Every finding on record at Lee County Health and Rehabilitation

Based on staff interviews and record review, the facility failed to ensure that medications were administered as care planned to ensure critical laboratory results remained within a therapeutic range for one of nine residents (R) (R1) sampled. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing, and nurse consultant via phone were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 10:15 am. The noncompliance related to the IJ was identified to have existed on 12/30/2023. An Acceptable IJ Removal Plan was received on 4/17/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/17/2024. Findings include: Review of R1's care plan revealed a care plan problem, dated 1/9/2024, for critical lab values. The care plan problem included an intervention for nursing staff to administer medications as ordered and labs as ordered. The goal of the care plan problem was that R1 would not require hospitalization related to critical lab values during the review period. A review of R1's clinical record revealed diagnoses that included but were not limited to, liver transplant status and gangrene of gallbladder in cholecystitis. A review of the physician's orders revealed that R1's medications on admission to the facility included the anti-rejection medication cyclosporine. The cyclosporine order included two 100 milligrams (mg) capsules to be administered two times per day for liver transplant status. A review of the December 2023 eMAR revealed that the medication was scheduled to be administered at 9:00 am and 9:00 pm. A review of the pharmacy's daily audit logs revealed that thirty 100 mg cyclosporine capsules were filled by the pharmacy for R1 on 12/22/2023. A review of R1's December 2023 eMAR revealed that the medication was documented as being started on 12/22/2023 at 9:00 pm. Based on the physician's order of two 100 mg capsules being administered two times daily, the thirty 100 mg capsules would have lasted through the 12/29/2023 9:00 pm dose. However, a review of the December 2023 and January 2024 eMARs revealed that both doses of the cyclosporine medication on 12/30/2023 and the 9:00 am dose on 12/31/2023 are documented as administered to R1. The 9:00 pm dose on 12/31/2023, both doses on 1/1/2024, and the 9:00 am dose on 1/2/2024 are not documented as being administered. Although the cyclosporine medication ran out on 12/29/2023, there was no evidence that facility nursing staff followed up with the pharmacy or that the cyclosporine medication was refilled until 1/2/2024. A review of R1's nurses' notes revealed a 1/19/2024 entry that the on-call pharmacist was notified of the change in the dosage of the cyclosporine and that the pharmacy had to order the medication. Further review of the nurses' notes revealed entries on 1/20/2024 and 1/21/2024 that documented nursing staff following up with the pharmacy concerning the status of the medication. The 1/20/2024 nurse's note entry documented that the pharmacist said the medication would be sent out on the night of 1/22/2024. The 1/21/2024 nurse's note entry documented that the pharmacist had contacted three local backup pharmacies, and none of them had the ordered dose of the cyclosporine medication. A review of the pharmacy daily audit logs and the January 2024 eMAR revealed that sixty 25 mg cyclosporine capsules were dispensed on 1/22/2024, and the medication was administered to R1 starting on 1/22/2024 at 9:00 pm. The order for three 25 mg capsules of cyclosporine two times per day continued until 2/8/2024. On 2/8/2024, the order was increased to cyclosporine 125 mg (one 100 mg capsule and one 25 mg capsule) two times per day. Further review of the pharmacy daily audit logs and the January 2024 and February 2024 eMAR revealed that thirty 25 mg cyclosporine capsules and thirty 100mg capsules were dispensed on 2/8/2024 and administered to R1 starting on 2/8/2024 at 9:00 pm. The order of cyclosporine 125 mg twice daily continued until R1 was discharged from the facility on 2/14/2024. Interview on 3/20/2024 at 10:13 am, Senior Manager HH confirmed that cyclosporine is the main immunosuppressant medication. When questioned if there were any other reasons the cyclosporine level would be undetectable other than the medication not being administered, Senior Manager HH responded no. She stated that the medication would either be an insufficient dose or not administered at all. Senior Manager HH stated that R1's initial cyclosporine goal on discharge from the hospital (12/21/2023) was 150-180, and the goal was to keep him within this range. She further revealed having difficulty getting lab work from the facility due to it being a send-out laboratory test for the facility. This would cause a delay in medication adjustments because of waiting for test results. The facility implemented the following actions to remove the IJ: 1.R1 was discharged from the facility on 2/14/2024 and no other residents in the facility are receiving antirejection medication. 2. On 4/16/2024, the policy for comprehensive care plans titled Patient's Plan of Care was reviewed by the Administrator, DON, and Divisional Nurse with no revisions made. 3. On 4/16/2024, The DON, Assistant Director of Nursing (ADON) and nurse managers reviewed all 58 of 58 resident's medication records and medication carts audited to ensure that medication was available for administration as indicated in the plan of care beginning at 2:20 pm and completed at 4:00 pm. 4. On 3/11/2024 at 3:45 pm, The Divisional Nurse in- serviced 5 of 5 nurse managers including the DON, ADON, Registered Nurse (RN) Nurse Manager, Resident Assessment Instrument (RAI) Director, and Wound Care Coordinator regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration to ensure the plan of care is being followed. 5. On 3/14/2024, The DON initiated education for licensed nurses and Certified Medication Aides (CMAs) regarding following the plan of care regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration. 6. On 3/15/2024, The Divisional Nurse implemented a monitoring tool, F656 Development/Implementation of Comprehensive POC Audit Tool regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends. 7. As of 4/16/2024, _11_ of _12_ nurses (_6_ RNs, _6_ LPNs for a total of 92%) and _6_ of _6_ CMAs (for a total of 100%) were educated on documentation and following the plan of care for medication administration. 8. The remaining _1_ LPN nurse will be in- serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process. 9. The Administrator reviewed the results of the audit on 4/16/2024 during an ADHOC QAPI meeting. 10. All Corrective Actions were completed on April 16, 2024. 11. The facility alleges that the IJ is removed on April 17, 2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. R1's discharge date was verified via review of the closed clinical record, including the 2/14/2024 Minimum Data Set (MDS) Discharge assessment. During an interview on 4/18/2024 at 2:50 pm, the DON confirmed there were no residents currently receiving antirejection medications. 2. Verified via review of a copy of the Patients Plan of Care policy signed as being reviewed on 4/16/2024 with no changes made. The signatures of the Administrator, DON and Divisional Nurse were included. During an interview on 4/18/2024 at 2:50 pm, the Administrator, DON, and Divisional Nurse confirmed they reviewed the policy on 4/16/2024 with no revisions. 3. Verified via review of the Quality Improvement Data Collection Grids labeled Medication ordered for administration was available and dated 4/16/2024. The audits included halls 100, 200, 300 and 400 and all indicated that ordered medications were available for administration. The 100 and 300 hall audit forms were signed as completed by DON. The 200-hall form was signed as completed by the DON and Education Nurse. The 400-hall form was signed as completed by the Education Nurse. During an interview on 4/18/2024 at 10:13 am, the Education Nurse confirmed she assisted the DON in completing the medication cart audits and all medications were available for administration. During an interview on 4/18/2024 at 2:50 pm, the DON confirmed completing the medication records and medication cart audits. Observations of medication administration for R12, R13, R14, R15, R16 and R17 were conducted on 4/18/2024 with LPN LL, RN MM, CMA AA, and CMA KK. Medications were observed to be available and were administered as care planned and ordered, with no significant medication errors. 4. Verified via review of a copy of the Medication Unavailable for Administration policy which included education was provided by the Divisional Nurse on 3/11/2024. The signatures of the DON, Education Nurse, Wound Care Coordinator, RAI Coordinator, and ADON were included. Staff interviews conducted on 4/18/2024 at 10:13 am with the Education Nurse, at 10:47 am with the Resident Assessment Instrument (RAI ) Director, at 11:10 am with the Wound Care Coordinator, at 12:25 pm with the ADON, at 2:50 pm with the Divisional Nurse, and DON who confirmed that the Divisional Nurse had in-serviced them on the policy. During the interview on 4/18/2024 at 10:47 am, the RAI Director stated that a care plan of administering medications as ordered was usually for a specific diagnosis or problem or acute situation that would include administering medications as ordered (to address the condition). 5. Verified via review of clinical meeting documentation, dated 3/14/2024, a copy of the new Medication Aide to Nurse Communication form, and staff signature sheets. The staff signature sheets included six CMAs, six LPNs and five RNs, for a total of 17 nursing staff educated. During an interview on 4/18/2024 at 12:50 pm, the Divisional Nurse clarified that the education was provided from 3/12/2024 through 3/14/2024. During an interview on 4/18/2024 at 2:50 pm, DON also confirmed that she initiated education on 3/12/2024 and it continued through 3/14/2024. During an interview on 4/18/2024 at 12:25 pm, ADON confirmed that the new process had been implemented. 6. Verified via review of the Quality Improvement Data Collection Grid audit tools that were labeled as: 1) Were there medications not administered? 2) Was the MD notified? 3) If applicable, was order placed to hold medication? The audit tools were dated as completed 3/18/2024 through 4/17/2024. The tools included additional comments and follow-up information for any medications that were not administered. During an interview on 4/18/2024 at 12:25 pm, ADON stated that she had assisted DON in completing the audits, and so far, they had gone well. During an interview on 4/18/2024 at 2:50 pm, the Divisional Nurse confirmed implementation of the audit tool and the DON confirmed completing the audits with the assistance of the ADON. 7. Verified via review of clinical meeting documentation, dated 3/14/2024, a copy of the new Medication Aide to Nurse Communication form, and staff signature sheets. The staff signature sheets included six CMAs, six LPNs and five RNs, for a total of 17 nursing staff educated. During an interview on 4/18/2024 at 10:40 am, the Divisional Nurse stated that the total of 12 nurses included in this education were all full-time nurses. She confirmed that there were three additional nurses; one on leave of absence (LOA), with no return date specified, and two that worked prn (as needed). She confirmed that education would be completed by the DON with the additional nurses when they returned to work. During an interview on 4/18/2024 at 12:50 pm, the Divisional Nurse clarified that the education was provided from 3/12/2024 through 3/14/2024. During an interview on 4/18/2024 at 2:50 pm, DON also confirmed that she initiated education on 3/12/2024 and it continued through 3/14/2024. During an interview on 4/18/2024 at 12:25 pm, ADON confirmed that the new process had been implemented. Staff interviews conducted on 4/18/2024 at 10:13 am with the Education/Infection Control RN JJ, at 10:27 am with CMA/Certified Nursing Assistant (CMA/CNA) KK, at 10:47 am with the RAI Director, at 11:00 am with LPN LL, at 11:10 am with the Wound Care Coordinator, at 11:25 am with RN Charge Nurse MM, at 11:37 am with CMA NN, at 12:00 pm with CMA AA, at 12:05 pm with CMA QQ, at 12:29 pm with LPN OO, at 2:13 pm with RN TT, at 2:21 pm with RN RR, and at 3:18 pm with LPN SS, confirmed they had received education regarding following the plan of care regarding medication administration that included inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration. They also confirmed they received education on documentation and following the plan of care for medication administration. 8. During an interview on 4/18/2024 at 10:40 am, the Divisional Nurse stated that the last full-time nurse (LPN PP) was educated on the evening of 4/17/2024. A review of the in-service signature sheet, labeled Hold medication order Education revealed that LPN PP had been educated on 4/17/2024. During the interview with the Divisional Nurse on 4/18/2024 at 10:40 am, she stated that there was one nurse on LOA (with no return date specified) and two nurses that worked on an as needed basis. She confirmed that education would be completed by the DON with the additional nurses when they returned to work. During an interview on 4/18/2024 at 2:21 pm, RN RR confirmed that she worked at the facility on an as needed basis and had received the in-service education from the DON. During an interview on 4/18/2024 at 2:50 pm the DON confirmed that education would be provided to newly hired RNs, LPNs, and CMAs during the orientation process by the nurse manager assigned to them at that time. 9. Verified via review of ADHOC QAPI meeting documentation, dated 4/16/2024, that included signatures of the Administrator, DON, Divisional Nurse, and Medical Director. Also verified via review of the Quality Improvement Data Collection Grid, dated 4/16/2024, and labeled as Audits of abatement were reviewed. The form included the Administrator's signature. 10. All Corrective Actions were completed on April 16, 2024. 11. The facility alleges that the IJ is removed on April 17, 2024.

Based on staff interviews, record reviews, and a review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy, the facility failed to ensure that one of nine sampled residents (R) (R1) obtained medications timely, administered as ordered, and medication trough levels were maintained within a therapeutic range for R1. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing, and nurse consultant via phone were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 10:15 am. The noncompliance related to the IJ was identified to have existed on 12/30/2023. An Acceptable IJ Removal Plan was received on 4/17/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/17/2024. Findings include: The facility policy titled Obtaining and Receiving Medications from Pharmacy, dated 2019 revealed the policy's Procedure section included that medication orders are faxed and/or electronically transmitted to the pharmacy. Once, received by the pharmacy, the pharmacy will dispense the medication after review. The nurse communicates to the pharmacy the required elements of an order. Review of R1's clinical record revealed that he resided at the facility from 12/21/2023 through 2/14/2024 and had diagnoses that included, but were not limited to, liver transplant status and gangrene of gallbladder in cholecystitis. Review of physician's orders revealed that R1's medications on admission to the facility included an anti-rejection medication, cyclosporine. The cyclosporine order included two 100 milligrams (mg) capsules to be administered two times per day for liver transplant status. A review of the December 2023 electronic Medical Record (eMAR) revealed that the medication was scheduled to be administered at 9:00 am and 9:00 pm. Review of the pharmacy daily audit logs revealed that thirty 100 mg cyclosporine capsules were filled by the pharmacy for R1 on 12/22/2023. Review of R1's December 2023 eMAR revealed that the medication was documented as being started on 12/22/2023 at 9:00 pm. Review of the December 2023 and January 2024 eMARs revealed that the 9:00 pm dose on 12/31/2023, the 9:00 am and 9:00 pm doses on 1/1/2024, and the 9:00 am dose on 1/2/2024 were not documented as being administered. Although there was no evidence that facility nursing staff followed up with the pharmacy or that the cyclosporine medication was refilled until 1/2/2024. Review of the pharmacy audit logs and R1's January 2024 eMARs revealed that thirty, 100 mg capsules of cyclosporine was refilled on 1/2/2024, and the medication was administered on 1/2/2024 at 9:00 pm. Further review of the pharmacy audit logs revealed that the cyclosporine medication was again refilled on 1/10/2024 with 30 capsules dispensed. Based on the physician's order of two 100 mg cyclosporine capsules being administered two times daily, the amount of medication dispensed would have lasted through the 9:00 am dose on 1/17/2024. However, further review of the January 2024 eMAR revealed that the 9:00 pm dose on 1/17/2024, both doses on 1/18/2024, and the 9:00 am dose on 1/19/2024 are documented as administered to R1. Review of the physician's order for R1 on 1/19/2024 revealed a cyclosporine order included for nursing staff to administer three 25 mg capsules twice daily. Review of the pharmacy daily audit logs and the January 2024 eMAR revealed that sixty 25 mg cyclosporine capsules were dispensed on 1/22/2024, and the medication was administered to R1 starting on 1/22/2024 at 9:00 pm. The order for three 25 mg capsules of cyclosporine two times per day continued until 2/8/2024. Review of the physician's order on 2/8/2024 revealed the order was increased to cyclosporine 125 mg (one 100 mg capsule and one 25 mg capsule) two times per day. Further review of the pharmacy daily audit logs and the January 2024 and February 2024 eMARs revealed that thirty 25 mg cyclosporine capsules and thirty 100mg capsules were dispensed on 2/8/2024 and administered to R1 starting on 2/8/2024 at 9:00 pm. The order of cyclosporine 125 mg twice daily continued until R1 was discharged from the facility on 2/14/2024. Review of hospital discharge documentation from R1's 12/21/2023 hospital discharge revealed that R1's cyclosporine goal range was 150-180 (measurement not specified). The purpose of the medication was noted to prevent rejection, and the medication should be taken after blood is drawn on lab days. A review of the physician's orders revealed a 12/26/2023 order for a cyclosporine level to be obtained every Monday and Thursday. Further review of the clinical record and laboratory test results revealed that cyclosporine trough levels were collected on 12/28/2023 at 2:28 am, 1/5/2024 at 4:05 pm, 1/9/2024 at 2:58 am, 1/18/2024 at 2:12 am, 1/20/2024 at 11:30 am, 1/22/2024 at 3:03 am, 1/25/2024 at 12:00 am, 1/29/2024 at 12 am and 9:30 am, 2/1/2024 at 8:15 am, 2/5/2024 at 12:00 am, 2/9/2024 at 9:00 am, 2/12/2024 at 12:00 am, and on 2/13/2024 at 8:50 am. All the cyclosporine laboratory samples that were obtained in December 2023, January 2024, and on 2/5/2024 and 2/12/2024 were obtained by the facility and sent to a local laboratory or were obtained by and sent to an outside laboratory service the facility utilized for obtaining routine laboratory tests. A review of the cyclosporine trough level laboratory results from the local laboratory and the outside laboratory service revealed that the type of test was an immunoassay, and the reference range was from 100-200 micrograms per liter (mcg/L) for kidney transplantation and 200-300 mcg/L for other organ transplants. The cyclosporine laboratory samples that were obtained on 2/1/2024, 2/9/2024, and 2/13/2024 were obtained using laboratory sample kits that were provided by R1's hospital transplant team that shipped to the facility, then were shipped back to the hospital laboratory, where R1 had his liver transplant performed. Review of the cyclosporine trough level laboratory results from the transplant hospital laboratory revealed the type of test was done by Liquid Chromatography Tandem Mass Spectrometry. The reference range was from 10-230 nanograms per milliliter (ng/ml). Review of R1's nurse's notes revealed a 1/29/2024 entry by the Assistant Director of Nursing (ADON) that documented contact with R1's hospital service, who inquired about the cyclosporine trough and times that it was drawn. The nurse stated that the trough could not be drawn by the lab at 3:00 am in the morning due to that being too close to the time that R1 received his every 12-hour cyclosporine dose. The note further documented that the trough needed to be drawn closer to 12 hours after R1 received a dose and before the next dose was given. The ADON documented that she informed the hospital service that she would start drawing the laboratory samples before R1 was given the morning dose of cyclosporine on Mondays and Thursdays. The samples would be taken to the local laboratory. The note documented that the hospital service agreed with the process until the facility received the laboratory kits; upon receipt of the laboratory kits, samples would then be sent back to the transplant hospital laboratory. Further review of the cyclosporine laboratory test results revealed that none of the cyclosporine laboratory results were within the goal range of 150-180 set at R1's 12/21/2023 hospital discharge and the facility admitted . For the cyclosporine trough levels obtained from the local hospital and outside laboratory service, only the 1/18/2024 cyclosporine trough (with a report date of 1/22/2024) of 271 mcg/L fell within the suggested range of 200-300 mcg/L for other organ transplants. Following an elevated 1/9/2024 cyclosporine trough level (with a report date of 1/14/2024) of 446 mcg/L, the cyclosporine order of two 100 mg capsules twice daily was decreased to three 25 mg capsules twice daily. Following the 2/1/2024 cyclosporine trough level (with a result date of 2/3/2024) of 47 ng/ml, the cyclosporine order was increased to 125 mg twice daily. However, despite the increase in the cyclosporine dose on 2/8/2024, the cyclosporine trough levels continued to decline. The 2/9/2024 trough level (with a result date of 2/12/2024) was 44 ng/ml. The 2/13/2024 trough level (with a result date of 2/15/2024, which was after discharge from the facility) was less than 20 (<20). R1 was discharged from the facility on 2/14/2024. A review of the Notice of Transfer or Discharge form, dated 2/14/2024, documented that R1 was finished with therapy and was going home. However, after R1 was discharged from the facility on 2/14/2024, he was directly admitted to the hospital (where he previously had a liver transplant) on 2/16/2024. A review of hospital documentation revealed a 2/17/2024 attestation statement by physician II that R1 was admitted in the setting of acutely elevated graft indices and jaundice in the setting of low cyclosporine levels with poor administration at the facility. The physician's notes documented suspected acute cellular rejection and that R1 was a direct admittance from the transplant clinic related to elevated Liver Function Tests (LFTs). Additional hospital physician documentation from 2/18/2024 included that R1 was possibly not (sic) getting medications in the facility on a timely basis. The cyclosporine level on 2/13/2024 was undetectable. Review of R1's physician's orders revealed that his medications also included another anti-rejection medication, mycophenolate mofetil. The mycophenolate mofetil order included one 500 mg mycophenolate to be administered two times per day for liver transplant status. The medication was ordered from 12/21/2023 through 2/14/2024. A review of the eMAR's revealed that the medication was scheduled to be administered at 9:00 am and 9:00 pm. Review of the pharmacy daily audit logs revealed that the pharmacy dispensed thirty 500 mg tablets of mycophenolate mofetil on 12/21/2023, 30 tablets on 1/20/2024, 13 tablets on 1/23/2024, 13 tablets on 2/3/2024, and 13 tablets on 2/8/2024 for a total of 99 tablets. Review of the Discharge Instructions for Care form, dated 2/14/2024, revealed that six of the mycophenolate mofetil tablets were sent home with R1 on discharge. Therefore, 93 of the 99 tablets dispensed from the pharmacy would have been available for administration during R1's stay at the facility. A review of the December 2023 eMAR's revealed that the medication was started on 12/21/2023 at 9:00 pm. Review of the clinical record revealed a 12/29/2023 nurse's note entry that documented a new order from R1's transplant team physician to place the mycophenolate mofetil on hold for five days. A review of the December 2023 eMAR's revealed that the medication was held as ordered from the 9:00 pm dose on 12/29/2023 through the 9:00 am dose on 1/3/2024. Further review of the December 2023, January 2024, and February 2024 eMAR's revealed that all other doses were documented as administered starting on 12/21/2023 at 9:00 pm through 2/14/2024 at 9:00 am. However, the number of doses of mycophenolate mofetil documented as administered totaled 100 tablets, which is seven more tablets than the 93 that would have been available to administer. Review of physician's orders for R1 dated 12/21/2023 through 1/16/2024 revealed an order for an antiviral medication, valganciclovir. Additional review of physician's orders revealed a 12/21/2023 order for two 450 mg tablets of valganciclovir to be administered two times per day for gangrene of the gallbladder in cholecystitis. A review of the December 2023 eMAR revealed that the medication was scheduled to be administered at 9:00 am and 9:00 pm. Review of the pharmacy daily audit logs revealed that the pharmacy dispensed fifteen 450 mg tablets of valganciclovir on 12/22/2023, 12 tablets on 12/30/2023, 12 tablets on 1/2/2024, 12 tablets on 1/6/2024, 12 tablets on 1/10/2024 and 12 tablets on 1/14/2024 for a total of 75 tablets (37.5 doses). A review of the December 2023 eMAR revealed that the medication was first administered on 12/22/2024 at 9:00 pm. Further review of the December 2023 eMAR and review of the January 2024 eMAR revealed that nursing staff documented administering a total of 47 doses (94 tablets) of valganciclovir, which is 8.5 (19 tablets) more than what was provided by the pharmacy. During an interview on 3/13/2024 at 11:45 am with the Licensed Practical Nurse (LPN) BB stated that routine medications that come in the packs are automatically refilled and delivered on Saturdays. For other medications, you just must keep an eye on when they are running low, and for narcotics, she usually reorders when a resident gets down to about 10 pills. During an interview on 3/18/2024 at 10:50 am with the Regional Nurse Consultant DD stated that the cyclosporine capsules were sent from the pharmacy in the manufacturer's packaging. During an interview on 3/18/2024 at 1:26 pm with a family member of R1 confirmed that R1 remained hospitalized . During an interview on 3/19/2024 at 2:25 pm with the Director of the hospital laboratory service explained that a cyclosporine trough level of <20 would be treated as a negative, and that there was no drug detectable in that sample. She stated that the lab test that was used (mass spectrometry) was highly accurate. During an interview on 3/20/2024 at 10:13 am with the Senior Manager HH of the hospital transplant clinic confirmed that R1 was admitted to the hospital for post-transplant rejection on 2/16/2024. She stated that he had stabilized and that his immunosuppressant had been changed. When asked if an undetectable cyclosporine level alone could cause liver transplant rejection, even if the patient were receiving other medications, she stated that it absolutely could. Senior Manager HH stated that the body's natural response is to attack (the donor's liver), and without the immunosuppressant to quell the response, the body will attack it. The immunosuppressant becomes the lifeline. Cyclosporine is the main immunosuppressant medication. When questioned if there were any other reasons the cyclosporine level would be undetectable other than the medication not being administered, Senior Manager HH responded no. She stated that the medication would either not be a sufficient dose or not be administered at all. Senior Manager HH stated that R1's initial cyclosporine goal on discharge from the hospital (12/21/2023) was 150-180 ng/ml. When questioned if the cyclosporine doses ordered by the physician (while at the facility) were sufficient to keep R1 within that goal range, she stated yes, the intent was to keep him within that range. Senior Manager HH stated that they had trouble getting lab work from the facility; there was a delay in getting cyclosporine trough levels because it was a send out laboratory test for the facility. It would be several days before they would get the results, and then they (the hospital service) would make medication adjustments. During an interview on 3/20/2024 at 2:15 pm, the Regional Nurse Consultant DD stated that the nurses could refill medication electronically from the eMAR. They can also pull the stickers (off the package) and fax them to the pharmacy. The traditional medications refill automatically. Regional Nurse Consultant DD stated that some examples of medications that would not be automatically refilled would be medications with limited duration, such as an antibiotic or a medication that is lab based and may change often. During an interview on 3/21/2024 at 12:35 pm with the ADON confirmed that she obtained R1's laboratory samples for the laboratory kits sent from the hospital transplant team. She stated that the samples were sent back overnight to the transplant hospital laboratory. The ADON stated that they (facility staff) discussed in the morning meeting that the cyclosporine trough samples needed to be drawn 12 hours after taking the medication and before the next dose was given, and they did not know that. The ADON stated that when she started obtaining R1's laboratory samples when she got to the facility in the morning, she would let the nurse or Certified Medication Aide (CMA) know not to give the cyclosporine medication before she drew the laboratory sample that morning. The facility implemented the following actions to remove the IJ: 1. R1 was discharged from the facility on 2/14/2024, there are no other residents in the facility receiving antirejection medication. 2. On 4/16/2024, the policy for Medication Unavailable for Administration was reviewed by the Division Nurse, DON, and Administrator with no changed in policy noted. 3. A root cause analysis was identified for medication being unavailable and a Performance Improvement Plan (PIP) was developed on 3/13/2024 regarding CMAs lack of awareness of the reordering process and reporting missing medication to the nurse. The PIP was updated on 3/15/2024 as an allegation of compliance and incorporated into the facility's Quality Assurance Performance Improvement (QAPI) process. An ADHOC QAPI meeting was conducted with the medical director on 3/22/2024. 4. On 3/14/2024, education was provided by the DON to Licensed Nurses (Registered Nurse (RN) and Licensed Practical Nurse (LPN)) and Certified Medication Aides (CMAs) regarding reordering of medication as outlined in the Medication Unavailable for Administration policy, including best practices for reordering medication when 5-7 days of medication are remaining as well as regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication. 5. On 3/15/2024, The Divisional Nurse implemented a monitoring tool, F760 Significant Medication Error regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends. 6. As of 4/16/2024, _11_ of _12_ nurses (_6_ RNs and _6_ LPNs for a total of 93%) and _6_ of _6_ CMAs (for a total of 100%) were educated on documentation and follow up with pharmacy and MD regarding medications not available and best practices for ordering of medication process. 7. The remaining _1_ LPN nurse will be in- serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process. 8. The Administrator reviewed the results of the audit on 4/16/2024 during an ADHOC QAPI meeting. 9. All Corrective Actions were completed on April 16, 2024. 10. The facility alleges that the IJ is removed on April 17, 2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. R1's discharge date was verified via review of the closed clinical record, including the 2/14/2024 Minimum Data Set (MDS) Discharge assessment. During an interview on 4/18/2024 at 2:50 pm, the DON confirmed there were no residents currently receiving antirejection medications. 2. Verified via review of a copy of the Medication Unavailable for Administration policy that was signed as being reviewed on 4/16/2024. The signatures of the Administrator, DON, and Divisional Nurse were included. During an interview on 4/18/2024 at 2:50 pm, the Administrator, DON and Divisional Nurse confirmed they reviewed the policy on 4/16/2024 with no revisions. 3. Verified via review of the Performance Improvement Project (PIP) form, dated 3/13/2024. The problem described on the PIP is nurses not notifying the provider when medication is not available. The root cause analysis was listed as CMAs lack of understanding of the reordering process and not always reporting missing medication to the nurse. Also verified via review of the Allegation of Compliance plan with a beginning date of 3/15/2024, that documented a corrective action plan for residents receiving medication in correct dosage and administration time. Also verified via review of the 3/22/2024 QAPI meeting minutes and staff signature sheet, which included the Medical Director. During an interview on 4/18/2024 at 12:50 pm, the Divisional Nurse confirmed development of the PIP on 3/13/2024 and then updated it to an Allegation of Compliance on 3/15/2024. During an interview on 4/18/2024 at 2:50 pm, the Administrator, DON and Divisional Nurse confirmed the QAPI meeting held on 3/22/2024. 4. Verified via review of clinical meeting documentation, dated 3/14/2024, a copy of the new Medication Aide to Nurse Communication form, and staff signature sheets. The staff signature sheets included six CMAs, six LPNs, and five RNs, for a total of 17 nursing staff educated. During an interview on 4/18/2024 at 12:50 pm, the Divisional Nurse clarified that the education was provided from 3/12/2024 through 3/14/2024. During an interview on 4/18/2024 at 2:50 pm, DON also confirmed that she initiated education on 3/12/2024 and it continued through 3/14/2024. The DON stated that communication between the CMAs and nurses had improved. During an interview on 4/18/2024 at 12:25 pm, ADON confirmed that the new process had been implemented. Observations of medication administration for R12, R13, R14, R15, R16 and R17 were conducted on 4/18/2024 with LPN LL, RN MM, CMA AA and CMA KK. Medications were seen to be available and were administered as ordered, with no significant medication errors. 5. Verified via review of the Quality Improvement Data Collection Grid audit tools that were labeled as: 1) Were there medications not administered? 2) Was the MD notified? 3) If applicable, was order placed to hold medication? The audit tools were dated as completed 3/18/2024 through 4/17/2024. The tools included additional comments and follow-up information for any medications that were not administered. During an interview on 4/18/2024 at 12:25 pm, the ADON stated that she had assisted the DON in completing the audits, and so far, they had gone well. During an interview on 4/18/2024 at 2:50 pm, the Divisional Nurse confirmed implementation of the audit tool and the DON confirmed completing the audits with the assistance of the ADON. 6. Verified via review of clinical meeting documentation, dated 3/14/2024, a copy of the new Medication Aide to Nurse Communication form, and staff signature sheets. The staff signature sheets included six CMAs, six LPNs and five RNs, for a total of 17 nursing staff educated. During an interview on 4/18/2024 at 10:40 am, the Divisional Nurse stated that the total of 12 nurses included in this education were all full-time nurses. She confirmed that there were three additional nurses; one on LOA (with no return date specified) and two that worked prn (as needed). She confirmed that education would be completed by the DON with the additional nurses when they returned to work. During an interview on 4/18/24 at 12:50 pm, the Divisional Nurse clarified that the education was provided from 3/12/2024 through 3/14/2024. During an interview on 4/18/2024 at 2:50 pm, DON also confirmed that she initiated education on 3/12/2024 and it continued through 3/14/2024. During an interview on 4/18/2024 at 12:25 pm, ADON confirmed that the new process had been implemented. Staff interviews conducted on 4/18/2024 at 10:13 am with the Education/Infection Control Registered Nurse (RN) JJ, at 10:27 am with CMA/Certified Nursing Assistant (CNA) KK, at 10:47 am with the Resident Assessment Instrument (RAI) Director, at 11:00 am with LPN LL, at 11:10 am with the Wound Care Coordinator, at 11:25 am with RN Charge Nurse MM, at 11:37 am with CMA NN, at 12:00 pm with CMA AA, at 12:05 pm with CMA QQ, at 12:29 pm with LPN OO, at 2:13 pm with RN TT, at 2:21 pm with RN RR, and at 3:18 pm with LPN SS, confirmed they had received education regarding medication administration that included inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration. They also confirmed they received education on documentation for medication administration. 7. During an interview on 4/18/2024 at 10:40 am, the Divisional Nurse stated that the last full-time nurse (LPN PP) was educated on the evening of 4/17/2024. A review of the in-service signature sheet, labeled Hold medication order Education revealed that LPN PP had been educated on 4/17/2024. During the interview with the Divisional Nurse on 4/18/2024 at 10:40 am, she stated that there was one nurse on LOA (with no return date specified) and two nurses that worked on an as needed basis. She confirmed that education would be completed by the DON with the additional nurses when they returned to work. During an interview on 4/18/2024 at 2:21 pm, RN RR confirmed that she worked at the facility on an as needed basis and had received the in-service education from the DON. During an interview on 4/18/2024 at 2:50 pm the DON confirmed that education would be provided to newly hired RNs, LPNs, and CMAs during the orientation process by the nurse manager assigned to them at that time. 8. Verified via review of ADHOC QAPI meeting documentation, dated 4/16/2024, that included signatures of the Administrator, DON, Divisional Nurse, and Medical Director. Also verified via review of the Quality Improvement Data Collection Grid, dated 4/16/2024, and labeled as Audits of abatement were reviewed. The form included the Administrator's signature. During a text exchange on 4/18/2024 at 1:41 pm, the Medical Director confirmed he attended the 4/16/2024 ADHOC QAPI meeting by phone. During an interview on 4/18/2024 at 2:50 pm the Administrator, DON, and Divisional Nurse confirmed the ADHOC QAPI meeting from 4/16/2024 and that the audit results were reviewed. The Administrator confirmed that the Medical Director attended via phone and came to the facility and signed the meeting documentation afterward. 9. All Corrective Actions were completed on April 16, 2024. 10. The facility alleges that the IJ is removed on April 17, 2024.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration-General, the facility failed to ensure the medication error rate was less than 5%. A total of 35 opportunities were observed with four errors for three residents (R) (R2, R7, and R8) resulting in an error rate of 11.4%. This failure had the potential to result in medication not being given in accordance with the physician's orders and had the potential to adversely affect R2, R7 and R8's clinical condition. Findings include: Review of the facility policy titled, Medication Administration-General, dated 2024. The policy guidelines included that medications are administered in accordance with a valid prescriber order. The guidelines also instructed the Nurse or Certified Medication Aide (CMA), prior to medication administration, to read the administration directions on the Medication Administration Record (MAR) and verify the correct medication, dose, and directions for use. Review of the clinical record revealed that R2 had a physician's order, dated 10/12/2023, for 2 grams of diclofenac 1% topical gel to be applied to her bilateral knees and hands two times per day for joint pain. Review of the electronic Medication Administration Record (eMAR) revealed that the medication was scheduled to be administered at 10:00 am and 10:00 pm. However, during an observation on 3/13/2024 at 9:35 am, Certified Medication Assistant (CMA) AA failed to administer the diclofenac topical gel as scheduled. At the time of the observation, CMA AA stated that the gel was not on the medication cart. During an interview on 3/13/2024 at 9:50 am, the Director of Nursing (DON) stated that the medication had been ordered electronically on 3/10/2024, but that the order did not go through for some reason. The pharmacy had been contacted and would send the medication that night. 2. Review of the clinical record revealed that R7 had a physician's order, dated 2/9/2022, for Artificial Tears 83%-15% eye ointment to be applied to both eyes two times per day for dry eye syndrome. Review of the eMAR revealed that the medication was scheduled to be administered at 9:00 am and 9:00 pm. However, during an observation on 3/13/2024 at 9:29 am, CMA AA failed to administer the Artificial Tears eye ointment as ordered. CMA AA administered Artificial Tears eye drops (two drops in each eye) in error. During an interview on 3/14/2024 at 8:50 am, the DON stated that Artificial Tears was a stock medication, and they only had the eye drops (not the ointment). A Further review of R7's clinical record revealed a physician's order, dated 11/4/2023, for 30 milliliters (ml) of lactulose 10grams/15ml to be mixed with 4 to 8 ounces of water and administered daily. Review of the eMAR revealed the medication was scheduled to be administered at 9:00 am. However, during an observation on 3/13/2024 at 9:30 am, CMA AA failed to administer the lactulose medication as ordered. At the time of the observation, CMA AA stated that the lactulose was not available on the medication cart. 3. Review of the clinical record revealed that R8 had a physician's order, dated 9/29/2022, for two 1000 milligram (mg) tablets of cyanocobalamin (vitamin B-12) to be administered daily for age-related osteoporosis. Review of the eMAR revealed that the medication was scheduled to be administered at 10:00 am. However, during an observation on 3/19/2024 at 9:25 am, Licensed Practical Nurse (LPN) BB only administered one 1000 mg cyanocobalamin tablet, instead of two, as ordered.

Based on record review, staff interview, and review of facility policy titled, 'Skilled Nursing Services-Fall Management', the facility failed to perform neurological checks for one resident (R#37) after a fall resulting in facial fracture. Findings include: Review of facility policy 'Skilled Nursing Services-Fall Management' last reviewed 12/20/2022 revealed: 'Fall Event: When a fall occurs: Conduct a head-to-toe assessment to identify injuries or changes in condition. Observe and interview the patient or witnesses to determine possible cause of the fall. Implement intervention/s to prevent recurrence and maintain patient safety. Complete the Initial Event in the Electronic Health Record (EHR) to capture the investigation of the fall and assessment of the patient. Notify the attending physician and the patient's family/responsible party of the fall and document notification. Implement any new orders received and update plan of care. Document the details of the occurrence in the patient's medical record. Communicate the fall with other care providers as needed. Assess the patient at least every shift for 72 hours or until the patient is stable. Document the assessment findings in the medical record. Review falls with the Interial Disciplinary Team (IDT) in the morning meeting to facilitate appropriate actions taken and documentation is accurate and complete (including Initial Event in EHR).' Resident #37 was admitted to the facility 4/30/2021 with diagnoses including but not limited to contracture of the left knee, contracture of the right knee, dementia, hemiplegia and hemiparesis, and osteoarthritis. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating severe cognitive decline. Section G-Functional Abilities revealed resident dependent on one-person physical assistance with activities of daily living. Review of progress note dated 2/24/2023 revealed nurse was notified of resident having an unwitnessed fall. Resident complained of pain and was noted to have a laceration to the nose. Further review of progress note dated 2/26/2023 revealed the results of facial x-ray showed acute mid nasal bone fracture. There is no evidence neurological checks were performed following unwitnessed fall. During interview on 3/12/2023 at 9:35 a.m. with Director of Nursing revealed neurological checks should have been performed on resident following unwitnessed fall with injury to head. Confirmed neurological checks were not performed on resident following unwitnessed fall. Further revealed an intervention was not put into place until 3 days following resident fall. Stated resident should have had an intervention put in place and neurological checks done.

Based on observation, record review, staff interview, and review of facility policy titled, Medication Administration - General, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, the facility failed to administer medications at the correct time as ordered. A total number of 28 medication opportunities were observed, and there were 10 errors for one of five residents (R) (R #48), for an error rate of 35.71%. Findings include: Review of the facility policy titled Medication Administration - General dated 2019 revealed the intent of the policy is to ensure medications are administered as prescribed, in accordance with good nursing principle. Medications are administered in accordance with a valid prescriber order. Prior to medication administration: the nurse should read the administration directions on the MAR (medication administration record) and verify correct medication, dose, and directions for use. Observation conducted on 3/11/2023 at 7:53 a.m. revealed Licensed Practical Nurse (LPN) AA administered medications to R#48 which included senna 8.6 mg tablet 1 tablet by mouth 2 times per day, cyanocobalamin (vit B-12) 1,000 mcg 2 tablets by mouth 1 time per day, fish oil 340 mg-1,000 mg capsule 2 capsule by mouth 1 time per day, multivitamin 1 tablet by mouth 1 time per day, clopidogrel 75 mg 1 tablet by mouth 1 time per day, furosemide 20 mg 1 tablet by mouth 1 time per day, losartan 25 mg tablet 1 tablet by mouth 1 time per day, oxybutynin chloride ER 10 mg tablet, extended release 24 hr 1 tablet extended release 24 hr by mouth 1 time per day, propranolol 40 mg tablet 1 tablet by mouth 2 times per day, and polyethylene glycol 3350 17 gram/dose oral powder 1 Capful by mouth 1 time per day Mix with 4-8 ounces of liquid. Record review of R#48's March 2023 Medication Administration Record revealed the times for administration per physician orders revealed: senna 8.6 mg tablet 1 tablet by mouth 2 times per day at 10:00 a.m. and 10:00 p.m., cyanocobalamin (vit B-12) 1,000 mcg 2 tablets by mouth 1 time per day at 10:00 a.m., fish oil 340 mg-1,000 mg capsule 2 capsule by mouth 1 time per day at 10:00 a.m., multivitamin 1 tablet by mouth 1 time per day at 10:00 a.m., clopidogrel 75 mg 1 tablet by mouth 1 time per day at 10:00 a.m., furosemide 20 mg 1 tablet by mouth 1 time per day at 10:00 a.m., losartan 25 mg tablet 1 tablet by mouth 1 time per day at 10:00 a.m., oxybutynin chloride ER 10 mg tablet, extended release 24 hr 1 tablet extended release 24 hr by mouth 1 time per day at 10:00 a.m., propranolol 40 mg tablet 1 tablet by mouth 2 times per day at 10:00 a.m. and 10:00 p.m., and polyethylene glycol 3350 17 gram/dose oral powder 1 Capful by mouth 1 time per day Mix with 4-8 ounces of liquid at 10:00 a.m. Interview on 3/11/2023 at 8:00 a.m. with LPN AA, revealed she is an agency nurse. She confirmed that she had given R# 48 medications earlier than ordered because some of her medications are ordered to give with meals and the other medications were vitamins. Interview on 3/11/2023 at 9:00 a.m. with Director of Nursing (DON) expectations of nurses to give medications as ordered with the one-hour time frame before and after the time medications are due per physician orders. She reported she would provide 1:1 education with LPN AA and all nurses on an ongoing basis.

Based on record review, staff interviews, and review of facility policy titled, 'Skilled Nursing Services-Patient's Plan of Care', the facility failed to develop and implement a person-centered care plan for two of 27 residents (R) (R#9 and R#40) related to restorative nursing services. Specifically, the facility failed to implement restorative services for R#9 as indicated by plan of care, and the facility also failed to ensure that a care plan was developed to include restorative services for R#40. Findings include: Review of facility policy titled; 'Skilled Nursing Services-Patient's Plan of Care' last reviewed 12/30/2022 revealed: 'Intent-To promote person-centered patient care through a comprehensive care plan. Guideline-Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs.' 1. R#40 was admitted to the facility 2/13/2020 with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, and contractures. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns revealed R#40 was never/rarely understood. Section O-Special Treatments and Therapies revealed resident did not receive any restorative nursing services during the seven day look back period. Review of R#40's discharge summary from Physical Therapy Services dated 7/21/2022 revealed a long-term goal for splinting to the right knee and left ankle with passive range of motion services. Review of restorative nursing minutes for February, and March 2020 revealed no documentation of restorative services. Review of R#40's care plan last reviewed 1/12/2023 revealed resident has self-care deficit with an intervention 'See Restorative Care Plan', however, no restorative care plan was located in the residents comprehensive care plans. During an interview on 3/11/2023 at 9:45 a.m. with Director of Nursing (DON) revealed the facility does not have a restorative nurse or certified nursing assistant (CNA) at this time. 42463 Findings include: 2. Record review of medical record diagnoses for R#9 included chronic respiratory failure, chronic obstructive pulmonary disease, unsteadiness on feet, muscle weakness, history of falling, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed: Section C- Cognitive Patterns, indicated Brief Mental Status score 13. Section G- Functional Status, indicated he required extensive/total- one person assist with transfers and locomotion. Section O, Specialized Services, indicated he received physical therapy (PT) x four times per week, occupational (OT) three times a week with restorative services during the review period. Review of OT Discharge Summary dated 2/15/2023 revealed R#9 received services from 1/20/2023-2/15/2023 with discharge disposition: Skilled Nursing Facility. Review of PT Discharge Summary dated 2/16/2023 revealed service dates from 1/20/2023-2/16/2023 with discharge disposition: Skilled Nursing Facility-Restorative and indicated a Functional Maintenance Program (FMP) was established for ambulation and exercise. Review of Restorative Program list indicated R#9 was on restorative for ROM exercises-group and walking. Review of the comprehensive care plans dated 1/29/2023 revealed a care plan for limited mobility with the following interventions: Assist with Activities of Daily Living (ADL)s as needed. Provide appropriate level of assistance to promote safety of resident. Provide cues as needed. Refer to Therapy as indicated. See ADL Plan of Care (POC) for assistance levels. Further review of care plans revealed that no restorative care plan had been developed. Interview on 3/12/2023 at 9:35 a.m. with Director of Nursing (DON) reported they do not have a restorative nurse or Certified Nursing Assistant (CNA) at this time. She reported the restorative program had been lacking. DON reported they have had staffing issues but once there is enough staff in place, they plan to pull one of their CNAs from the floor and the newly hired Assistant Director of Nursing (ADON) will be responsible and provide restorative. DON confirmed R#9 had not received or offered restorative-walking due to staffing issues and nor was there any documentation. She also confirmed R# 9 did not have a comprehensive care plan for restorative services because they did not have a restorative nurse who would have been responsible for making sure this was in place. DON reported both the MDS nurse and therapy staff were off and not available for interview. DON expectations of staff are to provide restorative services as ordered and to make sure comprehensive care plans are in place and followed.

Based on record review, staff interview, and review of facility policies titled, 'Skilled Nursing Services-Patient's Plan Care' and 'Skilled Nursing Services-Fall Management', the facility failed to ensure the care plan for one of four residents (R) (R#37) was revised after a fall with major injury. Findings include: Review of facility policy 'Skilled Nursing Services-Patient's Plan of Care' last reviewed 12/30/2022 revealed: 'Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. Review of facility policy 'Skilled Nursing Services-Fall Management' last reviewed 12/30/2022 revealed 'Fall Event: Implement intervention/s to prevent recurrence and maintain patient safety .Implement any new orders received and update plan of care.' Resident #37 was admitted to the facility 4/30/2021 with diagnoses including but not limited to contracture of the left knee, contracture of the right knee, dementia, hemiplegia and hemiparesis, and osteoarthritis. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating severe cognitive decline. Section G-Functional Abilities revealed resident dependent on one-person physical assistance with activities of daily living. Review of progress note dated 2/24/2023 revealed nurse was notified of resident having an unwitnessed fall. Resident complained of pain and was noted to have a laceration to the nose. Further review of progress note dated 2/26/2023 revealed the results of facial x-ray showed acute mid nasal bone fracture. Review of R#37's care plan did not reveal any updates to care plan following fall with major injury on 2/24/2023. During interview on 3/12/2023 at 9:35 a.m. with Director of Nursing revealed the care plan should have been updated immediately following resident's fall with new interventions put into place. Confirmed the care plan an intervention was not put into place until 3 days following resident fall. Stated residents' care plan should have reflected the fall with major injury.

42464 Based on observation, resident, and staff interviews, record review and review of facility policy 'Skilled Nursing Services Restorative', the facility failed to ensure that restorative nursing services were consistently provided for two 28 residents (R) (R#9 and R#40) reviewed for restorative nursing. Specifically, the facility failed to provide Restorative Services, which included walking, for R#9 and included Range of Motion (ROM) upper body, splint/brace assistance for R#40. Findings include: Review of facility policy 'Skilled Nursing Services Restorative' last reviewed 12/30/2022 revealed: 'Intent- To provide a formalized restorative care plan to be implemented by appropriately trained staff and overseen by a restorative nursing supervisor. To establish a communication system between nursing and skilled therapy to assure continuity of care between disciplines. To provide documentation as appropriate to allow for MDS coding per RAI guidelines to maintain regulatory compliance. 1. Resident #40 was admitted to the facility 2/13/2020 with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, and contractures. Review of quarterly Minimum Data Set, dated dated dated [DATE] revealed Section C-Cognitive Patterns revealed R#40 was never/rarely understood. Section O-Special Treatments and Therapies revealed resident did not receive any restorative nursing services during the seven day look back period. Review of R#40's discharge summary from Physical Therapy Services dated 7/21/2022 revealed a long-term goal for splinting to the right knee and left ankle with passive range of motion services. Review of restorative nursing minutes for February, and March 2020 revealed no documentation of restorative services. During an interview on 3/11/2023 at 9:45 a.m. with Director of Nursing (DON) revealed the facility does not have a restorative nurse or certified nursing assistant (CNA) at this time. Findings include: 2. Review of the medical record for R#9 revealed diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease, unsteadiness on feet, muscle weakness, history of falling, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed: Section C- Cognitive Patterns, indicated Brief Mental Status (BIMS) score of 13. Section G- Functional Status, indicated he required extensive/total- one person assist with transfers and locomotion. Section O, Specialized Services, indicated he received physical therapy (PT) x four times per week, occupational (OT) three times a week with restorative services during the review period. Review of OT Discharge Summary dated 2/15/2023 revealed R#9 received services from 1/20/2023-2/15/2023 with discharge disposition: skilled nursing facility. Review of PT Discharge Summary dated 2/16/2023 revealed service dates from 1/20/2023-2/16/2023 with discharge disposition: skilled nursing facility-restorative and indicated a Functional Maintenance Program (FMP) was established for ambulation and exercise. Review of the Restorative Care Plan dated 2/15/2023 for ROM exercises-group and walking, both had a frequency of 1/day x 5-6/week revealed the interventions/approaches: assist patient to daily group exercise activity and encourage to perform full body of Active Range of Motion (AROM) exercises in group setting and assist patient with performance of walking using roller walker (RW) assistive device as tolerated up to 200 feet with sitting or standing rest breaks as needed, with assistance (with supervision assistance). Provide prompting cues as needed (verbal, demonstration, or hands on cues, and/or segmenting tasks) and decrease assist/support as tolerated. Review of the Nursing Restorative Care Program documentation from 2/15/2023-3/10/2023 indicated R#9 refused ROM exercises-group and there was no indication that he had been assisted with walking nor were there any documentation to suggest that this task was refused by resident or discontinued. Interview on 3/11/2023 at 10:55 a.m. with R#9 revealed resident stated staff do not offer or provide restorative for him. He reported it had been three weeks since staff had assisted with him with walking. There was no observation of R#9 receiving restorative services for walking during the survey period 3/10/2023-3/12/2023. Interview on 3/12/2023 at 9:35 a.m. with Director of Nursing (DON) reported they do not have a restorative nurse or Certified Nursing Assistant (CNA) at this time. She reported the restorative program had been lacking. DON reported they have had staffing issues but once there is enough staff in place, they plan to pull one of their CNAs from the floor and the newly hired Assistant Director of Nursing (ADON) will be responsible and provide restorative. DON confirmed R#9 had not received or offered restorative-walking due to staffing issues and nor was there any documentation. She also confirmed R# 9 did not have a comprehensive care plan for restorative services because they did not have a restorative nurse who would have been responsible for making sure this was in place. DON reported both the Minimum Data Set (MDS) Nurse and Therapy staff were off and not available for interview. DON expectations of staff are to provide restorative services as ordered and to make sure comprehensive care plans are in place and followed.

Based on observation, record review, resident and staff interview, and review of the facility policy titled, Use of Oxygen Therapy the facility failed to follow the Physician's Order for one of three residents (R) (R#18) reviewed for oxygen therapy. Findings include: Review of the policy titled, Use of Oxygen Therapy copyrighted 2020, revealed the intent was to ensure patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. 1. Record review revealed that R#18 was a [AGE] year-old female, admitted in February 2021, full code status, and Brief Interview of Mental Status (BIMS) score of 08. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed R#18 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/21/21 at 1:55 p.m. R#18 was lying on a low bed, appeared to be asleep, O2 running at three liters per minute (3/LPM) via nasal cannula (n/c) water bottle dated 9/14/2021. During an observation on 9/22/21 at 9:04 a.m. R#18 was lying in bed, O2 running at 3/LPM via n/c, the water bottle was not dated. During an observation on 9/22/21 at 10:37 a.m. R#8 was resting in bed with O2 running at 3/LPM via n/c. During observations on 9/23/21 between 9:00 a.m. and 1:30 p.m. R#18 was up in a wheelchair throughout the facility, from portable O2 tank in caddy on back of wheelchair, O2 running at 3.5 LPM via nasal canula. An observation on 9/23/21 at 1:55 p.m., and interview at that time with the Licensed Practical Nurse (LPN) AA inside R#18's room with the surveyor, LPN AA was asked to confirm the O2 concentration. LPN AA confirmed the O2 was running at 3/liters, and it should be on 2/LPM and revealed the importance of O2 running as ordered. Interview revealed it was the responsibility of all nurses to check the concentration and make sure it was set at the correct concentration. Interview on 9/23/21 at 3:51 p.m. with the Administrator revealed her expectation that an order from the physician should be followed as ordered. Oxygen ordered for 2/LPM should be set at 2/LPM. Interview further revealed the nurse should be checking O2 concentration, confirming the physician order, and verifying by the MAR (Medication Administration Record).

Based on observation, record review, staff interviews, and review of the facility policy titled, Patient's Plan of Care the facility failed to follow care plan interventions for one resident (R) (R#18) receiving oxygen therapy. Findings include: Review of the policy titled, Patient's Plan of Care copyrighted 2020, revealed the intent was to ensure each patient have a person-centered comprehensive care plan developed and implemented to meet the patient's medical needs. 1. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#18 was a [AGE] year-old female, admitted in February 2021, full code status, and Brief Interview of Mental Status (BIMS) score of 08. Record review revealed R#18 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, page 13 of 15, revealed care area/problem included: a. Respiratory difficulties/ risk for further decline, with an onset date of 3/27/21, evidenced by shortness of breath- unable to lie flat, shortness of breath upon exertion, and oxygen use. Interventions included Administer meds/ treatment as ordered, and Oxygen as ordered. During an observation on 9/21/2021 at 1:55 p.m. R#18 was lying on a low bed, appeared to be asleep, O2 running at three liters per minute (3/LPM) via nasal cannula (n/c) water bottle dated 9/14/2021. During an observation on 9/22/2021 at 9:04 a.m. R#18 was lying in bed, O2 running at 3/LPM via n/c, the water bottle was not dated. During an observation on 9/22/2021 at 10:37 a.m. R#18 was resting in bed with O2 running at 3/LPM via nasal canula. An observation on 9/23/2021 at 1:55 p.m., and interview at that time with Licensed Practical Nurse (LPN) AA inside R#18's room, LPN AA confirmed the O2 was running at 3/liters per minute (LPM), confirmed the order and that the O2 should be set at 2/LPM. Interview on 9/23/2021 at 3:51 p.m. with the Administrator revealed her expectation that an order from the physician should be followed as ordered. Oxygen ordered for 2/LPM should be set at 2/LPM. Interview further revealed the Administrator confirmed that care plans should be followed. Cross Refer F695

Based on interviews, record reviews, and review of facility policies Skilled inpatient services: Patient's Plan of Care' and 'Skilled inpatient services: Fall Management the facility failed to update the care plans for three of 13 care plans reviewed. Specifically, for one resident with a fall (R#1), two residents with change of code status (R#1 and R#38), and one resident with a skin condition (R#38), and one resident with a significant weight loss (R#12). Findings include: Review of policy titled, 'Skilled inpatient services: Patient's Plan of Care' revealed 'Intent: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. 2. The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences, and needs of the patient in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes.' Review of policy titled 'Skilled inpatient services: Fall Management' revealed 'Overview: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for fall is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Fall event: 6. Implement any new orders received and update plan of care'. 1. Record review revealed R#1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Event-Initial Note revealed resident had a fall without injury on 9/12/2021. Review of the care plans for R#1 revealed it was not updated following the fall on 9/12/2021 and no new interventions were put into place. Further review revealed a POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's care plan revealed both full code status listed and do not resuscitate status, with interventions in place for both. 2. Record review revealed R#38 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] revealed a BIMS score of four out of 15, indicating severe cognitive impairment. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .' Review of R#38's care plan revealed it was not updated to include the abscess to resident left hip and new interventions. Further review of R#38's record revealed a POLST dated 3/22/2020 with a code status to 'Allow Natural Death (AND)-Do not Attempt Resuscitation'. Review of R#38's care plan revealed both full code status listed and do not resuscitate status, with interventions in place for both. 3. Record review revealed R#12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#12 weight on admission 4/30/2021 revealed a weight of 131 pounds (lb.). Weight on 9/1/2021 revealed a weight of 113 lbs. which was a 12.98% loss. Review of resident care plan does not reveal the care plan was updated to reflect this significant weight loss and new interventions. During an interview on 9/23/2021 at 10:31 a.m. with Registered Nurse (RN) FF revealed the care plans can be updated by all the interdisciplinary team members. Further stated the responsibility is not only one person but the entire team. RN FF also stated if a resident has a change in condition or status it is the nurse on duty at the time to update the care plan. During an interview on 9/23/2021 at 12:50 p.m. with LPN EE revealed she did not update the care plan to reflect the change in skin condition for R#38. Stated she did not feel the area needed to be care planned because it happened over the weekend and would likely heal quickly. During an interview on 9/23/2021 at 1:10 p.m. with Licensed Practical Nurse (LPN) GG revealed she is aware that R#12 had a significant weight change because she is over the nutrition program. LPN GG stated it was addressed by the Registered Dietician several times. LPN GG further revealed she did not update the care plan for significant weight change and that she has never updated care plans because she assumed the Registered Dietician would do it. During an interview on 9/23/2021 at 1:22 p.m. with the Director of Nursing revealed residents with falls, changes in skin condition, and weight loss are discussed weekly in interdisciplinary team meeting and care plans are updated if needed. The DON further revealed she expects residents care plans to be updated at time of changes. The DON confirmed the care plans for R#1, R#12, and R#38 had not been updated to reflect the fall, code status, change in skin condition, and significant weight loss. During an interview on 9/23/2021 at 3:50 p.m. the Administrator confirmed the care plans for R#1, R#12, and R#38 have not been updated and it is her expectation for care plans to be updated as changes with residents occur.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the facility had provided at least a sixteen-hour dining assistant training program to the activity director who was being allowed to feed a resident. The census size was 57 residents. Findings include: During an observation on 11/13/18 at 12:44 p.m. in the(NAME)Flint Dining Room, R#210 was physically assisted to eat by the activity director during the meal. During an interview on 11/15/18 at 9:40 a.m. with the activity director, she revealed her training was with the Director of Nursing (DON). She further stated the DON goes through a check off list, I've been checked off 2 1/2 years, this coming (MONTH) will be 3 years. She concluded by saying she was not a certified nursing assistant, she was a certifed activity director. During an interview on 11/15/18 at 10:25 a.m. with the DON she revealed the facility does not use paid feeding assistants. She further revealed when the activity director is feeding a resident that there is always a nurse around. She further stated that the activity director does not fit the definition of the paid feeding assistant. During an observation on 11/15/18 at 12:21 p.m. R# 210 was being fed by her daughter. A restorative aide and the speech therapist were present in the dining room. During an interview on 11/15/18 at 12:32 p.m. with the speech therapist she revealed for R#210, that in-attention was the main reason why she was screened, and that is the reason she is on the pureed diet. She further revealed she has never worked with the activity director concerning feeding R#210 or any other resident (s). During an interview on 11/15/18 at 1:46 p.m. with the Administrator she revealed that after reviewing the education by the DON that it does not meet the requirements for the activity director to feed residents. The Administrator further stated the activity director will no longer assist R#201 or any residents with eating.

Based on observation, staff interviews, and policy review the facility failed to ensure opened medications were labeled/dated and expired medications were discarded on two of two medication carts. The census was 59 residents. Findings include: Observation on 10/11/2017 at 11:20 a.m. with Registered nurse (RN) AA of the medication cart for hallway 100 and 300 revealed the following medications were outdated: Lortab 5/325 milligram (mg) 54 tablets with expiration date of 10/4/2017, Lortab 5/325 mg 34 tablets with an expiration date of 9/14/2017, Xanax 0.25 mg nine tablets with an expiration date of 10/2/2017. Observation on 10/11/2107 at 11:45 a.m. with RN BB of the floor medication cart for hallway 200 and 400 revealed the following medications were outdated or not labeled: Robafen 100mg/5 milliliters (ml), a partial bottle, with an expiration date of 9/2017, Pennsaid 2%, about one half bottle, with an expiration date of 9/2017, Ventolin 90 micrograms (mcg) open but not dated, Advair Diskus 250/50 opened but not dated. Interview on 10/11/2017 at 11:30 a.m. with RN AA who was assigned to the medication cart for the 100 and 300 hallways confirmed the expired medications. Interview on 10/11/2017 at 11:50 a.m. with RN BB who was assigned to the medication cart for the 200 and 400 hallways confirmed the expired medication dates and open but not dated medication. Interview via telephone on 10/11/2017 at 11:30 a.m. with Registered Pharmacist (CC), director of Pharmacy for contracted pharmacy, revealed that the pharmacy documented the incorrect year on the Lortab 5/325mg pack dated 10/4/2017 and the pack of Xanax 0.25 mg dated 10/2/2017 each of these should have been the year 2018 as they were both recently dispensed. Review of the policy Medication Administration Guidelines revealed no effective date or revision date. Continued review of the guidelines revealed the requirement number 14 stated the expiration date of the medication should be checked prior to administering drug. Under no circumstances should an expired medication be administered to a patient.

Based on observation, staff interview, and record review, the facility failed to ensure that the correct form of aspirin was administered for two (2) residents (#12 and #26) by one (1) of two (2) nurses on one (1) of two (2) medication carts for a medication error rate of 8%. Findings include: 1. During an observation of medication administration on 4/9/15 at 8:30 a.m., licensed nurse "AA" administered an 81 milligram (mg) [MEDICATION NAME] coated aspirin to resident #26. However, a review of resident #26's physician's orders [REDACTED]. 2. During an observation of medication administration on 4/9/15 at 8:20 a.m., licensed nurse "AA" administered an 81 mg [MEDICATION NAME] coated aspirin to resident #12. However, a review of resident #12's physician's orders [REDACTED]. During an interview and observation of the medication cart with Licensed nurse "AA" on 4/9/15 at 10:10 a.m., there was no 81 mg chewable aspirin available on the medication cart. LPN "AA" confirmed that an [MEDICATION NAME] coated aspirin was administered to both residents #12 and #26.

Based on observation and staff interview, it was determined the facility failed to ensure that an open, expired vial of Influenza vaccine was disposed of timely and the start date on a vial of purified protein derivative (PPD) was recorded to ensure timely disposal after expiration, in the medication storage room. Findings include: An observation of the medication room refrigerator on [DATE] at 9:00 a.m. revealed an open one (1) milliliter (ml) vial of PPD and a five (5) ml vial of influenza vaccine. The PPD vial box included a label that noted it would expire 30 days after opening. However, the PPD vial nor box were labeled as to when it was opened to ensure timely disposal within thirty (30) days. The five (5) ml vial of influenza vaccine contained a label that documented it was opened on [DATE]. The accompanying medication insert documented the medication would expire twenty eight (28) days after opening. During an interview on [DATE] at 9:00 a.m., the Director of Nursing (DON) stated she did not know when the vial of PPD had been opened.

Based on observation, staff interview and record review the facility failed to report an alleged allegation of abuse and complete a background check on a "contract agreement" worker inside of the facility. Findings include: 1. Review of the Abuse Protocol, due to an allegation of abuse complaint, and review of the facility Barber/Beautician Agreement Section A. #9 revealed that the contract was contingent upon receipt by the Nursing Center of a satisfactory drug screening report and a satisfactory criminal background report. An interview with the beautician on 5/14/14 at 12:05 p.m. revealed that she had never had a criminal background check completed. An interview with the Administrator on 5/14/14 at 11:30 a.m. confirmed a criminal background check had not been done for the beautician. 2. While investigating complaint related to abuse; an interview with certified nursing assistant (CNA) "BB" on 5/13/14 at 9:43 a.m. revealed that she would report abuse to the nurse supervisor and that she had actually done that less than two (2) months ago. She stated that she witnessed another CNA physically put their knee into a resident's groin area to hold the resident down because the resident was combative. A review of the Memo of Record dated 4/3/14 pertaining to the perpetrator, revealed that she was observed using sheets to restrict the movement of residents who were fighting her. It was also reported that the CNA was observed using her knee to pin down the resident who was fighting with her. The CNA was placed on a three (3) night suspension. In the memo of record the administrator noted it was a concern that history appeared to always involve non-cognitive behavioral residents with this CNA. The memo noted that the CNA felt justified in her reasoning to restrain residents with sheets. Based on past history of reports, and the fact that incidents always centered around non-cognitive residents, the decision was made to terminate the associate from employment to minimize risk to patients in the future. Although the facility did an investigation to an allegation of abuse, the facility failed to report the allegation to the state agency. An interview with the Administrator on 5/13/14 at 10:54 a.m. revealed that she thought it was not abuse but more so unacceptable practice. Therefore, she did not report the allegation to the state agency. Review of the facility Abuse Prohibition Policy and Procedures, Reporting: A. once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be immediately reported. 1. The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit. 3. The initial report of incident will be telephoned or faxed in within 24 hours of discovery to the Complaint Investigation Intake and Referral Unit.

Based on observation, record review and staff interview the facility failed to promote dignity and respect for one (1) resident #4 from a sample size of eleven (11) residents. Findings include: Record review of resident #4 revealed that on 04/08/14 the facility assessed the resident using the Minimum Data Set assessment instrument. The results of the residents BIM score was 99, which confirmed the resident was cognitively impaired. During the initial tour of the facility on 5/13/14 at 9:18 a.m., Resident #4 was observed in the beauty shop in a wheelchair. The assistant to the beautician was overheard saying to the resident in a short and snappy tone "I do not have time to put up with her today" and was observed to push the resident's wheelchair out of the salon allowing the resident to freely roll down the hall. The surveyor asked the assistant if she worked here. She stated yes, she shampooed the resident's hair. This observation was reported to the Administrator on 5/13/14 at 10:03 a.m. She confirmed that staff had complained about the assistants demeanor towards staff but not the residents. After surveyor inquiry, the Administrator asked the assistant to leave the building. During an interview with the sitter for resident "A" on 5/13/14 at 9:10 a.m. and on 5/14/14 at 11:15 a.m., revealed that she had observed the assistant being short tempered and snappy to the residents who were "not in their right mind". She stated that she last observed this behavior on 5/6/14 and that it happened all the time. An interview with the beautician on 5/14/14 at 12:05 p.m. revealed that she confirmed that she witnessed the assistant tell resident #4 that "she didn't have time to deal with her today" and she observed the assistant push the resident while she was in her wheelchair approximately three (3) feet down the hall. She stated that this was a typical reaction that she and her assistant had when dealing with residents that were cognitively impaired. She stated it got very exasperating dealing with residents like that. She stated that she and her assistant had never received any training on how to interact with a resident who was cognitively impaired or had dementia.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five (5)%. A total of thirty-one (31) medication opportunities were observed with two (2) errors by one (1) of three (3) nurses for one (1) of four (4) residents on one (1) of four (4) halls, for a total error rate of 6.4%. Findings include: Observation of the medication administration, on 1/22/14 at 9:45 a.m., with Licensed Practical Nurse "AA" revealed she administered [MEDICATION NAME] 10 milligrams and [MEDICATION NAME] liquid 20 milliters to resident #69. Review of the Physician order [REDACTED]. Review of the 12/2013 and 1/2014 Medication Administration Records revealed the resident continued to receive the medications despite the physician discontinuing the medications on 11/14/13. During an interview with the Director of Nursing on 1/23/14 at 10:45 a.m., she confirmed the medication error, stating the medications should have been discontinued on 11/14/13.

Based on observation, interview, and record review, it was determined that the facility failed to promptly assess one resident's ("B") level of pain and provide interventions to prevent an increase in pain from a total sample of 17 residents. This failure resulted in actual harm for resident "B". Findings include: During an observation of wound treatment for [REDACTED]. However, the treatment nurse asked the resident to wait outside the room until the care for resident "C" was complete. At 3:20 p.m., a staff member knocked on the door, entered and reported to the treatment nurse that resident "B" wanted to come into the room and lay down because he/she was "hurting." The treatment nurse responded by telling the staff member to ask resident "B" to wait a few more minutes. The treatment nurse also instructed the staff member to report the resident's complaints of pain to the medication nurse. However, at 3:45 p.m. (25 minutes later), as the treatment for [REDACTED]. At 3:50 p.m., resident "B" was observed sitting on his/her bed and rubbing his/her knees with a pained expression on his/her face. Licensed nurse "CC" was observed entering the room at that time to administer pain medication to the resident. The resident rated his/her pain at that time as a "10" on a scale of one to ten. Licensed nurse "CC" stated that staff had not reported the resident's pain to her. She stated that resident "B" had just reported the pain to her when she had entered the room to wash her hands before checking his/her roommate. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s complaints of feet, hip and back pain. Resident "B" stated during an interview on 10/27/10 at 12:45 p.m., that while waiting outside his/her room on 10/26/10 at 3:10 p.m., his/her pain increased from an 8 to a 10 before he/she could lay down and was given pain medication.

Based on observations and resident interviews, it was determined that the facility failed to ensure dignity during incontinence care for one resident (#3) and respect the private space of two residents in group and two additional residents from a total sample of seventeen residents. Findings include: 1. During an observation of CNA "AA" providing incontinence care on 10/27/10 at 10:30 a.m. for resident #3, a staff member knocked on the door and partially opened it twice to inquire about another resident's bed and chair alarms. 2. During the initial tour of the facility on 10/26/10 from 8:15 a.m. to 9:35 a.m., the Director of Nursing (DON) stated resident "A" could express his/her needs and was cognitive. During an interview on 10/28/10 at 9:30 a.m. resident "A" stated that staff members would enter his/her room as they knocked, but without waiting for permission to enter. 3. The two residents attending the group interview stated that the staff knocked on their doors but then entered their rooms without waiting for permission to enter. 4. During observations of a licensed nurse administering the medication pass on 10/27/10 at 8:45 a.m., another licensed nurse knocked and then entered room [ROOM NUMBER] without waiting for permission to enter.