Every finding on record at Life Care Center of New Market

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On [DATE] at approximately 10:15 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #1, assistant dietary manager. The following concerns were identified: 1. The facility staff failed to discard food that was available for use, found in the walk-in refrigerator located in the facility kitchen. On [DATE] at approximately 10:20 a.m., an observation of the inside of the facility's walk-in refrigerator revealed the following. a. A food container on a shelf with approximately two cups of shredded jack cheese dated [DATE]. b. A food container on a shelf with approximately two quarts of cheddar cheese dated [DATE]. c. A food container on a shelf with approximately two quarts of ham salad dated [DATE]. On [DATE] at approximately 11:00 a.m., an interview was conducted with OSM #1. When asked about the dates on the food containers stated above OSM #1 stated that the date indicated when the food was placed in the container and after three days from the date, the food should be discarded. He further stated that the above food items should have been discarded. When asked to describe the procedure they follow to prevent expired food from being used OSM #1 stated that the kitchen staff, including himself should be checking the dates daily. He further stated it was an oversight. The facility's policy Food Safety documented in part, Cold Food Storage. 10. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. 2. The facility staff failed to cover food that was prepared and available for use, found in the walk-in refrigerator located in the facility kitchen. On [DATE] at approximately 10:20 a.m., an observation of the inside of the facility's walk-in refrigerator revealed 2 - three-shelf carts. One cart contained three trays of approximately 96 plated sliced cake for the residents, uncovered, and the other cart contained two trays of approximately 18, four-ounce cups of beverages for the residents, uncovered. On [DATE] at approximately 11:00 a.m., an interview was conducted with OSM #1. When asked about the food items listed above, he stated that the dessert plates and beverages should have been covered to prevent contamination. 3. The facility staff failed to cover beverages that were prepared and available for use, found in the reach-in refrigerator located in the facility kitchen. On [DATE] at approximately 10:30 a.m., an observation of the inside of the facility's reach-in refrigerator revealed 3 two-quart pitchers containing beverages for the residents, uncovered. When asked about the beverage items listed above, he stated that the beverages should have been covered to prevent contamination. On [DATE] at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to implement their abuse policy for investigating and reporting a resident to resident altercation for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to implement their abuse policy to investigate and report a resident to resident altercation that was reported to facility staff on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken . On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to report a resident to resident altercation to the facility administrator and the State Survey Agency, for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to report a resident to resident altercation on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals .Reporting Allegations: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin to their direct supervisor or Abuse Coordinator immediately . On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review, facility document review and staff interview, it was determined that the facility failed to investigate a resident to resident altercation for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to investigate a resident to resident altercation that was reported to facility staff on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Investigate/Prevent/Correct Alleged Violation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .The facility does not condone resident abuse and/or neglect by anyone. This includes but is not limited to staff members, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, sponsors, friends, or other individuals. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin to their direct supervisor or Abuse Coordinator immediately . On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to implement the comprehensive care plan for two of 28 residents in the survey sample, Resident #4 and Resident #98. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan for the administration of physician ordered oxygen. R4 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 05/10/2023, coded R4 as scoring a 9 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R4 as receiving oxygen. On 07/10/2023 at approximately 2:43 p.m., R4 was observed lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set at four liters per minute. The physician's order for R4 dated 01/17/2023 documented, Oxygen at 2 liters per minute PRN (as needed) per nasal cannula. The comprehensive care plan for R4 dated 02/28/2023 documented in part, Focus. The resident has altered respiratory status/difficulty breathing r/t (related to) sleep apnea. Date Initiated: 02/28/2023. Under Interventions / Tasks it documented in part, Administer medication/puffers as ordered. Date Initiated: 02/28/2023. On 07/11/23 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked what the prescribed oxygen flow rate was for R4, she reviewed the electronic order and stated that the physician's order was for two liters per minute. When informed of the above observation LPN #1 stated that it was incorrect. When asked to describe the purpose of a resident's care plan, LPN #1 stated that it was to address any issues the resident may be having, for discharge purposes and for total care. After being informed of the above observation LPN #1 was asked if the care plan was being implemented for the administration of (R4's) oxygen; LPN #1 stated no. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 42106 2. For Resident #98 (R98), the facility staff failed to monitor compliance and/or non-compliance with ordered daily fluid restrictions per the plan of care. The comprehensive care plan for R98 documented in part, At risk for weight fluctuation r/t (related to) current health status, sepsis, r (right) BKA (below the knee amputation), dyslipidema, DM II (type 2 diabetes mellitus), CKD III (chronic kidney disease stage 3), HTN (hypertension), CHF (congestive heart failure), Kidney stones, anemia, afib (atrial fibrillation), hypokalemia, Fluid restriction. Date Initiated: 06/28/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Honor fluid restriction, encourage resident to adhere to restriction. Date Initiated: 07/03/2023. Revision on: 07/03/2023. The care plan further documented The resident has renal failure r/t ST (stage) III Kidney disease and kidney stones. Date Initiated: 07/03/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Fluids as ordered. Restrict or give as ordered. Date Initiated: 07/03/2023 . The physician's orders for R98 documented in part, Fluid Restriction: 1500 ml (milliliter)/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves (evenings) 150ml, Nights 0ml every shift. Document amount consumed. Order Date: 06/28/2023. The eMAR (electronic medication administration record) for R98 dated 6/1/2023-6/30/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented R98 having 680ml on days, 680 on evening and 240 on nights on 6/29/2023 for a total of 1600ml. The eMAR for R98 dated 7/1/2023-7/31/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented the following: - on 7/1/2023, 960ml on days, 720 on evening and 0 on nights for a total of 1680ml. - on 7/2/2023, 1320ml on days, 720 on evening and 50 on nights for a total of 2090ml. - on 7/4/2023, 1320ml on days, 560 on evening and 0 on nights for a total of 1880ml. - on 7/5/2023, 960ml on days, 480 on evening and 240 on nights for a total of 1680ml. - on 7/7/2023, 960ml on days, 820 on evening and 180 on nights for a total of 1960ml. - on 7/10/2023, 960ml on days, 600 on evening and 240 on nights for a total of 1800ml. The clinical record failed to evidence documentation of resident non-compliance with the fluid restrictions or physician notification of the resident's non-compliance with the fluid restrictions. On 07/11/2023 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of a resident's care plan was to address any issues the resident may be having, for discharge purposes and for total care. She stated that the care plan was not being implemented if a treatment or a procedure documented on the care plan was not provided. On 7/11/2023 at 3:51 p.m., an interview was conducted with RN (registered nurse) #2, unit manager. RN #2 stated that fluid restrictions were monitored by the physician's order. She stated that the order advised the staff what amount of fluids were allowed by dietary and by nursing and they documented the total amount of fluids taken in each shift on the eMAR. She stated that R98 was on fluid restrictions and was allowed 1500ml/day between dietary and nursing. She reviewed R98's eMAR for July 2023 with daily amounts totaling over 1500ml's and stated that there should be skilled notes documenting non-compliance if the resident was taking in more than the allotted amount and the physician or nurse practitioner should be notified. On 7/11/2023 at approximately 4:07 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to implement interventions to monitor compliance with ordered fluid restrictions for one of 28 residents, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to monitor compliance and/or non-compliance with ordered daily fluid restrictions. R98 was admitted to the facility with diagnoses that included but were not limited to chronic kidney disease, stage 3 (1) and congestive heart failure (2). The physician's orders for R98 documented in part, Fluid Restriction: 1500 ml (milliliter)/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves (evenings) 150ml, Nights 0ml every shift. Document amount consumed. Order Date: 06/28/2023. The eMAR (electronic medication administration record) for R98 dated 6/1/2023-6/30/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented R98 having 680ml on days, 680 on evening and 240 on nights on 6/29/2023 for a total of 1600ml. The eMAR for R98 dated 7/1/2023-7/31/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented the following: - on 7/1/2023, 960ml on days, 720 on evening and 0 on nights for a total of 1680ml. - on 7/2/2023, 1320ml on days, 720 on evening and 50 on nights for a total of 2090ml. - on 7/4/2023, 1320ml on days, 560 on evening and 0 on nights for a total of 1880ml. - on 7/5/2023, 960ml on days, 480 on evening and 240 on nights for a total of 1680ml. - on 7/7/2023, 960ml on days, 820 on evening and 180 on nights for a total of 1960ml. - on 7/10/2023, 960ml on days, 600 on evening and 240 on nights for a total of 1800ml. The clinical record failed to evidence documentation of resident non-compliance with the fluid restrictions or notification of the physician of resident non-compliance with fluid restrictions. The comprehensive care plan for R98 documented in part,The resident has renal failure r/t (related to) ST (stage) III Kidney disease and kidney stones. Date Initiated: 07/03/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Fluids as ordered. Restrict or give as ordered. Date Initiated: 07/03/2023 . On 7/11/2023 at 3:51 p.m., an interview was conducted with RN (registered nurse) #2, unit manager. RN #2 stated that fluid restrictions were monitored by the physician's order. She stated that the order advised the staff what amount of fluids were allowed by dietary and by nursing and they documented the total amount of fluids taken in each shift on the eMAR. She stated that R98 was on fluid restrictions and was allowed 1500ml/day between dietary and nursing. She reviewed R98's eMAR for July 2023 with daily amounts totaling over 1500ml's and stated that there should be skilled notes documenting non-compliance if the resident was taking in more than the allotted amount and the physician or nurse practitioner should be notified. The facility provided policy Fluid-Restriction Diet dated 4/24/2023 documented in part, .Indication: A fluid restriction diet is indicated in individuals with congestive heart failure, hypertension, fluid retention, pulmonary edema, hyponatremia, and renal failure . On 7/11/2023 at approximately 4:07 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) chronic kidney disease Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (2) congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services per physician's order for one of 28 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to maintain R4'S oxygen flow rate at two liters per minute according to the physician's orders. R4 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 05/10/2023, coded R4 as scoring a 9 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R4 as receiving oxygen. On 07/10/2023 at approximately 2:43 p.m., R4 was observed lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set at a flow rate of four liters per minute. The physician's order for R4 dated 01/17/2023 documented, Oxygen at 2 liters per minute PRN (as needed) per nasal cannula. The comprehensive care plan for R4 dated 02/28/2023 documented in part, Focus. The resident has altered respiratory status/difficulty breathing r/t (related to) sleep apnea. Date Initiated: 02/28/2023. Under Interventions / Tasks it documented in part, Administer medication/puffers as ordered. Date Initiated: 02/28/2023. On 07/11/23 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked if she was familiar with R4 she stated yes. When asked what the prescribed oxygen flow rate was ordered for R4 LPN #1 reviewed the electronic order and stated that the physician's order was for two liters per minute. When informed of the above observation LPN #1 stated that it was incorrect. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail inspections for three of 28 residents in the survey sample, Residents #17, #64 and #4. The findings include: 1. Resident #17 (R17) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:35 p.m. R17 was admitted to the facility with diagnosis that included but was not limited to: a history of falls. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R17. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R17, he stated that he was unable to locate documentation that a bed inspection was completed. The facility's policy Bed Inspection & Maintenance and Bed Rail Inspection documented in part, Procedure. 5. Quarterly inspections of the Seven Zones of Entrapment are required for all beds and when there are any changes to the bedframe, mattresses or side rails. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. 2. Resident #64 (R64) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:37 p.m. R64 was admitted to the facility with diagnosis that included but was not limited to: a history of falls. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R64. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R64, he stated that he was unable to locate documentation that a bed inspection was completed. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. 3. Resident #4 (R4) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:42 p.m. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R4. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R4, he stated that he was unable to locate documentation that a bed inspection was completed. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess 1 of 35 residents in the survey sample for safe self administration of medications, Resident #31. Resident #31 was observed with prescribed medications unsecured and unsupervised by staff in their room. The findings include: Resident #31 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/12/2021 coded Resident #31 as scoring a 15 on the BIMS (brief interview for mental status) assessment, 15- being cognitively intact for making daily decisions. Resident #31 was observed on 1/4/2022 at approximately 3:13 p.m. Resident #31 was out of bed sitting in a motorized wheelchair. The overbed table was in front of Resident #31 with a medication cup containing two visible medication tablets, and a second medication cup containing applesauce. At that time an interview was conducted with Resident #31. Resident #31 stated that the nurse had left the medications for her earlier to take after eating. Resident #31 stated that she had recently visited the neurologist who had advised her to wait at least 30 minutes after eating any protein to take her medication for [CONDITION(S)] and proceeded to take the medications on the bed side table with the applesauce. The eMAR (electronic medication administration record) dated 1/1/2022-1/31/2022 for Resident #31 documented medications most recently administered to Resident #31 at 1:00 p.m. on 1/4/2022. The comprehensive care plan for Resident #31 failed to evidence documentation of self-administration of medications. Review of Resident #31's clinical record failed to evidence an assessment for self-administration of medications or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/5/2022 at approximately 1:20 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated that Resident #31 had an order in place to give her medications as a bolus with applesauce but the medications were not supposed to be left unattended at the bedside. RN #2 stated that they were not aware that Resident #31 wished to take the medications 30 minutes after proteins until 1/4/2022. RN #2 stated that they should have brought the medication for [CONDITION(S)] back to Resident #31 after she had finished eating rather than leave them in the room. RN #2 stated that they completed self-administration of medication assessments on residents who could demonstrate taking their medications independently and normally did these on residents with inhalers or anyone who was leaving the facility with a medication. RN #2 stated that they did not have an assessment completed for Resident #31. On 1/5/2022 at approximately 4:00 p.m., a request was made for the facility policies on medication administration, medication storage and self administration of medication by residents. The facility policy, General Dose Preparation and Medication Administration dated 12/1/07 documented in part, .Facility staff should not leave medications or chemical unattended . The facility policy, Self Administration of Medications dated 11/28/16 documented in part, .2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .11. Facility should document the Self-Administration of medications in the resident's care plan. 12. Facility should document the self-storage of medications in the resident's care plan. The facility policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/1/07 documented in part, .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration . On 1/5/2022 at approximately 4:30 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. No further information was provided prior to exit. References: 1. [CONDITION(S)] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. 2. dysphagia A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 3. [CONDITION(S)] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html>

Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence that the physician wrote a note, and comprehensive care plan goals were provided to the receiving facility upon a hospital transfer, for 1 of 35 residents in the survey sample, Resident #39. The findings include: Resident #39 was admitted to the facility on [DATE], hospitalized on [DATE] and readmitted on [DATE]. Resident #39 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was 5-day readmission assessment with an ARD (Assessment Reference Date) of 11/17/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for all areas of activities of daily living except for eating, which required limited assistance. A review of the clinical record revealed the following nurse's notes: 11/7/21 at 2:47 AM: resident continues with confusion and lethargy this shift. resident had increased confusion, alert but not oriented to person, place, time and situation. resident repeating I dont (sic) know. resident's pupils reactive bilaterally, unable to follow simple commands like gripping fingers. resident states no to c/o (complaints of) pain. bil (bilateral) lung sounds clear, no respiratory distress noted. resident's BS (blood sugar): 201, Temp elevated at 101.6, room was very warm d/t (due to) roommate increasing temp (temperature) of room. resident given tylenol (1) per md (medical doctor) order, covid tested per facility protocol with negative results. resident's temp decreased to 99.5. resident now alert and oriented to person, able to answer simple questions appropriately, and follow commands. resident is resting quietly in bed with eyes closed with no pain or discomfort noted. 11/7/21 at 12:39 PM: Daughter (name) expressed concern about her dads confusion. This nurse called on call provider who ordered UA C&S (2 - urinalysis with culture and sensitivity) , CBC (3 - complete blood count), CMP (4 - complete metabolic panel), CXR (chest x-ray) and 1 gram of [MEDICATION(S)] (5) IM x 1 (intramuscularly for one dose). Daughter (name) informed about new orders. No concerns at this time. 11/7/21 at 2:56 PM: Resident was covid and flu tested during shift and was negative. MD/NP (nurse practitioner) aware, RP (responsible party) and resident aware of results. 11/7/21 at 7:01 PM: Resident is very lethargic and is unable to arouse at this time. Resident not eating or drinking d/t not being awake. UA in house done and looks positive. IM [MEDICATION(S)] administered @ (at) 1750 (5:50 PM) in right buttocks. Per Daughter requests, sending out to ER (emergency room ) (name of hospital) for evaluation. 11/7/21 at 8:38 PM: RP-Daughter, (name), was in facility visiting resident when it was decided to send resident out to ER. RP aware are requested resident to be sent out @ 1930. On Call Dr (doctor) (name) aware of resident being sent out. 11/8/21 at 12:47 AM: resident admitted to (name of hospital) for urosepsis. The above notes did not evidence what documentation was provided to the receiving hospital. There was no note located in the clinical record from the physician regarding this hospitalization . Further review of the clinical record revealed the Nursing Home to Hospital Transfer Form. This form documented resident demographics information, contact person, primary care physician, code status, clinical information, allergies, precautions, alerts, devices, treatments, etc. However, it did not document that the comprehensive care plan goals were provided to the hospital. In addition, there was no evidence the physician wrote a note regarding this hospitalization . On 1/6/22 at 10:00 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that a check list is completed when residents are transferred and that a copy of the checklist is kept in the clinical record. She stated that upon a transfer, the facesheet, medication list, care plan, nurses notes, transfer form, and pertinent labs are sent to the hospital and that the physician should write a note. LPN #5 was asked for a copy of this checklist. On 1/6/22 at 10:17 AM, in a follow up interview with LPN #5, she provided the checklist. A review of this checklist revealed that comprehensive care plan goals were listed. However, when asked if a copy of a completed checklist was in the clinical record for Resident #39 regarding the hospital transfer of 11/7/21, she stated that it was not. When asked if the physician wrote a note, she stated that he had not. A review of the facility policy, Transfers and Discharges documented, The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 1/5/22 at the end of day meeting at approximately 4:30 PM, ASM #1 and ASM #2 (Administrative Staff Member), the Executive Director and Director of Nursing, respectively, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Tylenol: is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (2) Urinalysis and Culture and Sensitivity: Urinalysis is the examination of urine for certain physical properties, solutes, cells, casts, crystals, organisms, or particulate matter. Because urinalysis is easy, cheap, and productive, it is recommended as part of the initial examination of all patients and should be repeated as clinically warranted. A urine culture is a lab test to check for bacteria or other germs in a urine sample. Sensitivity analysis determines the effectiveness of antibiotics against microorganisms (germs) such as bacteria that have been isolated from cultures. Information obtained from https://www.ncbi.nlm.nih.gov/books/NBK302/ Information obtained from https://medlineplus.gov/ency/article/ 1.htm Information obtained from https://medlineplus.gov/ency/article/ 1.htm (3) CBC: The CBC can help detect blood diseases and disorders, such as [CONDITION(S)], infections, clotting problems, blood cancers, and immune system disorders. This test measures many different parts of your blood. Information obtained from https://www.nhlbi.nih.gov/health-topics/blood-tests (4) CMP: A comprehensive metabolic panel is a group of blood tests. They provide an overall picture of your body's chemical balance and metabolism. Metabolism refers to all the physical and chemical processes in the body that use energy. Information obtained from https://medlineplus.gov/ency/article/ 8.htm (5) [MEDICATION(S)]: is used to treat certain infections Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html

Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to develop a care plan for side rail use for 1 of 35 residents in the survey sample; Resident #50. The findings include: Resident #50 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 11/23/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and extensive assistance for all other areas of activities of daily living. On 1/4/22 at 3:35 PM, Resident #50 was observed in bed asleep, with the head of the bed elevated, and the half length side rails up bilaterally. A review of the clinical record revealed an Evaluation For Use of Bed Rails form dated 2/1/21 that documented, Bed rail(s) are recommended at all times when resident is in bed. A review of the comprehensive care plan failed to reveal any evidence that it was reviewed and revised to include the use of side rails. On 1/6/22 at 10:00 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that the purpose of the care plan was to set goals for the resident and to guide care for the resident. She stated that any nurse can update the care plan. When asked if side rails should be care planned, she stated that they should be. A review of the facility policy Care Planning - Baseline, Comprehensive, and Routine Updates documented, The comprehensive Care Plan must be updated with each MDS assessment and periodically. It was noted in the electronic clinical record that the resident had 4 MDS's completed between the date of the side rail evaluation of 2/1/21 and the observation on 1/4/22. On 1/5/22 at the end of day meeting at approximately 4:30 PM, ASM #1 and ASM #2 (Administrative Staff Member), the Executive Director and Director of Nursing, respectively, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order to administer a medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs (millligrams) in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21: Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 mg (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain. DO NOT EXCEED 3 GMS (grams/1000 mgs) in 24 hours. A review of Resident #15's MARs (medication administration records) for October, November, and December 2021 revealed that on the following dates, Resident #35 received three doses of this medication in 24 hours, totaling 3900 milligrams (3.9 grams): 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. A review of Resident #35's comprehensive care plan dated 10/11/19 and updated 3/3/20 revealed, in part: Resident is at risk for pain/discomfort .Pain meds (medications) as ordered. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked to review Resident #35's orders and the MARs referenced above, she stated: It looks like he sometimes got more [Tylenol] than he should. When asked if the physician's order was being followed, she stated: No. She stated when she administers an as-needed medication, she looks back to determine the last time it was administered. She stated the order is clear; the resident is able to get two doses six hours apart in 24 hours; but should not receive any more than that. She stated the nurse is responsible for doing the math and ensuring the resident does not get too much medicine. She stated too much Tylenol can put the resident's liver function at risk. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, General Dose Preparation and Medication Administration, revealed, in part: Prior to administration of medication, facility staff should .verify .that it is the correct medication, at the correct dose, at the correct route, at the correct time . A review of the facility policy, Physician Orders, revealed no information related to the responsibility of the facility staff to follow the physician's orders. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to store respiratory treatment equipment in a sanitary manner for one of 35 residents in the survey sample, Resident #90. On two separate occasions, Resident #90's [CONDITION(S)] (continuous positive airway pressure) (1) mask was observed uncovered, and lying in contact with his pillows. The findings include: Resident #90 was admitted to the facility on 9//24/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). On 1/4/22 at 2:56 p.m. and 1/5/22 at 10:22 a.m. Resident #90's [CONDITION(S)] mask was observed uncovered, and in direct contact with his bed pillows. Resident #90 was sitting up in the wheelchair in his room. He stated the staff always cleans the [CONDITION(S)] mask and places it on his pillow, uncovered. A review of Resident #90's physician's orders revealed the following order, dated 4/9/20: [CONDITION(S)]/BIPAP: Pressure setting 13-16. Full face mask .on while sleeping/napping and off while awake .Clean [CONDITION(S)] mask with warm soapy water, rinse and air dry as needed daily. A review of Resident #90's MARs (medication administration records) for October, November, and December 2021 and for January 2022 revealed Resident #90 wore his [CONDITION(S)] as ordered, and that the mask was cleaned daily. A review of Resident #90's comprehensive care plan dated 7/15/19 and updated 3/30/20 revealed, in part: The resident has altered respiratory status/difficulty breathing related to sleep apnea .Clean [CONDITION(S)] per protocol .Store [CONDITION(S)] per protocol. On 1/5/22 at 1:19 p.m., CNA (certified nursing assistant) #1 was interviewed. When asked how a [CONDITION(S)] mask should be stored when not in use, she stated it should be stored in a plastic bag, and preferably placed inside a drawer. When asked why the mask should be stored this way, she stated: We don't want to have germs on it. She added the mask goes on the resident's face, and it needs to be clean to prevent infection. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the facility has specific bags for storage of all respiratory equipment in resident rooms. She stated it after the mask is washed, it should be air dried, and then placed in the bag. She stated [CONDITION(S)] mask storage is all about infection control. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, [CONDITION(S)] Administration Policy, failed to reveal an information related to sanitary storage of the [CONDITION(S)] mask when not in use by the resident. No further information was provided prior to exit. (1) [CONDITION(S)] (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a [CONDITION(S)] machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine's motor, and a motor that blows air into the tube. [CONDITION(S)] is used to treat sleep-related breathing disorders including sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/[CONDITION(S)].

Based on staff interview, facility document review, and clinical record review, the facility staff failed to prevent a resident from receiving unnecessary pain medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21: Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 mg (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain. DO NOT EXCEED 3 GMS (grams/1000 mgs) in 24 hours. A review of Resident #15's MARs (medication administration records) for October, November, and December 2021 revealed that on the following dates, Resident #35 received three doses of this medication in 24 hours, totaling 3900 milligrams (3.9 grams): 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. A review of Resident #35's comprehensive care plan dated 10/11/19 and updated 3/3/20 revealed, in part: Resident is at risk for pain/discomfort .Pain meds (medications) as ordered. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked to review Resident #35's orders and the MARs referenced above, she stated: It looks like he sometimes got more [Tylenol] than he should. When asked if the physician's order was being followed, she stated: No. She stated when she administers an as-needed medication, she looks back to determine the last time it was administered. She stated the order is clear; the resident is able to get two doses six hours apart in 24 hours; but should not receive any more than that. She stated the nurse is responsible for doing the math and ensuring the resident does not get too much medicine. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, General Dose Preparation and Medication Administration, revealed, in part: Prior to administration of medication, facility staff should .verify .that it is the correct medication, at the correct dose, at the correct route, at the correct time . No further information was provided prior to exit.

Based on clinical record review and staff interview, the facility staff failed to correctly code a significant change MDS (minimum data set) resident assessment for 1 of 35 residents in the survey sample, Resident #53. Resident #53 was not coded as receiving hospice services. The findings include: Resident #53 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's most recent MDS, a significant change assessment with an ARD of 12/8/2021, coded Resident #53 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section O failed to evidence documentation of Resident #53 receiving hospice services. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 12/7/2021. The comprehensive care plan for Resident #53 dated 12/7/2021 documented in part, The resident has a terminal prognosis. Hospice, Anticipate weight loss, delayed healing, decline in participation in ADLs (activities of daily living), decline in participation in activities of choice, decline in cognitive processing. Date Initiated: 12/07/2021 . On 1/06/2022 at 8:17 a.m., an interview was conducted with LPN (licensed practical nurse) #2, MDS coordinator. LPN #2 stated that the significant change assessment completed for Resident #53 was completed when they began hospice services. LPN #2 reviewed the significant change MDS with the ARD of 12/8/2021 and stated that hospice was not coded and they must have missed clicking the box to choose hospice services. LPN #2 stated that they followed the RAI (resident assessment instrument) manual for completion of the MDS assessments. LPN #2 stated that they would correct the MDS to include hospice services. According to the RAI Manual, Version 1.16, dated October 2018, page 2-23 documented in part, .A SCSA (significant change in status assessment) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place . On 1/6/2022 at approximately 8:45 a.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)] A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 2. [CONDITION(S)] Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to meet Advance Directive requirements for Thirteen of 47 residents in the survey sample, Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The facility staff failed to evidence resident advance directives or information for developing an advanced directive was periodically reviewed with the resident and/or Resident Representative (RR) to residents wished change anything or maintain the advanced directive as written and or formulate an advanced directive for Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The findings include: 1. The facility staff failed to evidence Resident #71's advance directives dated [DATE], was periodically reviewed with the resident and/or Resident Representative (RR) to determine if she wanted to change anything or maintain the advanced directive as written. Resident #71 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE] coded the resident as moderately significantly impaired in ability to make daily life decisions. A review of the clinical record revealed an advance directive dated [DATE]. Further review failed to reveal any evidence of periodic review with Resident #71 to determine if she wanted to change anything or maintain the advanced directive as written. On [DATE] at 12:30 PM in an interview with OHM #3 (Other Staff Member), Director of Social Services, when asked if the facility does periodic reviews of advance directives with the residents and/or RP, OHM #3 stated, I don't do that. I do not know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at 7:57 AM, a follow up interview was conducted with OHM #3. She provided notes where code status was reviewed with Resident #71, but nothing evidencing advance directives had been reviewed. When asked if a periodic review or opportunity to establish advance directives later other than at admission was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. The comprehensive care plan dated [DATE], documented, Resident has Advance Directive DNR - Do Not Resuscitate. This care plan included the interventions, Code status will be reviewed on a quarterly basis and PRN (as needed), and Resident has signed Do Not Resuscitate (DNR). The care plan did not include anything about the Advance Directives. A review of the facility policy, Advance Directives documented, An Advance Directive is a written document prepared by the resident as to how he/she wants medical decisions to be made should he or she lose the ability to make decisions for him or herself. The two most commonly prepared advance directives are a living will and durable power of attorney for health care. However, (facility) also recognizes the following medical orders for advance directives: Do Not Resuscitate (DNR) order Feeding Restrictions and Hydration Measures Medication Restrictions Do Not Hospitalize Organ Donation Autopsy Request Other Treatment Restrictions 7. Each time the resident is admitted to the facility, quarterly, after a significant change, and as needed, Social Services should review the advance directive information for accuracy with the resident or legal representative and document the findings in the progress notes. On [DATE] at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to evidence that a periodic review was conducted with Resident #52 and/or Resident Representative (RR) who did not have any Advance Directive, to determine if she wanted to develop an advanced directive at any time after the initial review and offer at the time of admission. Resident #52 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE], coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record failed to reveal any advance directive for Resident #52. The clinical record contained a POST (Virginia Physician Orders for Scope of Treatment) form dated [DATE], which contained some components of an Advance Directive (Section A: whether to attempt or not attempt CPR; Section B: whether to initiate comfort measures, limited interventions, or full interventions; and Section C: whether or not to provide artificially administered nutrition.) On [DATE] at 12:30 PM in an interview with OSM #3 (Other Staff Member), Director of Social Services, when asked if the facility does periodic reviews of advance directives with the residents and/or RP, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about advance directives. On [DATE] at 7:57 AM, in a follow up interview with OSM #3, she provided notes where code status was reviewed with Resident #52 but not advance directives. When asked if a periodic review or opportunity to establish advance directives other than at admission was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. The comprehensive care plan dated [DATE], documented, Resident has Advance Directive DNR - Do Not Resuscitate. This care plan included the interventions, Code status will be reviewed on a quarterly basis and PRN (as needed), and Resident has signed Do Not Resuscitate (DNR). The care plan did not include anything about a periodic review for advance directives. On [DATE] at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 3. The facility staff failed to evidence that the Advance Directives were periodically reviewed with Resident #64 and/or Resident Representative (RR) to determine if she wanted to change anything in her advance directive, dated [DATE], or maintain it as written. Resident #64 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE] coded the resident as being severely impaired in ability to make daily life decisions. A review of the clinical record revealed advance directive dated [DATE]. Further review failed to reveal any evidence of a periodic review to determine if Resident #64 and/or Resident Representative (RR) wanted to change anything in the advanced directive or maintain it as written. On [DATE] at 12:30 PM in an interview with OSM #3 (Other Staff Member), Director of Social Services, when asked if the facility does periodic reviews of advance directives with the residents and/or RP, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at 7:57 AM, in a follow up interview with OSM #3, she provided notes where code status was reviewed but not Advance Directives. When asked if a periodic review or opportunity to establish Advance Directives later other than at admission was done, she stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. A comprehensive care plan revealed dated [DATE], documented, Resident has Advance Directive CPR - Full Code. This care plan included the interventions, Code status will be reviewed on a quarterly basis and PRN (as needed), and Resident has decided to remain a Full Code. The care plan did not include anything about the Advance Directives. On [DATE] at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 4. The facility staff failed to periodically review Resident #27's (or the resident's representative) decisions regarding advance directives. Resident #27 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #27's [DIAGNOSES REDACTED]. Resident #27's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident #27 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Review of Resident #27's clinical record revealed a document Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt dated [DATE] but failed to evidence documentation of periodic review after [DATE]. Further review of the clinical record revealed a document Consent for Treatment dated [DATE], which documented the resident and/or resident's representative receiving information regarding advanced directives on readmission to the facility but failed to evidence documentation of periodic review after [DATE]. The comprehensive care plan for Resident #27 dated [DATE] documented Resident has Advance Directives DNR-Do Not Resuscitate; Date initiated: [DATE]; Revision on [DATE]. Under Goal it documented, Resident's Advance Directives will be honored. Date initiated: [DATE]. Under Interventions/Tasks it documented, Code status will be reviewed on a quarterly basis and PRN (as needed); Date initiated: [DATE]. On [DATE] at approximately 3:30 p.m., an interview was conducted with Resident #27. When asked if staff periodically review advance directives, Resident #27 stated, I don't think so. On [DATE] at 12:30 p.m., an interview was conducted with OSM (other staff member) #3, social services director. When asked if periodic reviews of Advance Directives are conducted with the residents and/or the resident's representative, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at approximately 1:00 p.m., a request was made in writing to ASM (administrative staff member) #2, the director of nursing, for additional information on any evidence of periodic advance directive review for Resident #27. On [DATE] at approximately 5:30 p.m., a progress note was received from ASM #2 for Resident #27. The note documented, Note Text: Significant Change of Condition: Resident was alert and oriented today. BIM (Brief Interview for Mental Status) score was ,[DATE]. MOOD (depression rating scale) score was 03 indicated minimal depression .Current code status is DNR (do not resuscitate). SS (social services) will continue to monitor for cognitive loss. The progress note failed to evidence documentation of periodic review of advance directives. On [DATE] at approximately 8:00 a.m., an interview was conducted with OSM (other staff member) #3, the director of social services. When asked what is discussed during care plan meetings, OSM #3 stated that currently only code status is being reviewed in care plan meetings. OSM #3 stated that periodic review or offering to establish an advance directive is not being done at the quarterly care plan meetings or periodically at the facility. The facility policy, Advance Directives documented, 7. Each time the resident is admitted to the facility, quarterly, after a significant change, and as needed, Social Services should review the advance directive information for accuracy with the resident or legal representative and document the findings in the progress notes. On [DATE] at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [MEDICAL CONDITION]- A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html 2. Diabetes- A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 5. The facility staff failed to periodically review Resident #82's (or the resident's representative) decisions regarding advance directives. Resident #82 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #82's [DIAGNOSES REDACTED]. Resident #82's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #82 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Review of Resident #82's clinical record revealed a document Consent for Treatment dated [DATE], which documented the resident and/or resident's representative receiving information regarding advanced directives on admission to the facility but failed to evidence documentation of periodic review after [DATE]. The comprehensive care plan for Resident #82 dated [DATE] documented Resident has Advance Directives DNR-Do Not Resuscitate; Date initiated: [DATE]; Revision on [DATE]. Under Goal it documented, Resident's Advance Directives will be honored. Date initiated: [DATE]. Under Interventions/Tasks it documented, Code status will be reviewed on a quarterly basis and PRN (as needed); Date initiated: [DATE]. On [DATE] at approximately 9:15 p.m., an interview was conducted with Resident #82. When asked if staff periodically review advance directives, Resident #82 stated that he did not know what that was. On [DATE] at 12:30 p.m., an interview was conducted with OSM (other staff member) #3, social services director. When asked if periodic reviews of Advance Directives are conducted with the residents and/or the resident's representative, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at approximately 1:00 p.m., a request was made in writing to ASM (administrative staff member) #2, the director of nursing, for additional information on any evidence of periodic advance directive review for Resident #82. On [DATE] at approximately 5:30 p.m., ASM #2 provided a packet of documents for Resident #82. The Care Plan Conference Record dated [DATE] documented Advance Directive: POST (Virginia Physician Orders for Scope of Treatment) Form. Review of the referenced document POST form for Resident #82 revealed a status of DNR (do not resuscitate)/No CPR (cardiopulmonary resuscitation), Comfort Measures, No feeding tube dated [DATE]. Additional documents provided by the facility revealed a progress note for Resident #82. The note documented, Note Text: Quarterly Note: BIM/PHQ9 (brief interview for mental status/patient health questionnaire) interview conducted with resident in the midafternoon in his room with minimal distractions. BIM score was 15 with no indication of cognitive loss .Resident current code status is DNR (do not resuscitate) .SS (social services will continue to monitor. On [DATE] at approximately 8:00 a.m., an interview was conducted with OSM (other staff member) #3, the director of social services. When asked what is discussed during care plan meetings, OSM #3 stated that currently only code status is being reviewed in care plan meetings. OSM #3 stated that periodic review or offering to establish an advance directive is not being done at the quarterly care plan meetings or periodically at the facility. On [DATE] at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Major [MEDICAL CONDITION] is a mood disorder. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm. 2. Diabetes is a chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm 6. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 88 and/or Resident # 88's representative, with the opportunity to develop an advance directive. Resident # 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 88's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 88 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 88 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3; she provided notes where Resident #89's code status was reviewed but not advance directives. When asked if a periodic review or opportunity to establish advance directives, at a later- time other than at admission, was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (2) Makes your bones weak and more likely to break. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 7. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 85 and/or Resident # 85's representative with the opportunity to develop an advance directive. Resident # 85 was admitted to the facility on [DATE] and a readmission of [DATE] with [DIAGNOSES REDACTED]. Resident # 85's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 85 as scoring a nine on the brief interview for mental status (BIMS) of a score of 0 - 15, nine - being moderately impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 88 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives, or to provide information and develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, in a follow up interview with OSM #3, she provided notes where Resident #85's code status was reviewed but no information for review of the residents advance directives. When asked if a periodic review or opportunity for the resident's right to establish advance directives, at a later- time other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (2) Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (3) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 8. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 49 and/or Resident # 49's representative with the opportunity to develop an advance directive. Resident # 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 49's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 49 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 49 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or provides information to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes where code status was reviewed for Resident #49 but not advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) (A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (2) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 9. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 15 and/or Resident # 15's representative with the opportunity to develop an advance directive. Resident # 15 was admitted to the facility on [DATE] and a readmission of [DATE] with [DIAGNOSES REDACTED]. Resident # 15's most recent MDS (minimum data set), an significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident # 15 as scoring a seven on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 15 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or provides information to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes documenting the code status for Resident #15was reviewed, but no documentation evidencing advance directives were reviewed. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Also called: [MEDICAL CONDITION], Palsy, [MEDICAL CONDITIONS]. Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) There are many different forms of [MEDICAL CONDITION]. The most common cause of [MEDICAL CONDITION] is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called [MEDICAL CONDITION] and happens slowly over time. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (3) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 10. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 8 and/or Resident # 8's representative with the opportunity to develop an advance directive. Resident # 8 was admitted to the facility on [DATE] and a readmission of [DATE] with [DIAGNOSES REDACTED]. Resident # 8's most recent MDS (minimum data set), an significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident # 8 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 8 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, she stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes where code status for Resident #8 was reviewed but no documentation evidencing advance directives were reviewed. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Also called: [MEDICAL CONDITION], Palsy, [MEDICAL CONDITIONS]. Paralysis is the loss of muscle function in part of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) There are many different forms of [MEDICAL CONDITION]. The most common cause of [MEDICAL CONDITION] is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called [MEDICAL CONDITION] and happens slowly over time. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (3) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 11. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 21 and/or Resident # 21's representative with the opportunity to develop an advance directive. Resident # 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 21's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 21 as scoring a five on the brief interview for mental status (BIMS) of a score of 0 - 15, five - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 21 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM (other staff member) # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, she stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3, she provided notes where Resident #21's code status was reviewed but not the residents advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time, other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. (2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/[MEDICAL CONDITION].html. 12 The facility staff failed to evidence periodic reviews were conducted to provide Resident # 50 and/or Resident # 50's representative with the opportunity to develop an advance directive. Resident # 50 was admitted to the facility on [DATE] and a readmission of [DATE] with [DIAGNOSES REDACTED]. Resident # 50's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 50 as s (TRUNCATED)

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for three of 47 residents in the survey sample, Resident #20, Resident #44 and Resident. On 10/11/19, a wound care specialist treated Resident #20. The facility did not act on the specialist's recommendations until 10/14/19, even though a facility staff member was in possession of the wound specialist's report/recommendation on the afternoon of 10/11/19. Staff also failed to monitor Resident #20's fluid intake as ordered by the physician on multiple shifts during (MONTH) 2019 and (MONTH) 2019 and the staff failed to look at Resident #44's abdominal binder every 30 minutes and failed to loosen the abdominal binder every two hours per physician orders. The findings include: 1. a. Resident #20 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 7/26/19, Resident #20 was coded as being cognitively intact for making daily decisions, have scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having a wound that was not a pressure ucler, and as having received [MEDICAL TREATMENT] during the look back period. A review of Resident #20's clinical record revealed a physician's order dated 9/6/19, that was discontinued on 10/14/19: Cleanse left heel with NS (normal saline), pat dry, and apply wet-to dry dressing. Cover with dry gauze, wrap with kerlix (gauze wrap) and ace wrap twice daily. Further review of the record revealed the following order dated 10/14/19: Clean left heel with normal saline, pat dry and apply [MEDICATION NAME] blue transfer foam kling and tape three times a week, every day shift every Monday, Wednesday, and Friday. A review of Resident #20's progress notes revealed the following nurse's note written 10/12/19 at 9:17 a.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily .Resident states that wound center told him dressing is to be changed 3X/week (three times a week) and that they would fax orders to facility. No new orders received resident declined dressing change. A review of Resident #20's progress notes revealed the following nurse's note dated 10/12/19 at 10:01 p.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily. /refused drsg (dressing) change. Stated it was not due today. A review of Resident #20's progress notes revealed the following nurse's note dated 10/13/19 at 9:32 p.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily. States dressing is not to be chaned (sic) yet. A review of Resident #20's progress notes revealed the following nurse's note dated 10/14/19 at 12:46 p.m.: Wound center returned call back with clarification with dressing changes. Should be cleaned with normal saline then apply [MEDICATION NAME] blue transfer foam kling and tape. Change three times a week. A review of Resident #20's comprehensive care plan dated 9/16/19 revealed, in part, the following: At risk for break in skin integrity; Resident has left heel wound .Treatment as ordered. On 10/24/19 at l0:10 a.m., LPN (licensed practical nurse) #5 was interviewed. When asked about the above-referenced orders and communication from the wound care center, physician for Resident #20, LPN #5 stated, Usually they come back from the wound center with a consult sheet. The sheet contains any new orders and we take the orders from the consult sheet and call the attending physician. Once they are approved, we start the treatment. When asked if a resident should wait three days before new wound care orders are implemented, LPN #5 stated, No. It should happen pretty much right away. On 10/24/19 at 10:45 a.m., OSM (other staff member) #10, the transportation coordinator, provided the surveyor with a copy of the wound care consultation, report for Resident #20 from 10/11/19. The fax date stamp at the top of the page was 10/11/19 at 2:33 p.m. Under the Recommendations section, the report documented: Cleanse left heel wound with normal saline then apply [MEDICATION NAME] blue transfer foam, kling wrap, and tape. Change three times a week. When asked where she got this report, OSM #10 stated, It was downstairs in my office. They always fax me so I know when to set up the transportation for the next appointment. When asked if she ever shares the faxes with the nursing staff, OSM #10 stated, No, because they get their own. On 10/24/19 at 11:13 a.m., RN (registered nurse) #3, the ADON (assistant director of nursing) was interviewed. She stated the process is for residents to return from outside appointments with a consult report with them. She stated the nurse is responsible for taking care of any new orders. She further stated that on 10/11/19, Resident #20 had gone straight from the wound care physician to [MEDICAL TREATMENT], and that Resident #20 had returned late in the day back to the facility. RN #3 stated that there was no wound care consult, report anywhere in the record for 10/11/19, and that Resident #20 must have returned from [MEDICAL TREATMENT] without the wound care consult, report. RN #3 stated that it was so late in the day (a Friday evening) that the wound care center would have been closed, and that no information would have been available about Resident #20's appointment until Monday morning, 10/14/19. At this time, RN #3 was informed about OSM #10 having the faxed wound care report. On 10/24/19 at 11:27 a.m., RN #3, returned and stated, I have been looking into this. I just now found out that the wound center also faxes the transport driver with the consultation reports. I didn't know that. I don't know how we are supposed to know that there is another fax. I don't know how the nurses are supposed to know that there is another fax somewhere in the building. Our hands were tied when the resident returned to the building too late for us to call the wound center. When asked if she could foresee a concern related to this lack of communication if a resident was not cognitively intact and could not speak up to tell the facility staff that there should be new orders, RN #3 stated, Yes. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A facility policy regarding outside consultation communication/coordination was requested. On 10/24/19 at 1:23 p.m., ASM #2 stated the facility did not have a policy on outside consultation communication/coordination. References: (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called [MEDICAL CONDITIONS]. This information is taken from the website https://medlineplus.gov/ency/article/ 0.htm. (2) [MEDICAL CONDITION] is a general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (3) Absorptive dressing combines two organic pigments ([MEDICATION NAME] blue and [MEDICATION NAME] violet) to create a wound environment that is prime for healing; suitable for use on partial and full thickness wounds. This information is taken from the website https://www.medline.com/product/[MEDICATION NAME]-Blue-Ready-Transfer-Foam-Dressings-by-[MEDICATION NAME]/Z05-PF 3. 1. b. The facility staff failed to monitor Resident #20's fluid intake as ordered by the physician on multiple shifts during (MONTH) 2019 and (MONTH) 2019. A review of Resident #20's clinical record revealed the following physician's order, dated 9/5/19: Fluid Restriction 1500 ml/day (milliliters per day). From Kitchen: Breakfast 720 ml, Lunch 240 ml, dinner 240 ml. From Nursing Days 150 ml, eves (evenings) 150 ml) nights 0 ml. Every shift document amount consumed. A review of Resident #20's (MONTH) 2019 and (MONTH) 2019 MARs (medication administration records revealed blanks on the following days in the space where the fluid restriction enforcement should have been documented: 9/7/19 day shift, 9/8/19 day shift, 9/9/19 day shift, 9/12/19 day and evening shifts, 9/19/19 evening shift, 9/21/19 day and evening shifts, 9/24/19 evening shift, 9/30/19 evening shift, 10/1/10 evening shift, 10/8/19 evening shift, 10/15/19 evening shift, and 10/18/19 day shift. A review of Resident #20's comprehensive care plan dated 9/16/19 revealed, in part, the following: [MEDICAL TREATMENT] r/t related to) renal (kidney) failure .Fluid restriction as ordered. On 10/24/19 at 9:01 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated she is not familiar with Resident #20's care. When shown the above-referenced MARs containing the blanks for the fluid restriction documentation, and when asked what these blanks mean, LPN #1 stated, I don't want to say what I think it means. Because I think, it's not good. I need to find out. On 10/24/19 at 10:07 a.m., LPN #5 was interviewed. She stated she was very familiar with Resident #20's care. When asked why Resident #20 was on a fluid restriction, LPN #5 stated, He is a [MEDICAL TREATMENT] patient. Typically, they have some kind of fluid restriction. When asked what she knew about Resident #20's restrictions, LPN #5 stated, His fluid intake is monitored every shift. We keep track of what the resident takes in. Sometimes the aides record it and sometimes I record it. But at the end of the shift, there is a box for me to add up all the totals and sign off on the total. When shown the MARs referenced above for Resident #20, and when directed to the blank spots, LPN #5 was asked what the blank spots mean. LPN #5 stated, If a box is not signed off and totaled, I can't tell how much he got. There is no way to tell. There is no way to know how much he would be allowed to have for the rest of the day. I can't see how anybody would miss that. When asked what the lack of documentation meant, LPN #5 stated, Well, if it's not documented, I can only imagine it wasn't done. It doesn't look like anybody kept up with his fluid on those shifts. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Fluid Restrictions, revealed, in part, the following: Fluid restrictions are coordinated between Nursing Services and Food and Nutrition Services .The fluid restriction is noted on the tray card and clearly identifies the type and amount of fluids to be served. No further information was provided prior to exit. 2. The faciity staff failed to look at Resident #44's abdominal binder every 30 minutes and failed loosen the abdominal binder every two hours per physician orders. Resident #44 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/3/19, Resident #44 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). He was coded as having an indwelling catheter in his bladder, and as having a physical restraint on a daily basis. On 10/23/19 from 1:51 p.m. until 4:01 p.m., (135-minute period), two surveyors continuously observed Resident #44. During this time, Resident #44 was positioned in a reclining chair across from a nurses' station, just outside the main dining room. Resident #44's legs, torso, and arms were covered with a blanket. At no time during this observation did any staff member look underneath the blanket to verify the position of or to loosen Resident #44's abdominal binder, worn under his shirt. A review of Resident #44's clinical record revealed the following physician's order dated 8/21/19: Abdominal binder: Check abdominal binder every 30 minutes and release every 2 hours every shift for safety, to keep resident from pulling at suprapubic catheter (3). A review of Resident #44's comprehensive care plan dated 8/28/19 revealed, in part, the following: The resident uses abdominal binder for suprapubic cath (catheter). The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation, or withdrawal through review date .Alternatives to abdominal binder was ABD (abdominal) pad and tape, but resident started pulling at suprapubic catheter; therefore abdominal binder was reinstated .RESTRAINT USE: Apply abdominal binder, check every 30 minutes and release every 2 hours. On 10/24/19 at 9:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if she had taken care of Resident #44 on 10/23/19, LPN #1 stated, Yes I did. When asked what restraint Resident #44 used, LPN #1 stated, He has an abdominal binder. He has a suprapubic catheter. Without the binder, he will rip (the catheter) out. He has pulled it out before and had to go back to have it replaced. That's why he has the binder. When asked what orders accompany the use of the abdominal binder, LPN #1 stated, We are supposed to check it every 30 minutes. When asked what checking the binder means, LPN #1 stated, We are supposed to actually look at it. That's all, I think. When asked if she was aware of anything that needed to be done every two hours, LPN #1 stated, No. I'm not familiar with anything else. LPN #1 was asked to review the physicians' orders for Resident #44. After reviewing the physician's orders, LPN #1 stated, We are supposed to loosen it every two hours. When asked if she had looked at Resident #44's abdominal binder every 30 minutes on 10/23/19, LPN #1 stated, No, I didn't. When asked if she loosened the resident's abdominal binder every two hours on 10/23/19, LPN #1 stated, No, I didn't do that either. I'm sorry. When asked why looking at the binder every 30 minutes and loosening the binder every two hours are important actions to take, LPN #1 stated, We need to make sure it is in the right place. There was a time when one of the binders we had was digging into him. This would let us see underneath it every now and then. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Restraint and Position Change Alarm Use, revealed, in part, the following: A physician's order is required for the use of the specific type of restraint. The order should include the specific type of restraint, the condition and/or medical symptom that warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be released .The use of the restraint must be individualized and must be based upon the resident's condition and medical symptoms that must be treated. The care plan is revised as needed and must include .The time and frequency the restraint should be released; the type of specific direct monitoring and supervision provided during the use of the restraint. No further information was provided prior to exit. (1) [MEDICAL CONDITION] is a condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information is taken from the website https://medlineplus.gov/ency/article/ 7.htm. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (3) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), [MEDICAL CONDITION] (not being able to urinate), surgery that made a catheter necessary, or another health problem. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/ 5.htm.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to treat one out of 47 residents in the survey sample, Resident #12, with dignity and respect. The findings include: Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/19 coded the resident as being severely impaired in ability to make daily life decisions, scoring a 3 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; and was coded as independent for eating. A nurse's notes dated 10/12/19 at 3:46 AM that documented, Resident came out of activities this evening and was sitting in her doorway moaning and pointing to her legs. she (sic) was told to stop her moaning if she was not going to be compliant with taking her medications and getting into bed to elevate her legs Resident has refused to go to bed tonight. She has been sleeping in WC (wheel chair) with legs down. On 10/23/19 at 3:02 PM, an interview was conducted with RN (registered nurse) #1, who wrote the note. RN #1 stated, Other residents complain about her moaning. She (Resident #12) wants you to fix her legs but doesn't want to take her meds (medications) for the [MEDICAL CONDITION] or elevate them. She (Resident # 12) doesn't want to be compliant but she wants you to fix it. She (Resident #12) is alert and oriented (Resident has a BIMS of 3). When asked if it is appropriate to tell a resident to stop your moaning if you are not going to be compliant, RN #1 stated, I don't know, I guess not. It wasn't meant to be disrespectful. My main goal with her moaning was not to keep other residents awake. When asked is that how was how it was documented and reflected in the note, RN #1 stated, It is not relayed in any way in the note. It probably wasn't worded appropriately. It wasn't meant as disrespectful. This was probably written after about 3 hours of trying to get her into bed. I just ran out of ideas on how to persuade her to help herself. On 10/23/19 at 4:16 PM, in an interview with RN #2, when asked how would it make her feel to be told to stop moaning if you are going to be non-compliant, RN #2 stated, I would feel like my needs are not being met, my needs are being over looked. That is kind of like stop you're whining. I think that is a dignity thing. The comprehensive care plan dated 7/30/19, documented, The resident has impaired cognition the interventions, dated 7/30/19, documented, Allow for extra time for resident to respond to questions and instructions, Ask yes or no questions in order to determine the resident's needs, Cue, reorient and supervise as needed, Face and speak clearly when communicating with resident A review of the facility policy, Dignity documented, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. On 10/24/19 at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed maintain a comfortable and homelike environment for one of 47 residents in the survey sample, Resident # 85. The facility staff failed to maintain Resident # 85's over-the-bed-table was in good repair. The findings include: Resident # 85 was admitted to the facility on [DATE] and a readmission of 04/08/2019 with [DIAGNOSES REDACTED]. Resident # 85's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/02/19, coded Resident # 85 as scoring a nine on the brief interview for mental status (BIMS) of a score of 0 - 15, nine - being moderately impaired of cognition for making daily decisions. On 10/22/19 at approximately 12:45 p.m., and 2:45 p.m., Resident # 85's over-the-bed-table was observed. The edges were chipped and peeling, the trim surrounding the edges of the table was separated from the table exposes the bare wood fiber edges. On 10/23/19 at approximately 2:47 p.m., an interview was conducted with Resident # 85. When asked about the condition of his over-the-bed-table, Resident # 85 stated, It needs to be fixed. On 10/24/19 at approximately 7:30 a.m., Resident # 85's over-the-bed-table was observed. The edges were chipped and peeling, the trim surrounding the edges of the table was separated from the table exposes the bare wood fiber edges. On 10/24/19 at approximately 7:30 a.m., Resident # 85's over-the-bed-table was observed with OSM (other staff member) # 1, director of maintenance. After observing the over-the-bed-table, OSM # 1 stated that it was in poor condition and in need of repair. OSAM # 1 was asked to measure the damaged edge of the table. Using a standardized carpenter's measuring tape, OSM # 1 stated that approximately twenty-five inches of the table edge was damaged. OSM #1 was asked to describe the process for identifying repairs in the facility's resident rooms. OSM # 1 stated, We (maintenance department) inspect five rooms a week and but if a staff member sees something in need of a repair or fixing, they complete a work order and we check them and address them throughout the day OSM # 1 stated that the condition of Resident # 1's over-the-bed-table should have been identified during rounds and replaced. On 10/24/19 at 12:10 p.m. ASM (administrative staff member) # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (2) Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (3) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the abuse policy for immediately reporting an allegation of abuse to the state agency for one of 47 residents in the survey sample, Resident #33. The facility staff failed to report an allegation of abuse from Resident #33 to the state agency immediately and or within the required two hours after learning of the allegation. The findings include: A review of the facility policy, Protection of Residents; Reducing the Threat of Abuse and Neglect, revealed, in part, the following: Reporting and Response .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin .will be immediately reported to the administrator and/or director of nursing .Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of 817/19, Resident #33 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). A review of a Facility Reported Incident (FRI) report related to Resident #33 revealed, in part, the following: Report date: 10/8/18 .Incident date: 10/4/18 (Resident #33) stated CNA (certified nursing assistant) was 'rough' with him during care and words she used was (sic) hurtful. The fax timestamp for this report to the state agency was 10/8/18. A review of Resident #33's clinical record revealed a progress note dated 10/6/18 at 11:20 a.m. This nurse's note documented, in part, the following: Resident continues with SNF (skilled nursing facility care) following right great toe amputation and right foot diabetic ulcer. Alert and oriented .Resident tearful over treatment last night stating that CNA (certified nursing assistant) told him that 'just because he had a bigger bed now did not mean that he owned the room' when she moved his bed over. Also reported that she was rough in repositioning him and his neck is sore today. DON (director of nursing) and unit manager notified and witness form filled out by resident. (The nurse who wrote this note was unavailable for interview at the time of survey. The CNA named in the allegation was also not available for interview at the time of survey.) On 10/23/19 at 3:19 p.m., CNA (certified nursing assistant) # 3 was interviewed regarding reporting abuse allegations. She stated that all allegations of abuse should be immediately reported to the supervisor. On 10/24/19 at 9:05 a.m., LPN (licensed practical nurse) #1 was interviewed regarding reporting abuse allegations. She stated, Any allegation should be reported as soon as possible to the DON (director of nursing) or whoever is on call for the facility for administration. On 10/24/19 at 11:05 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the DON (director of nursing), were interviewed. ASM #1 stated that the staff should report all allegations of abuse immediately, and that he or his designee should report them to the state agency within two hours of learning of the allegation. ASM #2 reviewed the FRI file regarding Resident #33 and stated, I don't remember this at all. I don't know why it took so long for us to report this. No further information was provided prior to exit.

Based on family interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of a significant medication error for one of 42 residents in the survey sample, Resident #55. The facility staff failed to ensure a complete review of hospital discharge orders for Resident #55, and failed transcribe an order for [REDACTED].#55 had a [MEDICAL CONDITION], resulting in harm and transfer to a local emergency room . The findings include: Resident #55 was admitted to the facility in (MONTH) 2004 with [DIAGNOSES REDACTED]. The extra chromosome causes problems with the way the body and brain develop. Dow[DIAGNOSES REDACTED] is one of the most common causes of birth defects.) (1), dementia, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as having short term memory difficulties and no long term memory difficulties. The resident was coded as being severely impaired to make daily cognitive decisions. Resident #55 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living. The MDS assessment, close to the date of the medication error, an annual assessment, with an ARD of [DATE], coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. Resident #55 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living. The Facility Reported Incident (FRI) dated [DATE], documented in part, Injuries: yes, [MEDICAL CONDITION], bit tongue with laceration. Prescribed medication ([MEDICATION NAME]*) omitted from [DATE] - [DATE], resulting in [MEDICAL CONDITION] activity in a.m.(morning) of [DATE]. Resident was sent to emergency room for evaluation and was not admitted and is returning to facility on [DATE]. *[MEDICATION NAME]- is used to treat certain types of [MEDICAL CONDITION] in the treatment of [REDACTED].(2) The pharmacokinetics of levetiracetam have been studied in healthy adult subjects, adults and pediatric patients with [MEDICAL CONDITION], elderly subjects and subjects with renal and hepatic impairment. [MEDICATION NAME] (Levetiracetam) is rapidly and almost completely absorbed after oral administration. [MEDICATION NAME] (Levetiracetam) plasma half-life in adults is 7 ± 1 hour. (4) The letter dated [DATE] to the state agency documented in part the following: It was reported to Unit Manager on [DATE] that above resident (Resident #55) had a [MEDICAL CONDITION] on the morning of [DATE] and was transferred to the hospital as a precautionary measure and resident returned from the same day, . Resident had been readmitted from the hospital on [DATE]. In reviewing the discharge orders from the hospital on [DATE] to this resident's previous orders, there were not any new orders noted by the Nurse or Physician or staff for a [MEDICAL CONDITION] medicine. This resident also was not on any [MEDICAL CONDITION] medication prior to his hospital stay. After this resident returned to the facility (on [DATE]), the facility received by fax, the After Discharge Summary. This was reviewed by Physician and forwarded to nursing unit with no new orders. Upon review of both documents it was noted that the After Discharge Summary, did contain a [MEDICAL CONDITION] medication, which this resident was not on prior to hospital stay. Nursing staff will be educated that all documents coming in for residents from the hospital or outside physician visits need to be reviewed for any changes and appropriate follow taken as needed. The physician orders [REDACTED].>A telephone order dated, [DATE] documented, [MEDICATION NAME] 500 mg (milligrams) po (by mouth) take 1 tab (tablet) po BID (twice a day) for [MEDICAL CONDITION]. The nurse's note dated, [DATE] at 5:20 a.m. documented in part, At 5:00 a.m. while receiving breathing tx (treatment), I entered the resident's room to find him with red face, grunting respirations, and his extremities with decorticate posturing. He was noted to have some light bleeding coming from his mouth. Breathing tx (treatment) stopped. Resident's normal skin tone returned to his face and he began to take deep breaths. Eyes were crossed and not focusing on anything. No response to verbal stimuli from resident. Cleansed outer lips, but resident wouldn't open his mouth so I could check for the source of bleeding. After a few minutes his eyes returned to their normal and resident closed his eyes and began with normal respirations. Before I left the room, the resident was smiling and moving his arms about normally. The nurse's note dated, [DATE] at 6:19 p.m., documented, 7a-7p (7:00 a.m. to 7:00 p.m.) nursing note: Resident was observed with [MEDICAL CONDITION] activity this morning [MEDICATION NAME] approximately ,[DATE] minutes. Resident was unresponsive, with no pupillary reflex, with abdominal breath at 32 breaths per minute. Resident was placed on side to prevent any further complications. Post [MEDICAL CONDITION] VS (vital signs) ,[DATE] (blood pressure) 93 (heart rate), 22 (respirations) O2 (Oxygen) sat (saturation) on RA (room Air). Resident was transported via ambulance to (initials of hospital) ER (emergency room ) for evaluation. Residents brother stated resident should have been taking [MEDICATION NAME] 500 mg BID after previous discharge from (initials of hospital). Order for [MEDICATION NAME] 500 mg BID obtained, faxed to Pharmacy and is pending in delivery. Residents brother stated that resident has not eaten anything all day and has maintained a 'decent blood glucose.' Resident arrived back from (initials of hospital) at 5:15 p.m. with a blood glucose of 327, no insulin given. All meds (medications) from 7 am until 4 p.m. have not been given due to resident being OOF (out of facility). Resident is currently in bed resting with eyes closed, with respiration being even and unlabored. Call bell is within reach. The comprehensive care plan dated, [DATE] and revised on [DATE], failed to evidence documentation of the new [DIAGNOSES REDACTED]. The Discharge Summary Notes dated, [DATE], documented in part, START taking these medications: [REDACTED]. An interview was conducted with Resident #55's family member on [DATE] at 4:00 p.m. the family member explained to this surveyor that when Resident #55 returned from the hospital on [DATE], from being treated for [REDACTED]. Upon his return to the facility, the family member asked a nurse, twice, about the order for [MEDICATION NAME]. Each time the nurse told him he (Resident #55) didn't have an order for [REDACTED]. On [DATE] at 6:08 p.m. administrative staff member (ASM) #1, the executive director, and ASM #2, the director of nursing, were made aware of the concern for harm. An interview was conducted with LPN (licensed practical nurse) #4, the nurse whom the family member asked twice about the order for [MEDICATION NAME]; on [DATE] at 6:41 p.m., LPN #4 was asked about the process staff follows for physician orders [REDACTED]. LPN #4 stated, Normally the physician gets the order from the hospital. They (the orders) are brought to us by (name of director of business development). The orders are on the top with the discharge summary stapled to the back. We take them to the doctor, he will write the [DIAGNOSES REDACTED]. The doctor signed the bottom of each page. After they sing them, we fax them to the pharmacy. After they go to the pharmacy, we call the pharmacy to verify that they received the orders. One nurse will import the physician orders [REDACTED]. After that is printed, another nurse compares and verify every order is correct. Both nurses sign the updated sheets. After that we print up the MARs (medication administration records) and TARs (treatment administration records), we both verify the MARs with the orders. LPN #4 was asked what she recalled from when Resident #55 returned to the facility on [DATE]. LPN #4 stated she took care of Resident #55 on the second or third day he was back. When asked if she remembered the family asking about [MEDICATION NAME], LPN #4 stated, No, I remember (name of family member) saying (Resident #55) received a medication for [MEDICAL CONDITION]. That triggered me to look at the chart. I looked at hospital records and our orders; there was no orders for [MEDICATION NAME]. Then I looked at the discharge packet, I noted that the resident had received [MEDICATION NAME]*. He asked me twice and I looked at the exact same spot. I then went on vacation. I came back and found out he had a new order for [MEDICATION NAME]. *([MEDICATION NAME] ([MEDICATION NAME]) is used to relieve anxiety. [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. (3) An interview was conducted with administrative staff member (ASM) #4, the medical director; on [DATE] at 6:51 p.m., ASM #4 stated the facility has had difficulty with obtaining the correct orders for residents transferred to the facility. He stated the facility goes by the AVS (after visit summary) to get the medications in the facility. Sometimes the facility receives a second and third AVS. He stated he has spoken to the hospital after this occurred and they are only sending one AVS. ASM #4 stated, The hospital sent the AVS (for Resident #55) and the [MEDICATION NAME] was not on it. It was reviewed by (ASM #5), the covering physician as ASM #4 stated he was out of town. Somehow, another AVS (for Resident #55) came in that same day, it was not signed by the physician and it was kept somewhere else. ASM #4 stated, now the process is if there is a change from what they originally sent, the hospital has to call us. ASM #4 stated that upon his return from vacation, we went through the entire paper record. The second AVS was there and had the order for the [MEDICATION NAME]. When asked who is ultimately responsible, ASM #4 stated, We are. An interview was conducted with RN (registered nurse) #3, the interim director of nursing at the time of the incident, on [DATE] at 9:15 a.m. When asked her knowledge of the incident, RN #3 stated, I know that there was an order set that had come in. A piece was out of it. We didn't have the page with the [MEDICATION NAME]. The family told us he was supposed to be on [MEDICATION NAME]. We couldn't find the order for it. We were missing a page of the orders. When asked if the order was found in the facility, RN #3 stated, Yes, (ASM #4 (medical director)) went through the record, page by page and found the order. An interview was conducted with other staff member (OSM) #17, the director of business development; on [DATE] at 9:23 a.m., OSM #17 was asked about the process in place during (MONTH) (YEAR), for reciving information from the hospital for an admission. OSM #17 stated, My process hasn't really changed. I will review the information in the computer program from the hospital. I print it out and hand it to the physician directly. That's the end of my involvement. When asked about the process in place now, OSM #17 stated, the hospital has an upgraded system and that the facility has access to the system. I still print the information and hand it to the medical provider. The AVS (after visit summary) is what the hospital sends. It used to be called discharge orders. It's essentially the medication list. I print the H&P (history and physical) and that set of orders. Then I hand it to (ASM #4) or (ASM #5). The papers go straight into the hands of the physician or nurse practitioner. When asked her knowledge of what happened with Resident #55 last September, OSM #17 stated that the first set of orders came in around 2:00 p.m. I took them down to the unit. A second set came over the fax around 4:00 p.m. It was a second document but an AVS (after visit summary). The hospital has up to 72 hours to provide a discharge summary but the AVS is what the doctors go by for the orders, and it was two hours before the second one arrived here. When asked why the documents at 2:00 p.m. didn't match the documents at 4:00 p.m., OSM #17 stated, Sometimes it doesn't the AVS is the one that the patient is walking in the door with. Discharge summaries are unpredictable they are late. The process for the admission steps is the same today as it was in September, last year. We still print the same documents and hand them to the physician directly. An interview was conducted with ASM #1, the executive director, on [DATE] at 9:55 a.m. When asked about his knowledge of the incident with Resident #55 on [DATE], ASM #1 stated the order had come into the facility. The doctor (ASM #5) reviewed the orders and then gave the orders to the nurse. It wasn't until he went out with the [MEDICAL CONDITION] that (ASM #4) the medical director, went through the clinical record, page by page, and found the order in the hospital paperwork. When asked who is ultimately responsible, ASM #1 stated, We are. ASM #1 stated there is now a double check system by two nurses that was put in place after this happened. A request was made at this time, for any documentation of the new process that the facility put into place after the incident. The facility policy, Physician order [REDACTED]. Or written by the physician, nurse practitioner or physician's assistant; obtained via telephone by the nursing staff from the physician, or transcribed from the transfer orders. A copy of the admitting orders will be faxed to the pharmacy as soon as possible. An initial set of Medication and Treatment Administration records will be created and placed in the appropriate medication/treatment books. On [DATE] at 11:51 a.m., ASM #1 presented a copy of the Quality Assurance and Performance Improvement Plan dated, [DATE], which documented Observation: Resident did not have [MEDICATION NAME] on admission orders [REDACTED]. MD (medical doctor) and responsible party was notified of [MEDICAL CONDITION] possible missing medications. Resident was sent to ER for evaluation. Resident was sent back to facility. All residents admitted since (ASM #5) had been assisting admission orders [REDACTED]. Nursing will be educated when orders are completed prior to resident arriving they must compare to orders received when resident arrives for any changes made prior to leaving hospital. Two nurses will review all new admissions. Nursing administration will review 5 days a week. All nurses not receiving in service training will not work until education is completed. Education will be added to orientation packet. DON (director of nursing) to report finding of daily audit 5 days a week to PI (performance improvement) for review and recommendations. Interviews were conducted with six current nurses. The nurses interviewed had been in the facility before the incident and two nurses had just started working at the facility a few months ago. All of the nurses could correctly state the double check system for admission/readmission orders [REDACTED] No further information was provided prior to exit. PAST NON-COMPLIANCE (1) This information was obtained from the following website: https://medlineplus.gov/ency/article/ 7.htm. (2) This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 98/?report=details (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html. (4) This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d 93-a8bc-4f31-a31b- d 5

Based on family interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 42 residents in the survey sample, Resident #55, was free of a significant medication error. Upon Resident #55's readmission to the facility, from the hospital on [DATE], the facility staff failed to administer a newly prescribed medication for [MEDICAL CONDITION] from ,[DATE] through [DATE], Resident #55 had a [MEDICAL CONDITION] on [DATE], resulting in harm, and transfer to a local emergency room . The findings include: Resident #55 was admitted to the facility in (MONTH) 2004 with [DIAGNOSES REDACTED]. The extra chromosome causes problems with the way the body and brain develop. Dow[DIAGNOSES REDACTED] is one of the most common causes of birth defects.) (1), dementia, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as having short term memory difficulties and no long term memory difficulties. The resident was coded as severely impaired for make daily cognitive decisions. Resident #55 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living. The MDS assessment, close to the date of the medication error, an annual assessment, with an ARD of [DATE], coded the resident as having both short and long term memory difficulties and as severely impaired to make daily cognitive decisions. Resident #55 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living. The Facility Reported Incident (FRI) dated [DATE], documented in part, Injuries: yes, [MEDICAL CONDITION], bit tongue with laceration. Prescribed medication ([MEDICATION NAME]*) omitted from [DATE] - [DATE], resulting in [MEDICAL CONDITION] activity in a.m.(morning) of [DATE]. Resident was sent to emergency room for evaluation and was not admitted and is returning to facility on [DATE]. *[MEDICATION NAME]- is used to treat certain types of [MEDICAL CONDITION] in the treatment of [REDACTED]. (2) The pharmacokinetics of levetiracetam have been studied in healthy adult subjects, adults and pediatric patients with [MEDICAL CONDITION], elderly subjects and subjects with renal and hepatic impairment. [MEDICATION NAME] (Levetiracetam) is rapidly and almost completely absorbed after oral administration. [MEDICATION NAME] (Levetiracetam) plasma half-life in adults is 7 ± 1 hour. (4) The letter dated [DATE] to the state agency documented in part the following: It was reported to Unit Manager on [DATE] that above resident (Resident #55) had a [MEDICAL CONDITION] on the morning of [DATE] and was transferred to the hospital as a precautionary measure and resident returned from the same day, . Resident had been readmitted from the hospital on [DATE]. In reviewing the discharge orders from the hospital on [DATE] to this resident's previous orders, there were not any new orders noted by the Nurse or Physician or staff for a [MEDICAL CONDITION] medicine. This resident also was not on any [MEDICAL CONDITION] medication prior to his hospital stay. After this resident returned to the facility (on [DATE]), the facility received by fax, the After Discharge Summary. This was reviewed by Physician and forwarded to nursing unit with no new orders. Upon review of both documents it was noted that the After Discharge Summary, did contain a [MEDICAL CONDITION] medication, which this resident was not on prior to hospital stay. Nursing staff will be educated that all documents coming in for residents from the hospital or outside physician visits need to be reviewed for any changes and appropriate follow taken as needed. The physician orders [REDACTED].>A telephone order dated, [DATE] documented, [MEDICATION NAME] 500 mg (milligrams) po (by mouth) take 1 tab (tablet) po BID (twice a day) for [MEDICAL CONDITION]. The nurse's note dated, [DATE] at 5:20 a.m. documented in part, At 5:00 a.m. while receiving breathing tx (treatment), I entered the resident's room to find him with red face, grunting respirations, and his extremities with decorticate posturing. He was noted to have some light bleeding coming from his mouth. Breathing tx (treatment) stopped. Resident's normal skin tone returned to his face and he began to take deep breaths. Eyes were crossed and not focusing on anything. No response to verbal stimuli from resident. Cleansed outer lips, but resident wouldn't open his mouth so I could check for the source of bleeding. After a few minutes his eyes returned to their normal and resident closed his eyes and began with normal respirations. Before I left the room, the resident was smiling and moving his arms about normally. The nurse's note dated, [DATE] at 6:19 p.m., documented, 7a-7p (7:00 a.m. to 7:00 p.m.) nursing note: Resident was observed with [MEDICAL CONDITION] activity this morning [MEDICATION NAME] approximately ,[DATE] minutes. Resident was unresponsive, with no pupillary reflex, with abdominal breath at 32 breaths per minute. Resident was placed on side to prevent any further complications. Post [MEDICAL CONDITION] VS (vital signs) ,[DATE] (blood pressure) 93 (heart rate), 22 (respirations) O2 (Oxygen) sat (saturation) on RA (room Air). Resident was transported via ambulance to (initials of hospital) ER (emergency room ) for evaluation. Residents brother stated resident should have been taking [MEDICATION NAME] 500 mg BID after previous discharge from (initials of hospital). Order for [MEDICATION NAME] 500 mg BID obtained, faxed to Pharmacy and is pending in delivery. Residents brother stated that resident has not eaten anything all day and has maintained a 'decent blood glucose.' Resident arrived back from (initials of hospital) at 5:15 p.m. with a blood glucose of 327, no insulin given. All meds (medications) from 7 am until 4 p.m. have not been given due to resident being OOF (out of facility). Resident is currently in bed resting with eyes closed, with respiration being even and unlabored. Call bell is within reach. The comprehensive care plan dated, [DATE] and revised on [DATE], failed to evidence documentation of the new [DIAGNOSES REDACTED]. The Discharge Summary Notes dated, [DATE], documented in part, START taking these medications: [REDACTED]. An interview was conducted with Resident #55's family member on [DATE] at 4:00 p.m. the family member explained to this surveyor that when Resident #55 returned from the hospital on [DATE], from being treated for [REDACTED]. Upon his return to the facility, the family member asked a nurse, twice, about the order for [MEDICATION NAME]. Each time the nurse told him he (Resident #55) didn't have an order for [REDACTED]. On [DATE] at 6:08 p.m. administrative staff member (ASM) #1, the executive director, and ASM #2, the director of nursing, were made aware of the concern for harm. An interview was conducted with LPN (licensed practical nurse) #4, the nurse whom the family member asked twice about the order for [MEDICATION NAME]; on [DATE] at 6:41 p.m., LPN #4 was asked about the process staff follows for physician orders [REDACTED]. LPN #4 stated, Normally the physician gets the order from the hospital. They (the orders) are brought to us by (name of director of business development). The orders are on the top with the discharge summary stapled to the back. We take them to the doctor, he will write the [DIAGNOSES REDACTED]. The doctor signed the bottom of each page. After they sing them, we fax them to the pharmacy. After they go to the pharmacy, we call the pharmacy to verify that they received the orders. One nurse will import the physician orders [REDACTED]. After that is printed, another nurse compares and verify every order is correct. Both nurses sign the updated sheets. After that we print up the MARs (medication administration records) and TARs (treatment administration records), we both verify the MARs with the orders. LPN #4 was asked what she recalled from when Resident #55 returned to the facility on [DATE]. LPN #4 stated she took care of Resident #55 on the second or third day he was back. When asked if she remembered the family asking about [MEDICATION NAME], LPN #4 stated, No, I remember (name of family member) saying (Resident #55) received a medication for [MEDICAL CONDITION]. That triggered me to look at the chart. I looked at hospital records and our orders; there was no orders for [MEDICATION NAME]. Then I looked at the discharge packet, I noted that the resident had received [MEDICATION NAME]*. He asked me twice and I looked at the exact same spot. I then went on vacation. I came back and found out he had a new order for [MEDICATION NAME]. *([MEDICATION NAME] ([MEDICATION NAME]) is used to relieve anxiety. [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. (3) An interview was conducted with administrative staff member (ASM) #4, the medical director; on [DATE] at 6:51 p.m., ASM #4 stated the facility has had difficulty with obtaining the correct orders for residents transferred to the facility. He stated the facility goes by the AVS (after visit summary) to get the medications in the facility. Sometimes the facility receives a second and third AVS. He stated he has spoken to the hospital after this occurred and they are only sending one AVS. ASM #4 stated, The hospital sent the AVS (for Resident #55) and the [MEDICATION NAME] was not on it. It was reviewed by (ASM #5), the covering physician as ASM #4 stated he was out of town. Somehow, another AVS (for Resident #55) came in that same day, it was not signed by the physician and it was kept somewhere else. ASM #4 stated, now the process is if there is a change from what they originally sent, the hospital has to call us. ASM #4 stated that upon his return from vacation, we went through the entire paper record. The second AVS was there and had the order for the [MEDICATION NAME]. When asked who is ultimately responsible, ASM #4 stated, We are. An interview was conducted with RN (registered nurse) #3, the interim director of nursing at the time of the incident, on [DATE] at 9:15 a.m. When asked her knowledge of the incident, RN #3 stated, I know that there was an order set that had come in. A piece was out of it. We didn't have the page with the [MEDICATION NAME]. The family told us he was supposed to be on [MEDICATION NAME]. We couldn't find the order for it. We were missing a page of the orders. When asked if the order was found in the facility, RN #3 stated, Yes, (ASM #4 (medical director)) went through the record, page by page and found the order. An interview was conducted with other staff member (OSM) #17, the director of business development; on [DATE] at 9:23 a.m., OSM #17 was asked about the process in place during (MONTH) (YEAR), for reciving information from the hospital for an admission. OSM #17 stated, My process hasn't really changed. I will review the information in the computer program from the hospital. I print it out and hand it to the physician directly. That's the end of my involvement. When asked about the process in place now, OSM #17 stated, the hospital has an upgraded system and that the facility has access to the system. I still print the information and hand it to the medical provider. The AVS (after visit summary) is what the hospital sends. It used to be called discharge orders. It's essentially the medication list. I print the H&P (history and physical) and that set of orders. Then I hand it to (ASM #4) or (ASM #5). The papers go straight into the hands of the physician or nurse practitioner. When asked her knowledge of what happened with Resident #55 last September, OSM #17 stated that the first set of orders came in around 2:00 p.m. I took them down to the unit. A second set came over the fax around 4:00 p.m. It was a second document but an AVS (after visit summary). The hospital has up to 72 hours to provide a discharge summary but the AVS is what the doctors go by for the orders, and it was two hours before the second one arrived here. When asked why the documents at 2:00 p.m. didn't match the documents at 4:00 p.m., OSM #17 stated, Sometimes it doesn't the AVS is the one that the patient is walking in the door with. Discharge summaries are unpredictable they are late. The process for the admission steps is the same today as it was in September, last year. We still print the same documents and hand them to the physician directly. An interview was conducted with ASM #1, the executive director, on [DATE] at 9:55 a.m. When asked about his knowledge of the incident with Resident #55 on [DATE], ASM #1 stated the order had come into the facility. The doctor (ASM #5) reviewed the orders and then gave the orders to the nurse. It wasn't until he went out with the [MEDICAL CONDITION] that (ASM #4) the medical director, went through the clinical record, page by page, and found the order in the hospital paperwork. When asked who is ultimately responsible, ASM #1 stated, We are. ASM #1 stated there is now a double check system by two nurses that was put in place after this happened. A request was made at this time, for any documentation of the new process that the facility put into place after the incident. The facility policy, Physician order [REDACTED]. Or written by the physician, nurse practitioner or physician's assistant; obtained via telephone by the nursing staff from the physician, or transcribed from the transfer orders. A copy of the admitting orders will be faxed to the pharmacy as soon as possible. An initial set of Medication and Treatment Administration records will be created and placed in the appropriate medication/treatment books. On [DATE] at 11:51 a.m., ASM #1 presented a copy of the Quality Assurance and Performance Improvement Plan dated, [DATE], which documented Observation: Resident did not have [MEDICATION NAME] on admission orders [REDACTED]. MD (medical doctor) and responsible party was notified of [MEDICAL CONDITION] possible missing medications. Resident was sent to ER for evaluation. Resident was sent back to facility. All residents admitted since (ASM #5) had been assisting admission orders [REDACTED]. Nursing will be educated when orders are completed prior to resident arriving they must compare to orders received when resident arrives for any changes made prior to leaving hospital. Two nurses will review all new admissions. Nursing administration will review 5 days a week. All nurses not receiving in service training will not work until education is completed. Education will be added to orientation packet. DON (director of nursing) to report finding of daily audit 5 days a week to PI (performance improvement) for review and recommendations. Interviews were conducted with six current nurses. The nurses interviewed had been in the facility before the incident and two nurses had just started working at the facility a few months ago. All of the nurses could correctly state the double check system for admission/readmission orders [REDACTED] No further information was provided prior to exit. PAST NON-COMPLIANCE (1) This information was obtained from the following website: https://medlineplus.gov/ency/article/ 7.htm. (2) This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 98/?report=details (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html. (4) This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d 93-a8bc-4f31-a31b- d 5