and picking up the laundry. Interview on 11/19/20 at approximately 9:45 a.m. with Staff G (Licensed Practical Nurse) revealed resident is in a private room on quarantine precautions due to being a new admit and on an antibiotic and that all staff that enter Resident #217 needs to wear all the personal protective equipment; which includes and N95, face shield, gloves and gown. Review on 11/20/20 of the CDC website titled, Preparing for COVID-19 in Nursing Homes, updated June 25,2020 revealed the following (retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html): Core Practices, Implement Source Control Measures, HCP (Health Care Personnel) should wear a facemask at all times while they are in the facility. Further review of the website revealed that the CDC defines HCP as the following: HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual HCP not employed by the healthcare facility, and persons not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

Based on observation, interview and record review, it was determined that the facility failed to maintain a sanitary environment in the main kitchen; and failed to label/date food items and then monitor for expired/unlabeled items in 1 of 1 food storage room and 1 of 2 refrigerators in accordance with professional standards for food service safety in the main kitchen. Findings include: Observation on [DATE] at approximately 9:20 a.m. during the initial tour of the kitchen revealed the following; -An air duct in the ceiling above the dishwasher with visible dust and a black grease-like substance; -A white fan mounted to wall above shelf pointing towards the dishwasher with visible dust; -An air conditioning unit in a window by the cleaning supply closet and refrigerator with visible dust and a black grease-like substance; -A white fan mounted to the wall by the cleaning supply closet with visible dust; -An air conditioning vent over the coffee maker and coffee cups with visible dust and a black grease-like substance. -A multi-tiered metal shelving rack next to the food prep center island that had visible dust and a black grease-like substance on all the shelves. There were clean baking sheets, pans, and utensils on the dusty shelves. Interview on [DATE] at approximately 9:25 a.m. with Staff A (Food Service Director) confirmed that the vents and fans were dusty/dirty and needed to be cleaned. Staff A was unsure when the vents had been last cleaned and stated the maintenance department was responsible for cleaning them. Staff A also stated the fans should not be in the kitchen and would request them be removed. Staff A confirmed that the dusty/dirty shelving rack had clean pans and utensils stored on it. Interview on [DATE] at approximately 9:30 a.m. with Staff B (Dietary Aide) revealed the air conditioning units had been used in the past couple of weeks. Interview on [DATE] at 10:45 a.m. with Staff C (Director of Maintenance) confirmed that he/she was responsible for cleaning the air-conditioning units and vents. Staff C could not recall when the vents/air-conditioning units in the kitchen had last been cleaned and stated the kitchen staff would let him/her know if they needed to be cleaned. Staff C was not aware of any fans in the kitchen. Review of the facility's Logbook Documentation of Exhaust Fans: Inspect exhaust fans for proper operation and clean if necessary revealed the Kitchen Roof was marked done on [DATE] by Staff C. Interview on [DATE] at 9:00 a.m. with Staff A revealed the shelving unit had been cleaned; however, would probably need to be power washed to remove all the built up dust. Food Storage Observation on [DATE] at approximately 9:20 a.m. during initial tour of the kitchen revealed 11 unopened four-ounce cartons of nutritional supplement in the refrigerator with no date of when they were removed from the freezer. Interview on [DATE] at approximately 9:20 a.m. with Staff A confirmed that the supplements should have a date when removed from the freezer and was unsure when they had been removed. Observation on [DATE] at 9:45 a.m. of the food storage room revealed the following: -Six bags of 1 pound pearl barley with a best by date of [DATE]; -Four unopened 5 pound brownie mixes in clear bags that had 0 (sic) stamped on them. There was a fifth opened bag with half the mix gone that had cling wrap around it; and there was no date to indicate when it had been opened. The large box that the brownie mix was in did not have a date it was delivered. -Six unopened dairy thickened product with a imprinted stamp date of [DATE]. The outer box they were in had a date of [DATE]. Interview on [DATE] at 9:45 a.m. with Staff A confirmed that the pearl barley had expired and should have been discarded. Staff A confirmed that the brownie box should have a date when received and thought that the 0 date was the product number and not a best-by or use-by date, but could not be sure of this. Staff A did not know when the opened bag of brownie mix had been opened. Staff A stated that the thickened dairy products were expired and should be discarded. Review on [DATE] of the facility's undated Labeling and Dating Inservice (sic) read, part: Importance of Labeling and Dating Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Guidelines for Labeling and Dating -All foods should be dated upon receipt before being stored. -Food labels must include: The food item name The date of preparation/receipt/removal from freezer The use by date as outlined in the attached guidelines -Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use-by date as outlined in the Retention Guide attached -Leftovers must be labeled and dated with the date they are prepared and the use-by date. Use By Dating Guidelines -The manufacturer's expiration date, when available, is the use by for unopened boxes Food Storage and Retention Guide . Baking Goods (cake, brownie, bread mixes) . dry storage . ,[DATE] months . Specialty Items - Shakes, Supplements, Thickened Beverages . dry storage . Manufacturer Guidelines . Review on [DATE] of the manufacturer's instructions for the 4 ounce cartons of liquid supplements provided by the facility read, in part, . store frozen. Thaw under refrigeration, refrigerate for up to 14 days .

Based on observation, interview and record review, it was determined that the facility failed to provide services that met professional standards in regards to following physicians orders for medications and treatments for 2 residents out of 13 residents reviewed in a final survey sample of 13 residents. (Resident identifiers are #4 and #120.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 707 To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Resident # 4 Observation on 11/19/20 at approximately 8:25 a.m. of Resident #4's medication administration revealed Staff G (Licensed Practical Nurse) while preparing medication for Resident #4 dispensed one tablet of [MEDICATION NAME] 20 mg (milligrams) Tablet to be given. Review on 11/19/20 at approximately 8:25 a.m. of Resident #4's current Medication Administration Record [REDACTED]. Interview on 11/19/20 at approximately 8:25 a.m. with Staff G confirmed one 20 mg tablet of [MEDICATION NAME] was dispensed for Resident #4 and the order was for a total dose of 40 mg of [MEDICATION NAME]. Observation on 11/18/20 at 10:18 a.m. of Resident #4 revealed that there was an oxygen concentrator next to Resident #4's bed with a nasal cannula attached to it. Oxygen was in use at this time by Resident #4. Observation on 11/19/20 at 12:16 p.m. revealed Resident #4's oxygen was in use at this time by Resident #4. Interview on 11/19/20 at approximately 12.16 p.m. with Resident #4 revealed that she has used oxygen since before her last readmission to the facility. Review on 11/19/20 of Resident #4's medical record revealed no current physician order [REDACTED].>Interview on 11/19/20 at approximately 1:10 p.m. with Staff G confirmed Resident #4 has used oxygen since before her admission to the unit. Staff G confirmed there was no current physician order [REDACTED].> Resident #120 Review on 11/20/20 of Resident #120 active physician orders [REDACTED].#21's physician orders [REDACTED]. Review on 11/20/20 of Resident #120's November 2020 Electronic Medication Administration Record [REDACTED] Review on 11/20/20 of Resident #120's nurse's notes revealed no nurse's notes about obtaining a one time physician order [REDACTED].>Interview on 11/20/20 at approximately 9:20 a.m. with Staff E (Unit Manager) confirmed the above findings. Interview on 11/20/20 at approximately 11:30 a.m. with Staff F (Clinical Quality Specialist) revealed that Staff F stated that Staff E should have obtained a one time order for quetiapine [MEDICATION NAME] use on 11/6/20 at 10:10 a.m. and document it in Resident #120's resident record.

Based on observation, interview, and record review, it was determined that the facility failed to label oxygen tubing to ensure it is maintained for safe use of oxygen for 2 residents out of 3 residents reviewed for respiratory care in a final survey sample of 13 residents. (Resident identifiers are #4 and #8). Findings include: Resident #4 Observation on 11/18/20 at 10:18 a.m. revealed that there was an oxygen concentrator next to Resident #4's bed with a nasal cannula attached to it. The oxygen tubing had no marking indicating the date the tubing was put into use. Oxygen was in use at this time by Resident #4. Observation on 11/19/20 at 12:16 p.m. revealed Resident #4's oxygen tubing remained with no date for initiation of tubing. Oxygen was in use at this time by Resident #4. Review on 11/19/20 at approximately 12:45 p.m. of Resident#4's current Medication Administration Record [REDACTED]. Interview on 11/19/20 at approximately 1:00 p.m. with Staff G (Licensed Practical Nurse) confirmed there was no date on Resident # 4's oxygen tubing. Staff G also stated that the oxygen tubing is normally changed on Thursday night by night shift and is supposed to be labeled with the date it is put into use. Interview on 11/19/20 at approximately 1:10 p.m. with Staff G confirmed there was no current physician order [REDACTED]. Resident #8 Observation on 11/18/20 at 10:51 a.m. revealed that there was an oxygen concentrator next to Resident #8's bed with oxygen tubing attached. The oxygen tubing had no marking indicating the date the tubing was put into use. Oxygen concentrator was in use at this time by Resident #8. There was also an oxygen cylinder across from Resident #8's bathroom door with oxygen tubing attached. The oxygen tubing had no marking indicating the date the tubing was put into use. Observation on 11/19/20 at 12:20 p.m. revealed Resident #8's oxygen concentrator and oxygen cylinder tubing remained with no date for initiation of tubing. Oxygen concentrator was in use at this time by Resident #8. Interview on 11/19/20 at approximately 1:00 p.m. with Staff G confirmed there was no date on Resident # 8's oxygen tubing for the oxygen concentrator as well as the oxygen cylinder. Review on 11/19/20 at approximately 12:45 p.m. of Resident #8's current physician's orders [REDACTED]. Review on 11/20/20 of the facilities policy titled Oxygen Nasal Cannula with a revision date of 11/01/19 read, in part .3.2 Nasal cannula labeled with date of initial set up .16. Replace disposable set every seven days. Date and store in treatment bag when not in use.

Based on record review, interview, policy and procedure review, it was determined that the facility failed to notify the physician about clinical changes in 3 residents out of a final sample of 18 residents. (Resident identifiers are #10, #120, and #121.) Resident #10 Review on 3/28/19 of Resident #10's medical record in the nurses notes revealed that Resident #10 had a fall on 3/20/19 at 8:45 p.m. Review on 3/28/19 of the RMS (risk management summary) dated 3/21/19 revealed that Resident #10 had complaints of some pain in left buttocks/hip during assessment prior to Resident #10 being moved. Review on 3/28/19 of Staff E, (Nurse Practitioner) progress noted dated, 3/21/19 13:12 revealed, (pronoun omitted) landed on (pronoun omitted) left hip/buttock region and had acute pain. (pronoun omitted) was hoyered to (pronoun omitted) recliner last night and been unable to stand since. (pronoun omitted) reports pain is 10/10. Review on 3/29/19 of the SBAR (situation, background, assessment, recommendation) dated, 3/21/19, 8:30 a.m. revealed: . Resident Evaluation . 9. Pain Evaluation Does the resident have pain? yes. Is the pain new? yes. Review on 3/28/19 of the Radiology report, date of service 3/21/19 11:52 a.m. revealed: . Conclusion: suspect left pubic fractures, Consider CT (Cat Scan) if indicated. Review on 3/28/19 of nurses notes revealed the following note dated 3/21/19, 5:55: . Dr. (pronoun omitted) updated about orthopedic suggestions (pronoun omitted) and ordered to send to ED (emergency department) for CT now. Patient sent 911 per (pronoun omitted). Interview on 3/29/19 at approximately 9:30 a.m. with Staff E revealed that there had been no notification of Resident #10's fall or pain until 3/21/19 at 9:00 a.m. Staff hoyered (pronoun omitted) into a recliner after the fall, stayed (pronoun omitted) stay in the recliner all night, and was not moved until I was notified of the fall around 9:00 a.m.) Review on 3/29/19 of the facility policy and procedure titled, NSG115 Physician/Advanced Practitioner Provider (APP) Notification, revision date 12/1/18 revealed: Policy Upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform clinical observations, and collect pertinent patient information such as age, diagnoses, prior vital signs, labs, recent changes in medications, previous incidents of a similar nature, code status, etc. and report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. . Purpose To communicate a change in patient's condition to physician/APP and initiate interventions as needed/ordered. Resident #120 Review on 3/29/19 of Resident #120's medical record revealed the following nursing note dated, 1/20/19 8:25: @ (at) change of shift this RN (Registered Nurse) was made aware of patients change in condition and assessed patient. Findings were: Patient alert, respirations 28-32, pulse ox (oximeter) 79% on 5 LPM (liters per minute) via NC (nasal cannula), HR (heart rate) irregular @144 BPM (beats per minute) apically, BP (blood pressure) stable 117/55. No c/o (complaints of) CP (chest pain), denies any discomfort anywhere. Foley patent draining CYU (clear yellow urine). Patients skin was cold and clammy. Patient is very difficult to understand any verbal communication. EMS (emergency medical services) notified of need for transfer to (pronoun omitted) and report called to (pronoun omitted) in the ED (emergency department). DPOA (durable power of attorney) notified, Portable DNR (do not resuscitate) sent with patient along with all pertinent care records. Per previous nurse attempts to notify MD (Medical Doctor) / on call of change in condition were unsuccessful. DON (Director of Nursing) made aware of transfer. Review on 3/29/19 of nursing notes for previous shift dated 1/20/19 revealed that there was no documentation of Resident #120's decline. Interview on 3/29/19 at approximately 11:45 a.m. with Staff A (Senior Center Nurse Executive) confirmed that there was no documentation of Resident #120's change in condition from the previous shift. Staff A was unable to locate/determine a time on when the previous shift nurse noted in the 1/20/19 nursing note attempted to notify the MD. Review on 3/29/19 of the (pronoun omitted) hospital discharge summary dated 1/27/18 revealed: . (pronoun omitted) transitioned to comfort care on 1/24/19. passed away a few hours after (pronoun omitted) was transitioned to comfort care. Cause of death is acute hypoxemic [MEDICAL CONDITION] in the settling of aspiration pneumonia and [MEDICAL CONDITION]. Contributing factors are rapid ventricular [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Interview on 3/29/19 at approximately 1:45 p.m. by telephone with Staff D (Licensed Practical Nurse) revealed that Resident #120's change in condition was verbally given during report by the previous nurse on 1/20/19. Staff D immediately assessed resident and sent Resident #120 to the hospital by EMS. (pronoun omitted) was hypoxic during my assessment. Staff D stated that during report the previous shift nurse stated that the on call MD was called about 1 1/2 to 2 hours prior to Staff D arriving with no call back to the facility. Resident #121 Review on 3/29/19 on Resident #121's progress notes dated 1/20/19 revealed the resident had a fall on 1/20/19 and the resident's right side was sore. The progress note indicated the Staff E (Nurse Practitioner) was notified. Interview on 3/29/19 at 9:35 a.m. with Staff E revealed that Staff E was not notified of a fall on 1/20/19. Staff E examined Resident #121's side on 1/25/19 where there was bruising from a fall. Staff E did not send Resident #121 to the hospital on [DATE] as Staff E did not think the ribs were broken and would not treat them any different if they were. Staff E revealed Resident #121 denied pain. Review on 4/1/19 of Resident #121's Nursing Home to Hospital Transfer Form dated 1/26/19 revealed that Resident #121 was transferred to the hospital because the daughter insisted. Review on 4/1/19 of Resident #121's hospital discharge summary dated 1/31/19 revealed that Resident #121 was admitted to the hospital on [DATE] for a fall, dyspnea and change in mental status. The resident was found to have right sided rib fractures and other unrelated diagnoses.

Based on interview and medical record review, it was determined that the facility failed to ensure that residents are free of significant medication errors for 1 of 2 residents reviewed on anticoagulation therapy in a final sample of 18 residents. (Resident identifier is #11.) Findings include: Review on 3/29/19 of Resident #11's physician orders [REDACTED]. There was no order for [MEDICATION NAME] after 3/24/19. Review on 3/29/19 of Resident #11's laboratory requisitions revealed a specimen was drawn on 3/25/19 with PT/INR ordered. Review on 3/29/19 of Resident #11's laboratory reports revealed no PT/INR testing reports dated 3/25/19. Review on 3/29/19 of Resident #11's Medication Administration Record [REDACTED]. Resident #11 did not received [MEDICATION NAME] after 3/24/19. Interview on 3/29/19 at approximately 11:00 a.m. with Staff A (Senior Center Nursing Executive) confirmed the above findings. Interview with Staff A further revealed that when the facility receives PT/INR results, they are called to the physician and new [MEDICATION NAME] orders are obtained. Staff A also revealed that Resident #11's PT/INR results were not received by the facility, and the facility did not follow up on the why they had not received results. Staff confirmed Resident #11 did not received [MEDICATION NAME] between 3/25/19 and 3/29/19.

Based on medical record review, observation, and interview, it was determined that the facility failed to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of 2 residents in a survey sample of 18 residents. (Resident identifier is #7) Resident #7 Review on 3/28/19 at 1:16 p.m. Resident #7's record showed that on 3/7/19 an order was written for [MEDICATION NAME] HCI tablet 50 MG (mailgram) Give 1 tablet by mouth one time a day for B-6 SUPP (supplement) From 3/7/19 - 3/25/19 this medication was not given due to it not being available as written on the MAR (Medication Administration Record). Interview on 3/29/10 with Staff A (Senior Center Nurse Executive) confirmed that this medication was not given until 3/26/19 when the facility got the medication.

Based on medical record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #121 and #120.) Findings include: Review of Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 reveals: Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #121 Review on 3/19/19 of Resident #121's physician orders [REDACTED]. Review on 3/29/49 of Resident #121's Medication Administration Record [REDACTED]. Interview on 4/1/19 at approximately 10:30 a.m. with Staff A (Senior Center Nurse Executive) confirmed the above finding. Resident #120 Review on 3/28/19 of Resident #120's Januarys MAR (Medication Administration Record) revealed the following physicians order, dated 12/17/18: [MEDICATION NAME] Tablet. Give 12.5 mg (milligrams) by mouth every 6 hours for heart HOLD for SBP (systolic blood pressure) <100/ HR (heart rate) <55. Review on 3/28/19 of Resident #120's medical record revealed that there were no blood pressures or heart rates recorded prior to Resident #120 receiving the medication. Interview on 3/28/19 at approximately 12:45 p.m. with Staff A, Senior Center Nurse Executive revealed that there was no documented blood pressures for Resident #120 prior to receiving the medication with parameters. Review on 3/29/19 of the facility policy and procedure titled, OPS402 Clinical Record: Charting and Documentation . 2. Chart pertinent changes in the patient's condition, reaction to treatment, medication, etc., as well as routine observations.