Every finding on record at McLean Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored and cooked food was properly labeled, dated and covered. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an observation on 9/2/26 at 10:25 am the following was observed in the freezer:A box of breakfast beef, open to airBag of sausage links no label or date, not in original boxZiplock baggy of meat, open to airBox of boneless pork chop fritters, open to air6 bags of guacamole, no label or date, not in original box5 brown bags of potatoes, no date, not in original box In an interview on 9/3/26 at 11:00 am the DM stated she had been trained by the dietician and the previous DM. She stated she was aware the food in the freezer should have been labeled and dated and closed to air. She stated she had constantly discussed with the kitchen staff to label and date all food items. She stated she checks the food in the freezer for labeling, dating and being sealed all the time. She stated the consequences of not having all foods labeled dated and closed to air were food borne illness for the residents. Record review of the policy dated 2012 titled, Dietary Food Service Personnel Policy and Procedures revealed: All employees receive instruction in sanitation during orientation and thorough in-service training. All unused food must be securely covered. All items are to be dated and labeled as to their content.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #5) of 12 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #5's MDS dated [DATE] was accurately coded to reflect he received insulin. This failure could place residents at risk of not receiving necessary care.Findings included: Record review of Resident #5's admission record dated 09/02/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic systolic congestive heart failure (heart has become too weak to squeeze hard enough in order to pump out enough blood to the body with each beat), type 2 diabetes mellitus (inability to process sugar), dehydration (loss of water in body), essential (primary) hypertension (abnormally high blood pressure that was not the result of a medical condition), and unsteadiness on feet. Record review of Resident #5's admission MDS assessment revealed a completion date of 06/21/26. Section C (Cognitive Patterns) revealed a BIMS score of 11 which indicated the resident's cognition was moderately impaired. Section N0300 & N0350 revealed Resident #5 had received insulin in the last 7 days of the 7-day lookback period. Section N0415 J revealed Resident #5 was not taking insulin. Record review of Resident #5's care plan completed on 06/09/26 revealed Resident #5 was taking insulin for his diabetes.Record review of Resident #5's active order summary report dated 09/02/2026 revealed the following orders: Lantus SoloStar Subcutaneous Pen-Injector 100 Unit/ML. Inject 10 unit subcutaneously at bedtime related to Type 2 Diabetes Mellites without complications . NovoLOG Injection Solution 100 Unit/ML. Inject as per sliding scale subcutaneously three times a day related to Type 2 Diabetes Mellites without complications .During an interview on 09/02/26 at 1:38 PM, Resident #5 stated he had been taking insulin for a long time and currently received insulin injections 3-4 times daily, depending on his blood sugar reading.During an interview on 09/03/26 at 9:57 AM, the MDS LVN stated she had worked at the facility since 2009 and was responsible for completing MDS assessments. She stated she used the RAI manual as her policy when completing MDS assessments. When asked if Resident #5 was taking insulin, she stated he was. After reviewing Resident #5's MDS, the MDS LVN stated Section N0415J was incorrect and should have been coded to reflect that the resident was taking insulin. She stated, I missed it. The MDS LVN stated a negative outcome of inaccurate MDS assessments could have affected resident's care and treatment, as well as facility funding.During an interview on 09/03/26 at 10:06 AM, the DON stated that the MDS LVN was responsible for completing MDS assessments. She stated it would have been an issue if a resident was taking insulin and it was not coded on the Resident's MDS. The DON stated an inaccurate MDS assessment could have impacted care for residents.During an interview on 09/03/26 at 10:09 AM, the CRN stated the MDS LVN was responsible for completing MDS assessments. She stated MDS assessments affected facility funding as well as continuity of care for residents.During an interview on 09/03/26 at 10:11 AM, the ADM stated that the MDS LVN was responsible for completing MDS assessments. She stated an incorrect MDS could have affected the resident's plan of care as well as facility funding. Record review of facility policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy, dated August 2025, revealed the following in part: The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. Federal regulations require that:1. The assessment accurately reflects the resident's status. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . N0415: High-Risk Drug Classes: Use and IndicationN0415J1. Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415J2. Hypoglycemic (including insulin): Check if there is an indication noted for all hypoglycemic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).Include any of these medications given to the resident by any route in any setting (e.g., at the nursing home, in a hospital emergency room) while a resident of the nursing home.Code a medication even if it was given only once during the look-back period.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 2 medication storage areas reviewed to meet the needs of each resident. The facility failed on [DATE] when staff had 3 of 10 inulin medications present in the medication cart that were expired according to the date documented on the bottle/pen when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings included: During an observation and interview on [DATE] at 11:20 AM of the medication cart used for all residents in the facility with LVN A present 10 insulins were observed. Of the 10 insulins 7 were marked with the open date and were within the 28 days of use. 3 had the following information:2-Novolog insulin marked with an open/accessed date of [DATE]. (opened 32 days prior to today's date)1-Lantus insulin marked with an open/accessed date of [DATE]. (opened 32 days prior to today's date)LVN A observed all three insulins, verified they had been opened, and were currently being used for treatment of residents. LVN A reported she thought the Lantus may have been opened [DATE] but she was not sure because the writing was difficult to read. LVN A reported she thought insulins were to be discarded about a month after they had been opened. LVN A reported if a resident receives an insulin that was expired then it might not be effective. During an interview on [DATE] at 11:29 AM DON C (the DON from a sister facility) viewed all three insulin and reported both Novolog insulins were opened on [DATE] and the Lantus was opened on [DATE] or [DATE] but she really could not tell due to the handwriting. DON C reported all three insulins were expired and the insulins should be discarded 28 days after they were opened. DON C reported if an insulin was administered that was expired it would have less potency. During an interview on [DATE] at 11:31 AM the ADON reviewed all three insulins to include both Novolog's and the Lantus insulin and reported all three were opened [DATE] and all three insulins were expired. The ADON reported insulins were to be discarded 28 days after opening and if an insulin was given to a resident that was expired it would have less potency. Record review of the facility provided policy titled Recommended Medication Storage revised 7/2012, revealed the following: Medications that requires an open date: as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used.Humalog and Humalog MixInsulin Glargine (Lantus)-Expires 28 days after initial use regardless of product storage.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free from accidents as was possible and each resident received adequate supervision and assistance devised to prevent accidents for 1 of 5 residents (Resident #2) reviewed for accidents, hazards, and supervision. The facility failed to ensure the TA securely fastened Resident #2's seat to the floor of the facility van when taking him to dialysis. Resident #2's seat tipped sideways, causing Resident #2 to strike the van door with his right shoulder and side, resulting in a fractured right collarbone and rib when the TA made a left turn. The noncompliance was identified as PNC. The IJ began on 3/18/26 when Resident #2 fell in the facility van and ended on 3/19/26. The facility had corrected the noncompliance before the surveyor entered the facility. This failure could place residents at risk of serious injury, harm or other medical complications. Findings Included: Record review of Resident #2's face sheet, dated 3/20/26, documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: congestive heart failure (heart cannot pump enough blood to meet the body's needs, causing fluid buildup in the lungs, legs and abdomen), mild dementia (memory loss, increased confusion, poor decision-making), end stage renal disease (kidneys no longer function on their own), gastro-esophageal reflux (stomach acid frequently flows back into the esophagus, causing irritation), abdominal aortic aneurysm (enlargement in the lower aorta, usually caused by a weakened [NAME] wall, aging and smoking), atrial Fibrillation ( fast, irregular heartbeat), cerebral infarction ( blockage in an artery supplying blood to the brain, resulting in oxygen deprivation and tissue death), atherosclerosis of renal artery (narrowing of kidney arteries due to plaque buildup), dependence on oxygen, hypertension (high blood pressure), skin cancer, kidney failure, severe protein-calorie malnutrition. Record review of Resident #2's quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Resident #2 was ambulatory with a walker. Record review of Resident #2's March 2026 nurses notes documented the following: -3/18/26 at 11:00 a.m. - The AD of facility called me (DON) and notified that residents chair tipped over during transport to dialysis and the resident did fall in-between the door of van and seat the resident was sitting in had tipped over. The DON notified the NP of the incident, and the resident had no visible injuries noted. The resident stated he had pain in right shoulder, and the resident could move the right shoulder at that time. The DON notified the NP and ordered for x-ray of shoulder when the resident arrived back at facility and to continue to dialysis treatment as the resident was in the parking lot about to go into dialysis. The Resident Statement: I was sitting in seat of facility van and when driver made turn, the chair tipped and I was against the door of the van. The Van driver stopped and helped me get back up and checked for injuries, MD, RP notified. Interventions: Monitoring loading/unloading and use of the van lift and secure of chairs to make sure everything in proper orders are in place. -3/19/26 at 8:25 a.m. - x-ray results of shoulder were negative for fractures. Resident notified. -3/27/26 at 4:12 p.m. - NP ordered CT without contrast of right shoulder due to shoulder pain scheduled for 3/30/26 at 8:00 a.m., resident notified. -3/30/26 at 1:46 p.m. - unable to do CT scan of right shoulder without contrast due to order not being received with physician signature. New appointment for CT of right shoulder without contrast scheduled for 4/3/26 at 4:00 p.m., resident notified of change of appointment. Record review of an x-ray dated 3/18/26 of Resident #2's right shoulder, revealed no acute fracture or dislocation of right shoulder. Record review of a CT scan dated 4/3/26 f Resident #2's right upper extremity, , documented an acute, mildly comminuted (multiple small, splintered pieces) and minimally displaced, fracture of the right distal clavicular (collarbone) head and neck, and acute, nondisplaced, right anterior 2nd rib fracture. (The facility received the results of the CT scan on 4/8/26 while the state surveyor was in the facility). Record review of the Provider Investigation Report, dated 3/18/26, revealed Resident #2 was being transported by the TA to dialysis. The AD was also in the van for resident shopping and witnessed the incident. During transport the TA was making a low speed left turn from a stop sign when the van seat/chair tipped sideways, which caused the resident to strike the van door. The driver immediately pulled over and secured the resident in a different chair. The TA asked Resident #2 if he was okay, and the resident said yes. Immediate actions taken to protect the resident's health and safety included immediately pulling over, checking on the resident who had no visible injuries, securing the resident in a different seat, and removing the TA from transport duties following the incident. The Administrator and MDS nurse drove to the dialysis center to safely transport the resident back to the facility. The resident was secured in a different chair. The van driver was suspended pending investigation. Witness statements from TA and AD were obtained and the TA was drug tested and the results were negative. Began abuse/neglect in-service. The chair was removed from the van.Investigation Summary: During the weekend, the van seat was repositioned to accommodate additional residents attending a parade in a local community. Subsequent inspection revealed the safety bar did not fully engage or seat properly within the groove intended to prevent the latch mechanism from loosening. The Administrator further determined the handle was difficult to manipulate into the position required to fully secure the seat within the floor track. As an immediate corrective action, the Maintenance Supervisor lubricated the latch hardware on all van seats and confirmed that each seat was properly locked and secured to the floor track. The van was removed for service for resident transport immediately and no residents will be transported in the van until it has been assessed by maintenance staff for proper function of all safety devices/equipment. In-serviced staff who transport or assist with transporting residents in the van on the following (with return demonstration) staff members not in-serviced will not transport residents - how to safely load and unload residents in the van using the lift. Properly securing a resident in the van - ambulatory resident - securing with seat belt., non-ambulatory resident - securing the wheelchair and the resident, maintain a list of staff who have completed training and provided return demonstration. Staff not listed will not transport residents. The medical director was notified of this incident. Each week the Administrator or designee monitors at least 4 instances of loading and /or unloading of a resident using the van lift to ensure the lift was used correctly and the resident was properly secured. This monitoring will continue for at least 4 weeks. The QAPI Committee will review the findings and make changes to this plan as needed. During an interview on 4/8/26 at 9:20 a.m., Resident #2 stated his shoulder still hurts from a fall in the van. Resident #2 stated the seat on the van was not latched good and he fell over and hit his head and bruised his shoulder. Resident #2 stated the TA pulled the van over and had to unhook him so he could get up from the floor of the van. Resident #2 stated he was sitting in a chair, not a wheelchair. Resident #2 stated after the fall, he went to dialysis and then back to the facility for an x-ray. Resident #2 stated the x-ray was negative. Resident #2 stated he had just gone to the hospital for a CT scan of his shoulder, but the facility had not gotten the results of the test yet. Resident #2 was ambulating in the hallway unassisted, had a steady gait and was carrying personal items in both arms. During an interview on 4/8/26 at 9:30 a.m., the TA stated she just did not understand how Resident #2 fell in the van. The TA stated she inspected the van before and after transporting residents. The TA stated there were three chairs in the van and they were all secured to the floor. The TA stated Resident #2 had his seat belt on him. The TA stated she was in a local community at a stop sign and when she turned the corner, that was when Resident #2 fell. The TA stated Resident #2 was leaning to the right of his chair when he fell over and hurt his shoulder on the van door. Record review of the Daily Vehicle Pre-Trip/Post-Trip book revealed the following, the inspection dated 3/18/26 (the day of Resident #2's fall), documented the van had chips on the windshield with no other concerns. The book revealed that any time the van was taken out, the pre and post inspections were completed. An observation and interview on 4/8/26 at 9:50 a.m., the van had two high back chairs that were latched to rails on the floor and they were secure. The TA explained that day, there was another chair in the van which was latched to the rails on the floor. The TA stated Resident #2 was sitting in the extra chair and he had his seat belt on. The TA stated there were usually only two chairs in the van and she could get two residents in wheelchairs in the van so she could transport 4 residents at a time. The two chairs were shaken, and both chairs were sturdy and secure. During an interview on 4/8/26 at 11:08 a.m., the DON stated the TA and Resident #2 were on their way to a local community for dialysis for Resident #2. The DON stated the AD checked all the chairs for safety reasons before they left in the van and all the chairs were secured. The DON stated Resident #2 tipped over and hit his shoulder. The DON stated Resident #2 was very close to dialysis so the TA was instructed to take Resident #2 to dialysis as they had nurses there who could assess him for any injury and he could also get his dialysis. The DON stated they got an x-ray of Resident #2's shoulder and it was negative for any fractures. The DON stated they got a CT scan on his shoulder, and they should have the results soon and said she would look to see if the results were back and she would bring the state surveyor a copy. The DON was gone a few minutes and came back with the CT scan results which showed a mildly comminuted and minimally displaced fracture of the collarbone and a right 2nd rib fracture. During an interview on 4/8/26 at 11:23 a.m., the AD stated it was the first time going with TA to go shopping. The AD stated the chair was on the outside of the van and TA put the chair in the van and secured it. The AD stated she looked at the chair and one of the front legs looked like it was not on the track properly. The AD stated she told the TA to check the chair, and she said it was not right, so she reattached the chair to the railing on the floor again. The AD stated she checked the chair before Resident #2 got into it, and the chair was sturdy and solid. The AD stated they were in a local community and at a stop sign, then the TA turned to go to the dialysis center when they heard a thud and Resident #2 was leaning way over and still strapped to the chair. The AD stated she called the DON and told her what happened and they got Resident #2 off the chair as he was still strapped in. The AD stated Resident #2 kept saying he was sorry and did not want to get anyone in trouble. The AD stated the Administrator called them because someone saw the facility van on the side of the road and called the facility about it, so he knew something was wrong. The AD stated they were instructed to get Resident #2 to the dialysis so the nurses at the center could assess him for any injuries. The AD stated Resident #2 said his shoulder hurt so the NP called to get an x-ray and that was negative for any fractures. The AD stated Resident #2 was still complaining of his shoulder hurting so he went for a CT scan, but she didn't think the results were back. During an interview on 4/8/26 at 11:54 a.m., the MS stated the chair that failed was put in the back shed. The MS stated he did weekly vehicle inspections on all the facility vans. The MS stated he checked over the chair that was tipped over and he could not find anything wrong with it. The MS stated the latch hardware was somewhat stiff, so he lubricated all the latches on the chairs, so they moved better. Record review of the Weekly Vehicle Inspection Report revealed the facility van was inspected weekly for the following items: vehicle interior including floors, seats, doors and steps all clean and free of debris/stains, seat belts in good working order, wheelchair tie-downs inspected and working properly. Also inspected - Exterior, fluid levels and emergency equipment. An observation on 4/8/26 at 12:15 p.m., of the chair that was taken out of the van revealed all the parts were in working order. An observation on 4/8/26 at 1:10 p.m., the TA inspected the van before taking the state surveyor on a ride in the neighborhood. The TA had a check list she filled out before transporting any resident and checked everything again when she got back to the facility after the outing. The TA demonstrated how she stopped at a stop sign, turned right and explained again how the resident tipped over and hit the van door. During a follow-up interview on 4/8/26 at 1:45 p.m., the TA stated she put the seat in the van that morning before she took Resident #2 to dialysis. The TA stated she started working at the facility in November 2025 and was trained over the wheelchair security on the van but not how to put the seats in the van and secure them. The TA stated the day Resident #2 fell in the van was the only time she had ever put a seat in the van. The TA stated she was told by the Administrator to not put seats in the van anymore as that would be the Maintenance Supervisors job. During an interview on 4/8/26 at 2:05 p.m., Administrator A stated the seat from the van was checked and the red pin at the bottom of the chair was hard to push down to properly secure the chair. Administrator A stated the TA should not put the seats in the van or out, that it was a job for the MS. Administrator A stated they in-serviced all staff who transport/assist with transporting resident. During an interview on 4/8/26 at 5:00 p.m., the ADO stated if the MS was not available to put seats in or out of the van, she would have the regional maintenance staff person do it and she would oversee it. During a telephone interview on 4/10/26 at 3:31 p.m., the DON stated she did not get a written assessment from the dialysis center about Resident #2. The DON stated the dialysis nurse told her Resident #2 said his shoulder hurt but he was fine and wanted to continue with dialysis treatment since he was already there. During an observation on 4/17/26 at 9:58 a.m., Resident #2 was ambulating unassisted on the front sidewalk with the TA walking behind him. Resident #2 was nicely dressed and had a sling around his waist with a strap going around his right arm. During an interview on 4/17/26 at 10:00 a.m., Resident #2 stated he was going to dialysis as he was starting to not fell well. Resident #2 stated he was not having any pain in his shoulder anymore. During an interview on 4/17/26 at 10:15 a.m., Administrator B stated she was made aware of the PNC with the fall in the van. Administrator B stated she had a feeling that state would come back for more information. Administrator B stated if the resident was not screaming out in pain or had blood everywhere, she would not expect EMS to be called for that. During an interview on 4/17/26 at 10:47 a.m., LVN C, dialysis nurse, stated RN D was on duty and assessed Resident #2 on the day he fell in the van. LVN C stated Resident #2 told them he had fallen in the van and his shoulder hurt. LVN C stated she remembered Resident #2 wanted his dialysis treatment and was not in a lot of pain. LVN C stated RN D was off today, but she could fax the paperwork for Resident #2's visit on 3/18/26. Awaiting fax from dialysis center. During a follow up interview on 4/17/26 at 10:58 a.m., the DON stated the AD called her and told her what had happened. The DON stated she asked the AD if Resident #2 was still on the floor. The DON stated she was informed they had already put him in a different chair. The DON stated she told them not to do anything else until she called the NP to see what she wanted done. The DON stated the NP was told the chair was tipped over and they had already got Resident #2 up and into a different chair, was in some pain but he could move his arms and legs and asked where they were at right now. The DON stated the NP said to ask him if he was able to go through dialysis, Resident #2 said yes, and the NP ordered a mobile x-ray when he got back from dialysis. The DON stated she was not sure of the distance Resident #2 was away from the dialysis center. Fax from the dialysis center was received 4/17/26 at 11:10 a.m. and it revealed the following:3/18/26 - patient complained of falling on his right shoulder. No swelling noted. Patient reports pain. PRN acetaminophen (over the counter pain reliever) administered for pain. NH DON reports patient is to have x-rays post treatment. NP (dialysis) informed of patient condition. No orders received. Low Blood Pressure before treatment. Temperature 98.4. Nursing Evaluation 3/18/26 at 11:48 a.m. - alert, oriented, ambulates with assistive device, uses walker, fall on shoulder, no associated symptoms, irregular pulse, pleasant, lungs are clear. During a follow-up interview on 4/17/26 at 11:20 a.m., the MS stated he was instructed to grease up the seats in the van by his company supervisor, and he would not have told him to do something that was not safe. The MS stated the facility van has over 75,000 miles and the levers on the seats must be greased occasionally because of the wind and dirt, the levers that attach the seats to the track start to rust if not greased. The MS stated he was not at the facility when the incident took place. Record review on 4/17/26 at 11:28 a.m. of maps documenting the distance from each location revealed the following:-Distance from incident to dialysis was 1.5 miles.-Distance from incident to facility was 37 miles. During an interview on 4/17/26 at 12:00 p.m., the AMS stated he conducted the checkoffs for the facility van, and it covered what to do in case of an accident. The AMS stated, moving forward, the MS or myself were the only ones to put the seats in the van or to take them out. The AMS stated he instructed MS to grease the levers on the seats to ensure they were working properly. During a follow-up telephone interview on 4/17/26 at 12:09 p.m., the AD stated she had already helped Resident #2 sit up because he was still attached to the seat, and she called the DON for direction. The AD stated that was the first time she was ever on the van and she was not sure of what to do so that was why she called the DON. The AD stated there was another resident, Resident #6, who was on the van at the time Resident #2 fell over. During a follow-up interview on 4/17/26 at 12:25 p.m., Administrator B stated the evidence that the van has been monitored every time it was taken out. Administrator B stated the Accident Reporting Procedures documented 911 would be called if the van was in an accident and the driver's responsibility was to call the facility or appropriate management and report the accident and that was what they did. Administrator B stated this incident was not a car accident and it was clearly due to the seat not being secured properly. An attempt on 4/17/26 at 1:01 p.m., to interview Resident #6 was unsuccessful due to the resident being out of the facility at Dahab. Record review of the Employee Auto Training Handbook, undated, revealed the following: Driver Responsibility: 1. Call the facility/appropriate management and report the accident. -Wheelchair Tie-Dow and Occupant Restraint SystemsEnvironmental conditions such as dirt, mud, oil, sand, solvents, grease or excessive sunlight, will reduce the service life of the system. Mechanical components such as cam or ratchet buckles should be periodically lubricated at any of the moving mental-to mental joints, to ensure proper operation and prolong the life of the system. -Driver Operating Rules7. Before driving a company automobile, the driver must be satisfied that it is in safe operating condition. Any defects or unsafe conditions should be reported to appropriate individual(s) immediately. -Management, Driver, Maintenance TrainingVehicle Inspection and Maintenance Requirements-A visual inspection should be conducted by the vehicle driver prior to use. Any defect or unsafe condition should be corrected prior to use. Repair documentation should be maintained in Maintenance Care. The designated staff should complete a vehicle inspection weekly. Any defects or unsafe conditions should be reported to the appropriate personnel. The defect or unsafe condition should be corrected before the vehicle is driven. Record review of the drug screen test results, dated 3/18/26, revealed the urine sample was collected at 5:45 p.m. and it was interpreted at 5:47 p.m. The test was negative for 12 different drugs. Record review of the Auto Accident/Incident Report, dated 3/18/26, revealed the conditions at the time of the accident/incident. The vehicle was in traffic, turning left at a stop sign. Road character: level and dry. Lighting: daylight and clear. Road defect: no defect. Vehicle defects: miscellaneous: driver was familiar with the road on which the accident occurred, driver familiar with vehicle, photo taken of accident sceneVan Seat Incident Investigation: Investigation Summary:During the weekend, the van seat was repositioned to accommodate additional residents attending the St. Patrick's Day Parage. Subsequent inspection revealed that the safety bar did not fully engage or seat properly within the groove intended to prevent the latch mechanism from loosening. The Administrator further determined that the handle was difficult to manipulate into the position required to fully secure the seat within the floor track. AS an immediate corrective action, the Maintenance Supervisor lubricated the latch hardware on all van seats and confirmed that each seat was properly locked and secured to the floor track. Record review of the Daily Vehicle Pre-Trip/Post Trip Inspection Checklist book revealed the van was checked before and after each use of the van, dating back to January 1, 2026. Inspect items below and check if ok, if not, report to the Administrator immediately. Complete this form daily. The pre and post checklist for 3/18/26 was completed and had all check marks - written in Notes: Chips on windshield. The checklist included the following:Exterior:-Tires-Turn signals-Mirrors-Emergency Flashers-Windshield Wipers-Body Damage - please note on diagram-Cleanliness-Spare tire/jack Interior:-Brakes/Emergency Brake-Wheelchair lift/Tie Down-Dash lights/Gauges-AC/Heater Safety Equipment:-Fire Extinguisher-First Aid Kit-Blood borne Pathogen Kit-Seat bets and seat belt cutter-Communication device (cell phone)-Accident Form/Facility contact list-Proof of Insurance Record review of the Employee Driver Training Log/In-Service provided to facility van drivers, dated 3/19/26, documented staff were educated over the following: -Company Driver Selection Process-Defensive Driving Techniques-Call Phone Usage-Accident/Emergency Procedures (What staff should do in the event of an accident/injury/fall during a van ride)-Wheelchair lift Operations-Wheelchair Tie-Downs and Occupant Restraint Systems (with return demonstration)-Height of the Vehicle-Driver Operating Rules-Road Tests-Vehicle Inspection and Maintenance Requirements-Use of Company Forms-Other: Six staff were trained and checked off by the RMS. Record review of the Van Incident Monitoring, start date, 3/20/26, and documented daily and reviewed in daily standup, there was no evidence of any potential neglect.In addition, staff were to monitor 4 instances of loading and /or unloading of a resident using the van lift to ensure the lift was used correctly and the resident was properly secured. Note any corrective actions on the back of this form. Monitoring concluded loading and/or unloading of residents was performed correctly consistently. Record review on 3/19/26, the QAPI Committee will review the findings and make changes to this plan as needed. The facility initially suspended the TA was suspended pending investigation. Witness statements from TA and AD were obtained. TA was drug tested which had negative results. Began Abuse/Neglect in-service. The chair was removed from the van. Van removed from service until assessed by maintenance staff for proper functioning of all safety devices/equipment. In-serviced staff who transport or assist with transporting resident in the van following (with return demonstration) - staff members not in-serviced will not transport residents: How to safely load and unload residents in the van using the lift. Properly securing a resident in the van: ambulatory resident - securing with seat belt, non-ambulatory resident - securing the wheelchair and the residents, maintain a list of staff who have completed training and provided return demonstration. Staff not listed will not transport residents. The Medical Director was notified of the incident. Each week the Administrator or designee monitors at least 4 instances of loading and /or unloading of a resident using the van lift to ensure the lift was used correctly and the resident was properly secured and will continue for four weeks. The QAPI Committee will review the findings and make changes to this plan as needed. Inspection revealed the safety bar did not fully engage or was not set properly within the groove intended to prevent the latch from loosening. Latch hardware was lubricated and all seats were confirmed to be working properly and were locked and secured to the floor track.This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The noncompliance began on 3/18/26 and ended on 3/19/26. The facility corrected the noncompliance before the survey began.

-Medication cart for the facility revealed the following:-The facility failed to discard Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -The facility failed to have an open date on Resident #19's Novolog 100units/ml. -The facility failed to discard Resident #16's Lantus 100units/ml with open date of 06/03/2025. -The facility failed to discard Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-The facility failed to have an open date on Resident #3's Novolog 100units/ml. -The facility failed to have an open date on Resident #3's Glargin-YFGN Injection pen. -The facility failed to have an open date on Resident #24's Novolog FlexPen. -The facility failed to discard Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -The facility failed to have an open date on Resident #22's Novolog FlexPen. -The facility failed to have an open date on Resident #9's Trelegy inhaler. -The facility failed to discard 1 bottle of Zyrtec with no expiration date on bottle. -The facility failed to store medications appropriately, 7 loose pills were found in the bottom of medication cart drawers. Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 1 medication carts (Medication cart) and 6 of 13 residents (Resident #3. #9, #16, #19, #22, and Resident #24) reviewed for medication storage. -Medication cart for the facility revealed the following:-The facility failed to discard Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -The facility failed to have an open date on Resident #19's Novolog 100units/ml. -The facility failed to discard Resident #16's Lantus 100units/ml with open date of 06/03/2025. -The facility failed to discard Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-The facility failed to have an open date on Resident #3's Novolog 100units/ml. -The facility failed to have an open date on Resident #3's Glargin-YFGN Injection pen. -The facility failed to have an open date on Resident #24's Novolog FlexPen. -The facility failed to discard Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -The facility failed to have an open date on Resident #22's Novolog FlexPen. -The facility failed to have an open date on Resident #9's Trelegy inhaler. -The facility failed to discard 1 bottle of Zyrtec with no expiration date on bottle. -The facility failed to store medications appropriately, 7 loose pills were found in the bottom of medication cart drawers. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included:During an observation on 07/07/25 at 9:43 AM the medication cart for the facility revealed the following:-Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -Resident #19's Novolog 100units/ml with no open date on bottle or box. -Resident #16's Lantus 100units/ml with open date of 06/03/2025. -Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-Resident #3's Novolog 100units/ml with no open date on bottle or box. -Resident #3's Glargin-YFGN Injection pen with no open date. -Resident #24's Novolog FlexPen with no open date written on pen. -Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -Resident #22's Novolog FlexPen with no open date. -Resident #9's Trelegy inhaler had no open date written on inhaler. -1 bottle of Zyrtec with no expiration date on bottle. -7 loose pills found in the bottom of medication cart drawers. During an interview on 07/07/25 at 10:05 AM ADON stated that a negative outcome for medications not having an expiration date on them was that staff would be unsure when medication expired, and the medication will not be effective for the residents. During an interview on 07/07/25 at 11:32 AM DON stated the negative outcome for having loose pills in the bottom of the medication cart drawers would be that the resident would miss a dose, and the staff doesn't know what the medication would be. DON stated the negative outcome for not having open dates on medications that require one would be the medication could be expired and not effective for the resident. Record review of the facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened.(fluticasone)-expires 6 weeks (50mcg strength) or 2months (100 and 250mcg strengths) after initial use.Novolog and Novolog MixInsulin Glargin (Lantus)Insulin Glargin (Apidra)-Refrigerate until initial use-Expires 28 days after initial use regardless of product storage (refrigerated or room temperature).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food.B. The facility failed to ensure personal items were not in the kitchen prep area. *This tag was written by [NAME]. However, she is out of the office at this time, so I am placing it here to get it turned into Enforcement timely. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. B. The facility failed to ensure personal items were not in the kitchen prep area. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an observation of the kitchen food prep area on 7/7/25 at 9:15 am revealed a pair of sunglasses, 2 cell phones, keys and papers on the kitchen counter prep table in the kitchen. In an observation of the kitchen food prep area on 7/7/25 at 11:30 am, a pair of sunglasses, 2 cell phones, keys and papers on the kitchen counter prep table in the kitchen. Lunch preparations were under way and resident drinks were being prepared on the same counter. In an observation on 7/7/25 at 11:35 am, the DM was observed preparing pork chops for lunch. The DM washed hands and changed gloves then picked up a large stainless bowl and took the bowl to the counter. The DM picked up pork chops, placed the chops into the bowl containing flour, breaded the pork chops with the flour coating, then picked up the stainless bowl with both hands and walked over to the fryer. The DM then shifted the stainless bowl to her hip and placed each pork chop into the fryer with her hands. In an observation on 7/7/25 at 11:40 am the DM was observed to have washed hands and changed gloves. The DM picked up the blender pieces and set up the blender for use. The DM then carried the container of pork chops to the blender table and picked up a knife. The DM began to cut the pork chops with a knife using her gloved hands to hold the meat. The DM touched the meat pieces to see if she had missed any bones then put the meat into the blender with her gloved hands. The DM used her gloved hands to put the pork chops into the blender. The DM then put the lid on the blender and started the blender. During the blending a bone was caught in the blender. The DM took the lid off the blender and took out the bone with her gloved hands, took out the bone and put the lid back on the blender. The DM started the blender again and continued blending the meat. The DM did not change her gloves or wash her hands. The DM stated she realized she had touched the food and should have washed her hands and changed her gloves during the meal preparations. She stated the consequences of the food contamination were cross contamination and could make the residents sick. In an observation of the kitchen food prep area on 7/8/25 at 10:00 am revealed a cell phone on top of a box of trash can liners on the counter of the food prep counter in the kitchen. Next to the personal phone sitting on trash bag liners was a crock pot cooking food for lunch. In an interview on 7/9/25 at 9:30 am, the Registered Dietician (RD) stated she had spoken to the DM about glove changes and hand washing. She stated she had trained staff on hand hygiene and glove changes recently. She stated she had not seen many issues since she had started monitoring the facility in April. She stated she had discussed personal items not being on the counter each time she had gone to the facility. She stated she expected personal items would be put away and would not be on the counter. She stated if the phones were out the staff were probably looking at them and touching them and then touching the food. She stated that would cause cross contamination. She stated she would address all issues with the DM on her next visit. In an interview on 7/9/25 at 10:25 am, the DM stated she did have her phones out on the kitchen prep table. She stated she was not aware she could not have her phone out. She stated she thought that was just for personal drinks. She stated the sunglasses and keys were [NAME] D's. She stated of the glove changes and hand hygiene she would in-service the staff on hand hygiene again. She stated personal items could cause cross contamination and food borne illness in residents. In an interview on 7/9/25 at 12:40 PM, [NAME] D stated those were his sunglasses on the counter and he was not aware personal items could not be on the kitchen counter. He stated the consequences of personal items in the kitchen would be cross contamination. Record review of the policy dated 2012 titled, Dietary Food Service Personnel Policy and Procedures revealed: All personal belongings (papers, cell phones, purses, etc.) must be kept out of the food preparation area.Do not handle food with bare hands. Remember to change gloves after touching anything that should not contact food. Wash your hands. Before starting work, after coughing.Touching something that is not clean and then handling food can cause food poisoning. All employees receive instruction in sanitation during orientation and thorough in-service training. Record review of the policy dated 2012 titled, Food Safety revealed we will ensure all food items shall be prepared in compliance with all State, Federal and local laws and regulations. Food shall be handled in a safe manner.

CNA B and CNA C did not provide privacy to Resident #10 during incontinent care. Based on observation, interview, and record review, the facility failed to provide each resident personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 1 (Resident #10) of 13 residents reviewed for privacy. CNA B and CNA C did not provide privacy to Resident #10 during incontinent care. This failure could place residents at risk of a lack of dignified existence, lowered self-esteem, or a decreased quality of life. Findings include: During an observation on 07/08/25 at 10:17 AM CNA B and CNA C performed incontinent care for Resident #10. Neither CNA provided privacy for Resident #10. Door and curtain were never closed or pulled at any time during resident care. During an interview on 07/09/25 at 11:08 AM CNA B stated the negative outcome would be that the resident would feel embarrassed, and they do not have privacy. During an interview on 07/09/25 at 11:11 AM CNA C stated the negative outcome for not pulling the curtain or shutting the door was that someone could walk by and see the resident and the resident exposed and the resident could feel embarrassed. During an interview on 07/09/25 at 11:32 AM DON stated that the negative outcome for not providing privacy during resident cares was the resident could feel embarrassed. During an interview on 07/09/25 at 11:37 AM Resident #10 stated that she would like for the door to be shut so that someone would not see her. Record review of facility provided policy titled, Residents Rights, revised 11/28/2016, revealed the following: . The resident has a right to be treated with respect and dignity, .The resident has a right to personal privacy.1. Personal privacy includes accommodations, medical treatment, .

Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records.The facility failed to ensure Resident #15 had orders for his catheter.Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records.The facility failed to ensure Resident #15 had orders for his catheter.These failures could place residents at risk of not receiving necessary care/treatment due to inaccurate medical records.Findings Included:Record review of Resident #15's admission record dated 07/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull), obstructive and reflux uropathy (urine cannot drain through the urinary tract). The onset date for the obstructive and reflux uropathy diagnosis was 06/10/25.Record review of Resident #15's significant change MDS completed on 05/13/25 revealed a BIMS of 2 which indicated severely impaired cognition. Resident #15 was not coded as having a catheter.Record review of Resident #15's care plan revealed he had a catheter due to his obstructive uropathy diagnosis. This focus area was initiated on 06/12/25 and revised on 06/17/25. The goal was, The resident will be/remain free from catheter-related trauma through review date [sic] The goal was revised on 07/01/25 Interventions listed included, Change the catheter as ordered. Monitor and document intake and output . Monitor/record/report to MD for s/sx UTI: . The interventions were initiated on 06/12/25. The intervention to Change the catheter as ordered. was revised on 07/01/25.Record review of Resident #15's active orders dated 07/08/25 revealed no mention of his catheter. He did have the following order with start date of 07/07/25: Macrobid Oral Capsule (Nitrofuratoin Monohyd Macro) Give 100 mg by mouth two times a day for UTI for 7 days.Record review of Resident #15's discontinued, struck out, and/or completed orders revealed the following orders with start date of 06/10/25 and end date of 06/15/25: Change Foley Catheter using 16 fr 10 ml bulb one time a day every 30 day(s)Empty drainage bag every shiftMonitor F/C q shift for leakage, blockage, sediment buildup, or low outputUrinary Catheter 16 F to gravity drainageEnsure foley bag is in privacy bag while in bed or w/c every shiftEnsure catheter strap in place and holding every shift . change as needed.Record review of Resident #15's MAR and TAR for June and July 2025 revealed no mention of a catheter.During an observation and attempted interview on 07/07/25 at 09:31 AM Resident #15 was reclined in a geri chair in his room. He was dressed in a T-shirt and a brief was visible on his left hip. A blanket covered his legs and right hip. No catheter or tubing was visible. He was unable or unwilling to answer when asked if he had a catheter.During an observation on 07/07/25 at 12:39 PM Resident #15 was seated in the dining room in a geri chair. No catheter or tubing was visible.During an interview on 07/09/25 at 09:21 AM RN A stated she worked for the facility PRN. She stated Resident #15 had a catheter and she and CNAs were responsible for doing catheter care. She stated only nurses were responsible to change a catheter. RN A stated nurses would know when to change Resident #15's catheter by referring to his physician orders. She stated the information would be in the TAR regarding catheter care. RN A stated a resident with a catheter and no physician's orders regarding the catheter could get a catheter associated infection due to lack of catheter care. She stated nurses could put orders in a Resident's chart and inaccurate medical records could negatively affect resident care.During an observation and interview on 07/09/25 at 09:56 AM DON stated Resident #15 had a catheter. She stated she, ADON, and charge nurses were responsible for changing his catheter. DON stated nurses would know when to change a catheter and what size to use because they would refer to the order. She stated nurses were not trained regularly on catheter care as it is part of nursing school. DON searched her computer for orders for Resident #15's catheter. She stated, I don't see some (orders). She stated Resident #15 had his catheter out for a little while and then it was placed back in by hospice nurses and the orders were never put back into his chart. She stated she, ADON, and charge nurses were responsible for entering orders into resident charts. She stated inaccurate medical records could negatively affect residents. DON stated without orders for catheter care a resident could be negatively affected because you wouldn't be able to know when to change or document that you were changing it (the catheter).During an interview on 07/09/25 at 10:04 AM MDS LVN stated Resident #15 had a catheter. She stated inaccurate medical records, such as a resident with a catheter and no orders for the catheter could negatively affect residents. She stated without orders for a catheter in the chart, staff would not know when to change the catheter, would not document urine output, might not recognize s/sx of UTI, or know if the catheter was kinked or the resident was having trouble with the catheter. She stated nurses and CNAs were responsible for catheter care.During an interview on 07/09/25 at 10:09 AM ADM stated nurses were responsible for changing catheters. He stated residents might not receive needed treatment if their medical records were inaccurate.Record review of facility policy titled Documentation and dated 2003 revealed the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

-ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 of 13 residents (Resident #1) reviewed for infection control. -ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. These deficient practices could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 07/07/25 at 11:37 AM ADON was observed going into Resident #1's room to perform a blood glucose check and did not don a gown to perform this task. ADON placed the container of glucose strips on the bedside table of Resident #1 who was on contact precautions for MRSA. ADON did not wipe glucose strip bottle when she removed it from Resident #1's room and placed it back in the medication cart. During an observation on 07/08/25 at 08:18 AM ADON went into Resident #1's room to administer IV medications and did not don a gown. During an interview on 07/08/25 01:32 PM ADON stated the negative outcome for not cleaning the glucose strip container and not donning a gown was I can spread whatever they (Residents that are on EBP) have to other residents. During an interview on 07/09/25 at 11:03 AM DON stated the negative outcome for not donning a gown during prolonged care for a resident who was on EBP could lead to the spread of infection to other residents. DON stated the negative outcome for not cleaning equipment properly would also lead to cross contamination. Record review of facility provided policy titled, Enhanced Barrier Precautions, dated 04/01/2024, revealed the following:.Donning PPE for Residents on EBP based on activity provided/assistance while in resident room.Device care or use: central line, .Any other high-contact activity that includes close bodily contact or coming into contact.

Based on observation, interview and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all food items being served to residents, were within their expiration or best by dates. This failure could place residents at risk of food-borne illness and a diminished quality of life. Findings included: On [DATE] beginning at 9:31AM an initial observation of the kitchen was conducted. An observation of the dry panty revealed: (3) 5-ounce cans LaChoy Chow Mein Noodles with expiration date [DATE]. (1) 5-ounce can LaChoy Chow Mein Noodles with expiration date [DATE]. (4) 3-ounce cans LaChoy Asian-style Crunchy Noodles with expiration date [DATE]. (1) 19-ounce can Progresso Chicken and Sausage Gumbo Soup with expiration date [DATE]. (2) partial 15-ounce bottles of Lime Juice with exp. date of [DATE]. Refrigerate after opening stamped on both bottles by manufacturer. Both were in dry pantry. (1) 2-pound bag Honey Nut Cereal Rounds-no date received. 2 loaves white bread with no date received and a best by date of [DATE]. 2 loaves white bread with no date received and a best by date of [DATE]. An observation of the freezer revealed: (1) partial 3-pound bag of frozen triple berry blend fruit-open to air. (1) partial 2-pound zip seal bag of tortilla quarters-no label/no date. An observation of the refrigerator revealed the following: (5) 30 count fresh eggs-with no date received or use by date. (1) partial 12-ounce bottle of brown mustard with exp. date [DATE]. An interview with the Dietary Manager on [DATE] at 1:13PM revealed the negative outcome of serving residents expired food would be sickness, interaction with medications and possible food aversions, if residents were aware of which food(s) made them sick. Record review of the facility's Sanitation and Food Handling Policy and Procedure dated 2012 revealed: o All unused food must be securely covered. All items are to be labeled and dated as to their content. o Stock is to be rotated on a first in, first out basis. Record review of the facility's Food Safety Policy and Procedures dated 2012 revealed: o Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. o Do not keep potentially hazardous foods in refrigerator past the labeled expiration date. Record review of the facility's undated Recommended Maximum Storage Period of Unopened Food revealed: o Eggs in shell: Follow expiration date.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 5 Residents (Resident #1) reviewed. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #1. This failure could place all newly admitted patients at risk for lack of care, needs not being met, and goals not targeted towards the individual needs of the resident. Findings Included: Record review of Resident #1's face sheet, undated, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to Systemic Lupus (autoimmune disease), Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints), and Diabetes Mellitus (body has high sugar levels for prolonged periods of time) with unspecified complications. Record review of Resident #1's care plans, undated, showed a care plan beginning on 10/31/23. Further review revealed no baseline care plan completed. Record review of care plan assessments completed for Resident #1 since admission did not show a baseline care plan. An interview with ADON on 10/31/23 at 1:39 PM revealed that everyone does the care plans, but MDS C was who was in charge of the assessments and submitting the care plans. MDS C scheduled the meetings. ADON stated that baseline must be done withing 24 hours of admission and the admission nurse oversees completing the baseline care plans. ADON stated a negative outcome can be quality of care. In an interview with MDS C on 10/31/23 at 1:42 PM revealed that she (MDS C) oversees the MDS assessments and care plans. MDS C stated that the baseline care plan had to be completed within 24 hours and they were part of the admission process. Entry MDS was done and sent in, then they had 14 days to complete the MDS assessment and then 7 days after that to finish the care plan. They had a regional nurse above them that reviews the assessments and care plans all the time; above her there was a whole team of people who were constantly auditing them. MDS C stated that the regional nurse comes in one to two times a quarter and she was always in their charts. They sent a report once a week and her (Resident #1) care plan was not triggered. MDS C stated she did it today. MDS C confirmed the care plan was not done within 48 hours of admission and stated a negative outcome was not knowing much about the resident, what type of food they like, any injuries, and could be on the wrong diet. Baseline care plan policy was not obtained prior to exiting facility.

The facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one room observed for infection control precautions. HK A did not follow transmission-based precautions for a resident under contact precautions by not utilizing PPE while in the room. This failure could place all residents in the facility by exposing them to care that could lead to infection, communicable diseases, and feelings of isolation related to poor hygiene. Findings included: An observation on 10/31/23 at 11:12 AM revealed a resident sitting in Contact Isolation Room on C Hall that had transmission base precautions posted on door for contact precautions. A plastic, 3 drawer container was beside the door with PPE in each drawer. An observation and interview on 10/31/23 at 2:44 PM showed HK A was cleaning the room with contact precautions sign on the door. HK A did not don PPE while in room with transmission-based precautions posted. HK A indicated that housekeeping was to wear PPE when transmission-based precautions were placed on door. HK A stated a negative outcome was that infection can spread to the rest of facility. An interview on 10/31/23 at 2:48 PM, HK B stated that rooms were cleaned one time a day or as needed. HK B confirmed that PPE must be worn if precautions are posted. HK B stated that HK Sup reminds staff if there were any issues. HK B stated a negative outcome was that it was not good for the residents. An interview on 10/31/23 at 2:53 PM, HK Sup stated that infection control training was annually or as needed. Last training was approximately one month ago. HK Sup confirmed contact precautions were posted on the door located in Contact Isolation Room on C Hall. HK Sup stated all staff were required to use PPE and it includes housekeeping. HK Sup stated a negative outcome was the spread of infection. Record review of in-service training report, dated 8/22/23, showed HK A received training for PPE use. Handout for training of donning and doffing PPE included with in- service. Record review of policy titled Infection Control Plan, updated 03/2023, under heading 11- Preventing Infections Related to the Use of Specific Devices, section 5, line 2 stated gowns are also worn by personnel during the care of patients infected with the epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment.

Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 6 residents reviewed for medication errors (Resident #1). RN A incorrectly administered another resident's Metoprolol Tartrate Oral tablet 25mg to Resident #1. The significant medication error caused Resident #1 to have an altered blood pressure requiring transfer to the local hospital for further evaluation. The facility's failure could place residents at risk for adverse reactions, health complications and hospitalization and death. Findings include: Record Review of Resident #1's facility clinical record revealed: Resident #1 was a [AGE] year-old female with an admitted [DATE]. She was admitted to the facility for rehabilitation services after a diagnosis of pneumonia in the community. Resident #1 had diagnoses of pneumonia, unspecified protein calorie malnutrition, chronic pain, unsteadiness on feet, muscle wasting, major depression, single episode. Resident #1 was discharged home on 9/15/23 after the emergency room visit. Record Review of Resident #1's MDS, dated [DATE], indicated the following: Resident #1 had adequate vision and hearing; BIMS-14, was independent in bed mobility, transfers, dressing, and toileting, independent in mobility; had no upper or lower extremity impairment; was occasionally incontinent of bowel and bladder; had some complaints of pain requiring medication; and was at risk for falls. Record Review of the care plan for Resident #1, dated 8/16/23, indicated: Resident #1 was independent in activities of daily living, had pain, and was at risk for falls. Record Review of the Physician's Orders for Resident #1 dated 8/16/23 to 8/31/23 and 9/1/23- 9/30/23, revealed no orders for Metoprolol. Record Review of Resident #1's facility progress notes dated 9/15/23 at 12:03 pm stated: Blood pressure medication Metoprolol administered in error by RN A. Immediate assessment completed. Resident was alert, oriented and has no signs of lethargy or distress. Manual blood pressurewas 82/58. NP notified, and orders received to send resident to the emergency room for closer evaluation. Record Review of the facility, Medication Error Forms, for Resident #1's medication error dated 9/15/23 at 12:04 pm stated: Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed. No signs of lethargy or distress. Manual blood pressure 82/58. NP notified and orders received to transfer resident to emergency room . Record Review of the facility incident report for Resident #1's medication error dated 9/15/23 at 12:05 pm indicated: Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed and resident showed no signs or symptoms of distress or lethargy. Resident had a history of hypotension. Manual blood pressure 82/58. NP notified and orders received to transfer resident to hospital. Resident #1 was alert and oriented. Resident #1 stated she did not feel any different than normal. Resident was oriented to time place and person. Predisposing physiological factors- hypotensive. During an interview on 9/20/23 at 10:00 a.m., RN A stated she was the nurse that committed the medication error while caring for Resident #1. RN A stated she was completing med pass when she was distracted and overwhelmed with other residents asking for her attention and a resident wandering into the covid rooms. She stated was redirecting the wandering resident and trying to assist the other residents with their requests and was not thinking when she gave the Metoprolol to Resident #1 instead of the correct resident. She stated shortly after giving the medication to Resident #1 she realized she had given the medication to the wrong resident. During an interview on 9/20/23 at 1:00 pm, Resident #1's family member (Family Member #2) stated there was no significant problem to Resident #1 after the wrong medication was given. She stated the hospital told her Resident #1 's vital signs were normal, and she did not have any aftereffects of being given the medication. Family Member #2 stated RN A was a good nurse, and she did not give Resident #1 the medication on purpose. During an interview on 9/20/23 at 2:00 pm, the MD stated he was aware of the wrong medication being administered to Resident #1. He stated her blood pressure did go down to the 80's and she was sent to the hospital emergency room . MD stated she did not require any treatment at the emergency room because of this. The MD stated the metoprolol has a 12-hour half-life and within 6 hours we would not expect her to have any ill effects. During an interview on 9/20/23 at 2:45 pm, the DON stated she was notified immediately after the medication error and an assessment was started. The DON stated Resident #1's blood pressure was 82/58. The NP was contacted, and the resident was sent to the emergency room . The DON stated she believed this happened because the nurse was on the way to give the medication and was interrupted with a situation involving another resident needing immediate attention. The DON stated she was responsible for the actions of the nurses and has in-service and trained all the nurses in medication administration. The DON stated the consequences of this incident could be death, confusion, or an allergic reaction of a resident to the wrong medication. During an interview on 9/20/23 at 2:55 pm, the ADM stated she was notified immediately after the medication error and an assessment was started on Resident #1. The ADM stated she thought RN#1 was overwhelmed accidentally gave the medication to the wrong resident. The ADM stated to ensure this does not happen again, all nurses were in-serviced on medication administration and fell ing overwhelmed. The ADM stated the DON was also doing med pass monitoring for the next month. The ADM stated the consequences of a resident getting the wrong medication was death, or an allergic reaction to the wrong medication. Record Review of the facility policy titled, Medication Administration Procedures, dated 2003, stated: Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. Medications prescribed for one resident are not to be administered to any other resident. Medication errors are immediately reported to the resident's physician. In addition, the DON should be notified of any medication errors.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in one of one kitchen reviewed for proper food storage. 1. The facility failed to ensure refrigerated foods were properly labelled and dated. 2. The facility failed to ensure pantry foods were properly labelled, dated, and stored in airtight containers. 3. The facility failed to ensure expired foods and leftovers past the use by date were removed from the refrigerator, pantry, and spice shelf. These failures could place residents at risk for food-borne illness. Findings included: Observation of the upright refrigerator on [DATE] at 09:57 AM revealed the following: -a white plastic tub of chicken base with no date -a resealable plastic bag of what appeared to be slices of ham dated [DATE] -a bag of celery with no date -a resealable plastic bag of what appeared to be tortillas dated [DATE] -a resealable plastic bag of what appeared to be half a green pepper dated [DATE] -mango slices in rectangular plastic package with a use by date of [DATE] -a grocery store produce bag with what appeared to be two nectarines, one of which had two black fuzzy spots the size of dimes on one side -two kiwi in square plastic package dated [DATE] -a resealable plastic bag of what appeared to be half a red onion dated [DATE] -a resealable plastic bag of what appeared to be 4 limes dated [DATE] -a resealable plastic bag of what appeared to be 5 garlic cloves which were orange in color and slimy, dated [DATE] Observation of the spice shelf in the kitchen on [DATE] at 10:06 AM revealed a small opaque white storage tub with lid labelled caramel sauce with a use by date of [DATE]. Observation of the pantry on [DATE] at 10:07 AM revealed the following: -a bag of powdered sugar with no date -an open bag of chocolate chips with no date -a bag of chocolate chips with no date -an open bag of grape drink mix with no date -a bag of lemon gelatin with no date -a 5-gallon opaque white storage tub with lid approximately ,d+[DATE] full of a crumb-like substance no label or date -a large bag of Japanese breadcrumbs open to air with no date -three gallons of lemon juice with expiration dates of [DATE] -4 gallons of mustard in a box with no date -3 cans of cooking spray in a box with no date -2 large cans of mandarin orange slices with dents on the sides of the cans near the top During an interview on [DATE] at 10:18 AM Cook B stated pantry foods should be dated on the top of the packaging. Observation of the chest refrigerator on [DATE] at 10:20 AM revealed a gallon of lemon juice ,d+[DATE] full had an expiration date of [DATE]. Observation of the freezer on [DATE] at 10:25 AM revealed a foil wrapped package labelled cilantro with a use by date of [DATE]. During an interview on [DATE] at 02:21 PM the ADM stated canned goods that are not dented are assumed to be good for consumption indefinitely. During an interview on [DATE] at 03:24 PM the DM stated she and the cooks were responsible for throwing out expired food or food past it's use by date. She stated a possible negative outcome of not throwing out said food was residents could get sick or vomit. During an interview on [DATE] at 03:26 PM Cook C stated part of her job responsibility was to throw out expired food. She stated a possible negative outcome of serving expired food to residents was they could get food poisoning or get sick. During an interview on [DATE] at 09:54 AM the DM stated she and the cooks were responsible to label and date food that comes into the kitchen. She stated a possible negative outcome of having undated and unlabeled food was the food could be spoiled. She stated leftovers were to be dated the date they were made and the date they should be thrown away. The DM stated leftovers were to be thrown away 7 days after they were made. She stated produce was good for two to three weeks. The DM stated she had trained her staff on throwing away expired food and leftovers as well as labelling and dating food properly. During an interview on [DATE] at 09:50 AM Cook C stated the cooks were responsible for labelling and dating food. She stated a possible negative outcome of not labelling and dating food was, We wouldn't know when it was opened or if it is fresh to serve out and people could get sit from that. Cook C stated produce is good for ,d+[DATE] days. She stated leftovers are dated the date they were made and 7 days after that. Cook C stated she had been trained on how to date and label food as well as on throwing out expired food from the pantry, refrigerator, and freezer. Record review of an in-service training report dated [DATE] listed the DM as instructor and revealed the following: Make sure everything it [sic] labeled and dated. Items in fridge must have labels and dates. When it was put in fridge and 7 days out. Record review of facility's policy titled, Storage Refrigerators and dated 2012 revealed the following: .5. Food must be covered, when stored, with a date label identifying what is in the container. Record review of facility's policy titled Dry Storage and Supplies and dated 2012 revealed the following: .3. Dry bulk foods are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of facility's policy titled Food Storage and Supplies and dated 2012 revealed the following: .8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil.If a food has developed such spoilage characteristics it should not be eaten.if possible food spoilage is observed prior to the best by date, the product will be discarded. 9. Perishable and non-perishable foods are classified based on their pH and water content.Perishable items that are refrigerated are dated once opened and used within 7 days .but non-perishable items that are refrigerated once opened should be dated when opened . Record review of facility's policy titled Food Safety and dated 2012 revealed the following: . 2. Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #4, #11 and #13) of 16 residents reviewed for advanced directives. Resident #4 had a DNR is her record that had no information in the Physicians Statement Section and no second signature for the physician. Resident #11 had a DNR in her record with no information in the Two Witnesses Section. Resident #13 was listed in her chart as a full code with a correctly completed DNR present in her medical records. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #4 Record review of the face sheet dated [DATE] in the clinical record for Resident #4 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), hypertension (a condition in which the foresee of the blood against the artery walls is too high), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and aortic stenosis (narrowing of the valve in the large blood vessel branching of the heart), Under the section Advanced Directives Resident #4 was listed as a DNR. Record review of the clinical record for Resident #4 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS 0f 9 indicating she was moderately cognitively impaired, and she required set-up assistance with all her activities of daily living. Record review of the clinical record for Resident #4 revealed a care plan (date initiated [DATE]) with an admitted [DATE] with the following: Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated [DATE] Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated [DATE] In the absence of b/p, pulse, respirations, CPR will not be initiated -date initiated [DATE] Record review of the clinical record for Resident #4 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with a start date of [DATE]) Record review of the clinical record for Resident #4 revealed a DNR dated [DATE] (by Resident #4's adult child) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no second signature for the physician in the All person who have signed above must sign below, acknowledging that this document has been properly completed section. Resident #11 Record review of the face sheet dated [DATE] in the clinical record for Resident #11 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), Parkinson's (a disorder of the central nervous system that affects movements to include tremors), malignant neoplasm of the right and left lung (a fast-growing cancer that spreads to other areas of the body), and malnutrition (lack of proper nutrition). Under the section Advanced Directives Resident #11 was listed as a DNR. Record review of the clinical record for Resident #11 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring one to two-person assistance with activities of daily living. Record review of the clinical record for Resident #11 revealed a care plan (date initiated [DATE]) with an admitted [DATE] with the following: Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated [DATE] Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated [DATE] Focus: Resident requires hospice as evidenced by terminal illness. She has been diagnosed with lung cancer. -Date initiated [DATE] Interventions: -there were no interventions listed related to the DNR process. Record review of the clinical record for Resident #11 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with a start date of [DATE]) Admit to hospice services (with a start dated of [DATE]) Record review of the clinical record for Resident #11 revealed a DNR dated [DATE] (by Resident #11's Medical Power of Attorney) with the following: Section-Two Witnesses-there was no information Section-All person who have signed about must sign below, acknowledging that this document has been properly completed-there was a signature on the Notary line and a notary stamp. Resident #13 Record review of the face sheet dated [DATE] in the clinical record for Resident #13 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), malnutrition (lack of proper nutrition), Lymphoma (a cancer of the lymph system), and schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly. Under the section Advanced Directives Resident #13 was listed as a Full Code. Record review of the clinical record for Resident #13 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 6 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with all her activities of daily living. Record review of the clinical record for Resident #13 revealed a care plan with admitted [DATE] with the following: Focus: Resident is a full code-Date initiated [DATE] Intervention-Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMS -Date Initiated: [DATE] Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of [DATE] with the following order: Full code (with an order date 0f [DATE]) Record review of the clinical record for Resident #13 revealed a DNR dated [DATE] (by Resident #13's Medical Power of Attorney) that was completed correctly. During an interview on [DATE] at 02:36 PM LVN F reported that if a resident was a DNR and she assessed that resident to not have a heart rate and/or pulse then she would not start CPR, she would notify the family, hospice if they were involved with the resident's care, and notify the physician. LVN F attempted to verify Resident #4, Resident #11, and Resident #13's DNR status by the markings placed on each Residents door. LVN F reported that a green sticker will be placed on the resident's door if that resident is a DNR, but the door markings were inconsistent and LVN F reported that she would have to verify each resident's DNR status by the resident information kept at the nurse's station. LVN F checked the master file at the nurse station and reported that the information had not been updated since [DATE] so she would have to check each resident's chart in the computer system. LVN F checked Resident #13's electronic record and reported that Resident #13 was listed as a full code and that she would immediately start CPR and have another staff member contact 911, Resident #11 and Resident #4 were both listed as a DNR on their face sheet in their electronic record and therefor LVN F would not start CPR and would notify family and the physician for Resident #4 and family, physician, and hospice for Resident #11. LVN F was asked to check each resident's DNR form in the electronic record. LVN F reviewed Resident #11's DNR form and reported that it was missing the witness's signature, therefore it was invalid, not a legal document, and that the resident would have to be changed to a full code until the DNR form could be corrected with the right document. LVN F then checked Resident #4 and reported that the DNR form did not have any physician information and therefore was not a legal document and would have to be handled the same as Resident 11's DNR. LVN F then checked Resident #13's electronic record and reported that Resident #13 was a full code. When asked to check the document section of Resident 13's electronic record LVN F found the DNR form, reported that it was filled out correctly as of [DATE], and that Resident #13 would have to be changed to a DNR status. LVN F reported that it was the Social Workers responsibility to ensure that the DNR's were correct and that if the DNR's were not correct then the resident wishes would not be followed. During an interview on [DATE] at 02:52 PM the DON and CN verified that Resident #11 was missing the witness signatures and was not a valid DNR, Resident #4 was missing all the physician information and was not a valid DNR, and Resident #13 was listed as a full code with a valid DNR in her record. Both the DON and CN verified that the social worker was responsible for making sure the DNR's were correct. The DON reported that it would cause problems for the staff, and it could result in the resident, or the families wishes not being followed if the DNR process was not followed correctly. During an interview on [DATE] at 03:21 PM the SW went to the medical records office an pulled the original DNR form for Resident #11 and verified it was missing the witness signature, pulled Resident #4's DNR form and verified it was missing the physician information, and reported that she did not know why both DNR forms were not signed. The SW reported that she would try to do a monthly review of all resident DNR's, and she again reported that she did not know Resident #4 and Resident #11's DNR's were not signed. The SW did report that if the DNR form process is not complete and accurate then it can be a mess because the process will not be followed correctly. The SW reported that she would get both DNR forms corrected immediately. During an interview on [DATE] at 09:17 AM the CN reported that they did an audit of the original medical record charts kept in the medical records office the previous evening and was able to find the original DNR forms for Resident #11 that had the second witness signature that was a notary but when it was copied the witness signature did not copy correctly in the Resident #11's electronic chart or the hospice record which would be the records that staff would access when completing a code and they found the original DNR form for Resident #4 that when copied cut off the bottom of the form to include the physicians signature section and that is the reason why the physicians signature section was missing in the copy placed in Resident #4's electronic chart which would be the record that staff would access when completing a code. The CN reported that the facility was going to implement an immediate in-service with staff to reeducated on the DNR/Code process and implement a monthly audit of all DNR forms to ensure that they are complete and accurate. Record review of facility provided policy titled Do Not Resuscitate Order, revised [DATE], revealed the following: Out of Hospital DNR Form The Out of Hospital DNR form was designed by the Texas Department of Human Services to comply with the requirement as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts. 5. In all cases the form must be signed and dated by two witnesses 11. All validly executed DNR orders will be honored by the facility. Record review of the facility provided policy titled Self Determination End of Life Measures and Advanced Directives, undated, revealed the following: 8. The residents right to execute and advanced directive or make changes to an existing advanced directive .will be recognized an applicable under Texas state law. 11. There are two witnesses required for all advance directive documents . Residents who have completed a valid OOH (Out of Hospital) DNR (Do Not Resuscitate) form will have their wishes be honored. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional 48209 Resident #4 Advance Directives

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #16) of 16 residents reviewed for respiratory care. Resident #16 had orders for oxygen at 5 liters per minute and was receiving oxygen at lower concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organ), shortness of breath, and hypoxia (insufficient levels of oxygen in the tissues of the body for normal life functions). Findings included: Record review of Resident #16's face sheet, dated 05/09/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), anxiety disorder, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), emphysema (a lung disease which results in shortness of breath). Record review of Resident #16's Quarterly MDS, dated [DATE], revealed a BIMS score of 7 out of 15 which indicated severely impaired cognition. He required limited to extensive one-person assistance with bed mobility, transfer, bathing, walking, locomotion and personal hygiene. He was independent in eating and toilet use. The MDS documented a need for oxygen therapy while a resident. Record review of Resident #16's care plan, dated 03/13/23, revealed he had congestive heart failure, emphysema, and chronic obstructive pulmonary disorder with a history of low O2 [oxygen] saturations. The care plan listed an intervention of continuous oxygen at 2-5 liters per minute via nasal cannula. It further noted, Give oxygen therapy as ordered by the physician. The care plan noted the resident had oxygen therapy and medications were to be given as ordered by physician. The care plan noted hospice provided a second concentrator to be kept in the dining room for Resident #16 to use during meals. The care plan again noted the resident was to take oxygen at 2-5 liters per minute via nasal cannula. The care plan noted the resident had altered respiratory status/difficulty breathing/ shortness of breath. Record review of Resident #16's active orders revealed an order by his primary physician, dated 02/24/23, for oxygen via N/C [nasal cannula] at 5 LPM [liter per minute] continuously. Record review of Resident #16's oxygen saturation summary, dated 05/09/23 revealed his oxygen levels were checked between two and five times per day. His oxygen levels dropped below 90% 14 times in the last 3 months. Ten of those times Resident #16 was not receiving oxygen via nasal cannula as ordered but was breathing room air. During an observation on 05/08/23 at 12:26 PM Resident #16 was sitting at a table in the dining room taking oxygen via nasal cannula hooked to a concentrator near his table set at 4.5 liters per minute. He appeared alert and oriented as he ate his lunch. During an observation on 05/08/23 at 01:58 PM Resident #16 was observed sitting in his w/c in the hallway taking oxygen via nasal cannula from a tank on the back of his w/c set to 4 liters per minute. During an observation on 05/08/23 at 02:01 PM Resident #16 was sitting in his w/c in his room taking oxygen via nasal cannula at 4 liters per minute. He was fully dressed and appeared to be sleepy but willing to talk. During an observation on 05/08/23 at 02:25 PM Resident #16 walked from his room to the drink station in the hall without oxygen. During an observation on 05/09/23 at 12:06 PM Resident #16 stood in front of his closet with no oxygen looking for a new shirt to wear. During an observation on 05/09/23 at 12:21 PM Resident #16 was sitting in the dining room with his oxygen via nasal cannula hooked to the oxygen tank on the back of his w/c. The oxygen tank was set to 0 liters per minute. The oxygen concentrator near his table was not on. During an observation on 05/09/23 at 01:29 PM Resident #16 was sitting in his w/c in the hallway. He was taking oxygen via nasal cannula hooked to the tank on his w/c which was set to 3 liters per minute. During an observation on 05/09/23 at 02:42 PM Resident #16 was lying in his bed on his back under a blanket with his eyes closed taking oxygen via nasal cannula hooked to the concentrator near his bed which was set to 3.75 liters per minute. During an observation on 05/10/23 at 08:22 AM Resident #16 was sitting at a table in the dining room eating his breakfast taking oxygen via nasal cannula hooked to the concentrator near his table which was set to 4 liters per minute. During an interview on 05/10/23 at 09:32 AM CNA E stated the nurses were responsible for setting the oxygen concentration levels for residents. She stated if a resident complained to her or showed signs of struggling to breathe, she would get a nurse. During an interview on 05/10/23 at 09:32 AM LVN D stated the nurses were responsible to set the oxygen concentration levels for residents based on the physician's orders. She stated the physician's orders were found in the chart of the resident. LVN D stated a possible negative outcome of a resident taking oxygen at a lower concentration than ordered by the physician was the resident would not be able to breathe well, they would not get the right amount of oxygen. During an interview on 05/10/23 at 09:44 AM RN A stated the nurses were responsible for physically setting the oxygen concentration levels for residents. She stated she knew what level to set a resident's oxygen concentration to by reading the physician's orders in the resident's chart. She stated if a resident took oxygen at a lower concentration than ordered by the physician it could lead to shortness of break and decreased oxygen saturation. RN A stated she cared for Resident #16. When asked why his oxygen concentration levels did not match his orders for 5 liters per minute, RN A got online and looked at Resident #16's orders. She stated he had a new order dated 05/10/23 for oxygen at 4 liters per minute. During an interview on 05/10/23 at 09:49 AM the DON stated the nurses were responsible for setting the oxygen levels for residents to the correct concentration. She stated the nurses found the physician's orders regarding oxygen in the resident's chart. The DON stated a resident receiving oxygen at a lower concentration than ordered by the physician might experience oxygen desaturation. She stated the nurses were responsible for entering physician's orders into the electronic health record. When asked why Resident #16 was not receiving oxygen at the concentration ordered she stated she changed his order that morning because he had an order for 2-5 liters per minute and she knew they were not allowed to have orders with ranges, so she changed it to 4 liters per minute. Record review of facility's policy titled Medication Orders and dated 2003 revealed the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Record review of a facility's policy titled Oxygen Administration and dated 2007 revealed the following: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. 7. Place nasal cannula .in the nares . 9. Turn on oxygen after properly setting volume .

Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 out of 16 residents (Resident #131) whose care plans were reviewed. The facility failed to implement the care plan of Resident #131 in that they did not monitor for and/or document monitoring for complications related to the resident's anticoagulant therapy as called for in the resident's care plan. This failure could place residents at risk of not receiving the care required to meet their medical, nursing, and/or mental and psychosocial needs; and place them at an increased and unnecessary risk for complications such as excessive bleeding. Findings Include: Record review of Resident #131's face sheet, dated 04/13/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #131's active physician orders, dated 04/13/2022, revealed an order with a start date of 04/08/2022 that read [MEDICATION(S)] Tablet 20 mg ([MEDICATION(S)]) Give 20 mg by mouth at bedtime for blood thinner. Record review of Resident #131's care plan, not dated, revealed a focus area titled The resident is on Anticoagulant therapy that had the goal of The resident will be free from discomfort or adverse reactions related to anticoagulant use and interventions for that goal that included Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Record review of Resident #131's TAR for the month of April 2020, dated 04/01/2022 through 04/30/2022, revealed no documentation or evidence of monitoring for complications related anticoagulant therapy. During an interview on 04/14/2022 at 11:30 AM, ADON was asked to help surveyors locate evidence of anticoagulant complication monitoring and documentation for that monitoring for Resident #131. ADON reported she would attempt to locate such evidence. During an interview on 04/14/2022 at 1:26 PM, ADON reported that Resident #131 takes [MEDICATION(S)], which is an anticoagulant blood thinner, and that the resident's care plan indicates that monitoring for complications of the medication should be done and documented. ADON reported that such documentation should be present in the resident's TAR, but it was not present because it was not being documented. ADON reported that it was not being documented in the TAR because the monitoring order was not put into the system by the admitting nurse, which was herself. ADON reported that the admitting nurse, which in this case was her, is responsible for putting a section in the TAR for that type of monitoring for staff to document it. ADON reported that the potential consequences of not performing and/or documenting this type of monitoring include that the resident could experience bruising or excessive bleeding. During an interview on 04/14/2022 at 1:32 PM, DON reported that she was familiar with Resident #131 and that the resident received [MEDICATION(S)], which is an anticoagulant medication. DON reported that the resident's care plan contained an intervention for staff to monitor for side effects of the medication and document that monitoring. DON reported that documentation of that monitoring was not getting done and should have been. DON reported that she did not know why it was not being done, and that potential consequences of it not being done could include DIC (a serious disorder affecting the blood's ability to clot and stop bleeding), bruising, and bleeding. During and observation and interview on 04/15/2022 at 10:02 AM, Resident #131 reported that she takes blood thinner medication and has for years. Resident #131 reported that she bruises easily and currently had bruising but denied having a recent bloody noses or other problems related to bleeding. Resident #131 rolled up her sleeve and presented her left arm on which there was a large area of bruising on the inside of the arm located in the area opposite to her elbow (antecubital space). The resident had no concerns about the bruise stating that it was just something that happens at my age. Record review of facility provided policy titled Comprehensive Care Planning, not dated, revealed in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Record review of facility provided policy titled Anticoagulation - Clinical Protocol, dated November 2018, revealed in part: Monitoring and Follow-Up 2. Staff will monitor for symptoms of abnormal bleeding or clotting.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #6) reviewed for incontinence and catheter care. -Resident #6 was left in her room for 2 hours with her catheter bag on the floor. These deficient practices could place residents at risk for the spread of [CONDITION(S)]/bacterial infections, and poor hygiene. Findings include: Record review of Resident #6's face sheet dated 4-13-2022 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #6's last MDS was a significant change in status completed 4-6-2022 listing her with a BIMS of 9 indicating she was moderately cognitively impaired, and she had a functionality of requiring one-to-two-person assistance with activities of daily living. Record review of Section H titled Bowel and Bladder of Resident #6's 4-6-2022 MDS revealed the following: H0100 Appliances: A, Indwelling Catheter-Resident #6 was marked as having this appliance. During an observation on 04/13/22 at 10:22 AM, Resident #6 was in bed sleeping under her covers. Resident #6 did not wake to knocking or introduction. Resident #6 had her catheter hanging off the left side of the foot of her bed. This surveyor noted 200 cc of amber colored urine in the bag and there was no bag cover. During an observation on 04/14/22 at 08:37 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 09:38 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:06 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:28 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:37 AM, MS entered Resident #6's room and picked Resident #6's catheter bag up off the floor and placed it on Resident #6's bed frame. The Maintenance Supervisor then washed her hands and exited the room. The Maintenance Supervisor reported that the catheter bag should not be on the floor the urine cannot flow right and it's an infection control issue. The Maintenance Supervisor reported that floor staff round every two hours. The Maintenance Supervisor reported that she is the officer for Champion Rounds for this hallway is the reason why she was checking the resident rooms. The Maintenance Supervisor reported that she is a Certified Nurse Aide. During an interview on 04/14/22 at 11:02 AM, CNA A reported that CNAs are supposed to do rounds every two hours and they attempt to do them at 6, 8, 10, 12, 2, etc. CNA A verified that she is currently assigned to Resident #6's hallway and that Resident #6's catheter should not have been on the floor. CNA A reported that a catheter bag left on the floor can get stepped on, it could leak out, and it could not drain right. During an observation and interview on 04/14/22 at 12:46 PM, Resident #6 was up sitting at the side of her bed eating her lunch. Resident #6's catheter was noted hanging from the foot of her bed in a privacy bag. Resident #6 became confused and replied Ok to this surveyor's introduction and questions. Resident #6 was unable to effectively respond to any questions concerning her care, stay, or her catheter care. During an interview on 04/14/22 at 01:21 PM the DON reported that all CNA staff should make rounds every two hours. That a catheter should be stored in a privacy bag that will allow flow to gravity. When advised that a catheter was left on the floor for two hours, the DON reported that a catheter should not be left on the floor. When asked why the DON stated that it could get stepped on, it could be tripped over, and it could cause contamination. The DON verified that all facility direct care staff have been trained on catheter care to include Foley bag storage. The DON then stated, we will do an immediate retraining of all our staff. During an interview on 4/15/2022 at 09:30 AM the DON provided the policy titled Catheter Care and stated, We have looked, and this is the only policy we have that addresses the use of catheter bags. Record review of the facility provided policy titled Catheter Care undated, revealed the following: General Guidelines: 10. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review the facility failed to ensure that its residents are free of any significant medication errors for 1 out of 6 residents (Resident # 1) reviewed. The facility failed to administer IV [MEDICATION(S)] (an antibiotic medication) in a manner that was consistent with accepted professional standards and principles in that the medication was administered without appropriate monitoring to prevent complications from 5/1/21 - 5/9/21 which resulted in Resident # 1 experiencing acute [CONDITION(S)] requiring mechanical ventilation, acute kidney failure requiring [CONDITION(S)], and hospitalization . This failure could affect residents receiving medications with a narrow therapeutic index by placing them at risk of insufficient therapeutic levels required for treatment, medication overdose or toxicity resulting in physical harm, or death. An IJ was determined to have existed from 05/01/2021 through 05/09/2021. This IJ was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The findings include: Record review of Resident # 1's face sheet, dated 05/11/2021, revealed that Resident # 1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 1's admission MDS, dated [DATE], indicated that the resident had a BIMS score of 06 out of 15, indicating severe cognitive impairment. Section G of the MDS indicated that Resident # 1 required extensive assistance from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Section O of the MDS indicated that Resident # 1 received IV medications while a resident within the last 14 days. Section N of the MDS indicated that Resident # 1 received an antibiotic medication on 7 out of 7 days during the look-back period. Record review of Resident # 1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on Resident # 1's active physician orders, dated 05/11/2021, revealed an order to change the dose of the resident's [MEDICATION(S)], with a start date of 05/04/2021, that read [MEDICATION(S)] HCl solution use 1 gram intravenously every 12 hours for UTI for 38 days. The orders did not contain order for laboratory or other monitoring of the [MEDICATION(S)]. Record review of Resident # 1's current care plan, dated 05/11/2021, revealed the following intervention: Give antibiotic therapy as ordered. Monitor/document side effects and effectiveness. Record review of Resident # 1's MAR/TAR for the month of April 2021, not dated, revealed that the resident's doses of [MEDICATION(S)] on 04/30/2021 were documented as not being administered due to lack of drug availability. Record review of Resident # 1's MAR/TAR for the month of May 2021, not dated, revealed that [MEDICATION(S)] was documented as being administered to the resident twice a day on 05/01/2021, 05/02/2021, and 05/03/2021 at a dose of 1.25 grams by IV; and administered to the resident twice a day on 05/04/2021, 05/05/2021, 05/06/2021, 05/07/2021, and 05/08/2021 at a dose of 1 gram by IV. The document revealed no documentation of monitoring for laboratory values, side effects, or effectiveness of the medication. Record review of Resident # 1's laboratory documents revealed a document of labs completed on 04/30/2021 that did not include a serum [MEDICATION(S)] trough level (a laboratory test commonly used to monitor therapeutic levels of [MEDICATION(S)] in the blood), and a document of labs completed on 05/04/2021 that did not include a serum [MEDICATION(S)] trough level. There was a laboratory document dated 05/08/2021 containing a [MEDICATION(S)] trough level for Resident # 1 that resulted 130.4 mcg/mL. The document indicted that this result was critically high, and that the reference (normal) range was 5.0 to 10.0 mcg/mL. Record review of Resident # 1's progress notes for dates of 05/01/2021 through 05/08/2021 revealed no documented evidence of monitoring for lab work, side effects, or effectiveness of [MEDICATION(S)]. The progress notes contained the following notes: A note dated 05/08/2021 at 9:41 PM that read, Stat Order received for Portable 2 view chest x-ray for weakness/comatose, unable to leave facility d/t recent brain surgery/stroke/weakness per [name of MD A]. A note dated 05/09/2021 at 12:46 AM that read Received report from [named of lab] that resident's vanc level is 130.4. Left message for [name of MD A], notified [name of DON] and [name of ADON]. A note dated 05/09/2021 at 1:01 AM that read, Received lab results and faxed to [name of MD A]. A noted dated 05/09/2021 at 5:14 AM that read, Resident remains lethargic but will open eyes at times when touched. No signs of respiratory distress noted. Skin warm and dry to touch. Will continue to monitor. Still waiting results of ex-rays [sic]. An order note dated 05/09/2021 at 9:35 AM that read, Vanc level high Hold till further notice. A note dated 05/09/2021 at 1:40 PM that read, [Named of Resident # 1] was transferred to a hospital on 05/09/2021 12:00 related to Vanc Toxicity. A note dated 05/10/2021 at 6:10 AM that read, Called [name of hospital] to check on resident. They stated she was shipped to [named of another hospital] due to [NAME] being full. They stated she stopped breathing on the way to Lubbock she was intubated and is currently on a vent. DX is Vanc toxicity and altered mental. She is stable at this time. Record review of Resident # 1's hospital records revealed a History and Physical, dated 05/10/2021, that revealed the following in part: Intensivist Assessment/Plan (1) Acute [CONDITION(S)] Problem Specific A/P: Plan by systems: 3. Pulmonary: Intubated for airway protection enroute to the hospital, stable on minimal vent settings. 4. Renal: AKI due to [MEDICATION(S)] toxicity, Nephrology has been consulted and are planning for possible HD later today, monitor I/O closely and replace electrolytes as needed. 10. Prognosis: Guarded. (4) ARF (acute renal failure) (5) [MEDICATION(S)] poisoning During an interview on 05/11/2021 at 9:20 AM, ADM reported that Resident # 1 was admitted to the facility on [DATE] with an order to receive [MEDICATION(S)] but did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADM reported that the facility drew a trough level on 05/08/2021 that resulted as being critical high and the patient became unresponsive on 05/09/2021. ADM reported that after the [MEDICATION(S)] had been placed on hold due to the lab result, the resident was sent to a local hospital. ADM reported that the local hospital transferred the resident to a larger hospital where the resident remains with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ADM reported that the facility reported this incident to the State agency, in-serviced staff, conducted a QA review of the incident, in-serviced staff, and acquired new standing orders for [MEDICATION(S)] trough levels to be drawn on residents receiving the medication. During an interview on 05/11/2021 at 9:46 AM, LVN B reported that she was familiar with the medication [MEDICATION(S)]. When asked about the nursing considerations for [MEDICATION(S)] LVN B reported that when administering the medication, a nurse should, monitor for signs and symptoms of toxicity and check trough levels. When asked why trough levels are important when administering [MEDICATION(S)], LVN B replied, to ensure the resident is getting the right amount, not too low and not too much. When asked about the signs and symptoms of [MEDICATION(S)] toxicity, LVN B reported that they were, redness of skin, lethargy, and confusion. LVN B stated that she was never assigned to care for Resident # 1. During an interview on 05/11/2021 at 10:05 AM, LVN C reported that she was familiar with the medication [MEDICATION(S)]. When asked about the nursing considerations for [MEDICATION(S)] LVN C reported that when administering the medication, a nurse should, you need to be very careful about getting a trough level drawn, at least an hour before every fourth dose. When asked why trough levels are important when administering [MEDICATION(S)], LVN C replied, So you can see if they're in a therapeutic level of if they're getting too much of it. When asked what types of things can happen if a patient gets too much [MEDICATION(S)], LVN C replied, They could go into shock, red man syndrome, respiratory drive would shut down. When asked about the signs and symptoms of [MEDICATION(S)] toxicity, LVN C reported that they were, flushing, redness, paresthesia, unresponsiveness, irregular or excessive respirations. LVN C reported that she had cared for Resident # 1 before and that, to her knowledge, a [MEDICATION(S)] trough had been drawn only once while the resident was in the facility on 05/08/2021. LVN C reported that Resident # 1 was receiving [MEDICATION(S)] for a UTI. LVN C stated, It should have been done more often. One hour before every fourth dose. During a telephonic interview on 05/11/2021 at 10:25 AM, FM D reported that she was Resident # 1's family member and representative. FM D reported that Resident # 1 received [MEDICATION(S)] while in the facility, and believed it was for the resident's brain [CONDITION(S)], but was not certain. FM D reported that she was informed of Resident # 1's recent hospitalization immediately by the facility, and that the facility apologized to her because they had made a mistake. FM D reported that Resident # 1 was still in the hospital in the ICU on a ventilator and was getting [CONDITION(S)] to flush her kidneys out due to the antibiotic being in her blood. FM D reported that the hospital staff have told her that Resident # 1 got too much antibiotic without getting some kind of test done. During an interview on 05/11/2021 at 11:16 AM, ADON reported that she was familiar with the medication [MEDICATION(S)]. When asked about the nursing considerations for [MEDICATION(S)] ADON reported that when administering the medication, a nurse should, monitor the levels. When asked to clarify her response, ADON replied, draw a trough however often a doctor orders, typically every fourth dose. ADON was asked what a nurse should do if no orders are present for such lab work and replied, you need to call and get one. When asked about the potential consequences of not properly monitoring [MEDICATION(S)], ADON replied, kidneys shut down, rash, toxicity, altered mental status. ADON reported that she was familiar with Resident # 1 and that the resident was currently in the hospital for [MEDICATION(S)] toxicity and altered mental status. That's what they (hospital staff) told me when I called and checked on her. ADON confirmed that the facility was not monitoring Resident # 1's [MEDICATION(S)] trough levels, and when asked why they were not doing so ADON replied, I don't even have an answer for that, overlooked, I honestly don't know. We should have added that to the admitting labs and got the orders for however they wanted it done. ADON reported that Resident # 1's [MEDICATION(S)] trough was checked once on 05/08/2021 after the resident began acting differently and they received an order to do so from the resident's provider. ADON reported that [MEDICATION(S)] troughs should have been being done. During an interview on 05/11/2021 at 11:24 AM, DON reported that she was familiar with the medication [MEDICATION(S)] and that nursing considerations for the medication include, it can have a toxic level, so lab draws, assess IV site, monitor for adverse reactions. DON was asked how [MEDICATION(S)] levels are typically monitored and replied, draw trough, peak and trough. DON was asked how often [MEDICATION(S)] trough levels should be drawn and replied, usually after every third dose, depends on the doctor, some are weekly. Our procedure here, now, will be every third dose. DON was asked what her expectations are if a new resident admits with orders for [MEDICATION(S)] but without orders for lab monitoring, and DON replied, to call physician before administering any for lab orders. DON continued to state, now we have standing orders for them. DON was asked about the potential consequences of not monitoring [MEDICATION(S)] and replied, acute renal failure, altered mental status, vanc toxicity, [CONDITION(S)]. The patient could be harmed. DON was asked why Resident # 1 was currently in the hospital and replied, acute renal failure and [MEDICATION(S)] toxicity, the acute renal failure is due to the toxicity. DON was asked why Resident # 1 ended up with [MEDICATION(S)] toxicity and replied, we didn't draw any troughs, we didn't have any orders to draw troughs. DON was asked why they never got orders to draw [MEDICATION(S)] trough levels for Resident # 1 and replied, I don't know. There was a breakdown in communication between us and [name of another facility], we didn't' communicate with our provider to get orders. During a telephonic interview on 05/11/2021 at 11:54 AM, MD A reported that when a resident is receiving [MEDICATION(S)] it is monitored by trough levels that are typically checked every third dose, or fourth dose, either way they're checked frequently, and BUN and creatinine weekly. MD A reported that he and his provider staff had provided orders for Resident # 1 to have [MEDICATION(S)] trough levels drawn regularly at a previous facility, and that they had presumed those orders followed the resident to the new facility. MD A was asked what he expects of facility staff if a resident is admitted without [MEDICATION(S)] trough orders but is order the medication and replied, Our anticipation would be that they would give us a call and gotten some lab orders. During a telephonic interview on 05/11/2021 at 12:43 PM, LVN E reported that she was the nurse that admitted Resident # 1 to the facility on [DATE]. LVN E reported that Resident # 1 was in the hospital and claimed the reason was for [MEDICATION(S)] toxicity. LVN E reported that the resident had orders for [MEDICATION(S)] when she was admitted , and when asked about lab orders, LVN E stated, I can't honestly say if she had orders for labs or not. I don't think she had orders for labs. LVN E was asked if she was aware of any labs that should be ordered for patients on [MEDICATION(S)] and reported, trough level. LVN E claimed that she sent a text message to FNP F, who is a provider under MD A, to verify Resident # 1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN E reported she did not notice the text message from FNP F until the evening of 04/30/2021, when she was no longer at work. LVN E reported that she never told anyone at the facility about the text message from FNP F because, I told them about the [MEDICATION(S)] in report the night before. I just assumed it would've been taken care of. LVN E could not recall the name of the nurse she gave report to. During an interview on 05/11/2021 at 2:15 PM, DON reported that she was just made aware that LVN E, the nurse who admitted Resident # 1, had received orders by text message from a provider that included [MEDICATION(S)] trough orders. DON reported that LVN E will be coached and staff will be in-serviced not to text message providers or accept text messages from providers regarding orders, and that such action must be conducted in person or by telephone conversation. DON reported that they have been trying to contact FNP F, and at such time they are able to contact her, it will be requested that she no longer use text messaging with staff. FNP F could not be contacted for interview during the investigation. Record review of facility provided policy titled Medication Administration Procedures, dated 10/25/ , revealed in part: 13. When ordered or indicated, Include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. Record review of label information for [MEDICATION(S)] [MEDICATION(S)] for injection by the United Stated Food and Drug Administration, dated 07/2018, and accessed on 05/11/2021 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/ 1s000lbl.pdf, revealed in part: HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use [MEDICATION(S)] [MEDICATION(S)] FOR INJECTION safely and effectively. See full prescribing information for [MEDICATION(S)] [MEDICATION(S)] FOR INJECTION. WARNINGS AND PRECAUTIONS Nephrotoxicity: Systemic [MEDICATION(S)] exposure may result in acute kidney injury (AKI) including acute renal failure, mainly due to interstitial [CONDITION(S)] or less commonly acute tubular necrosis. Monitor serum [MEDICATION(S)] concentrations and renal function. (5.2) Ototoxicity: Ototoxicity has occurred in patients receiving [MEDICATION(S)] [MEDICATION(S)]. Monitor for signs and symptoms of ototoxicity during therapy. Monitor serum [MEDICATION(S)] concentrations and renal function. Assessment of auditory function may be appropriate in some instances. (5.3) 5.2 Nephrotoxicity Monitor serum [MEDICATION(S)] concentrations and renal function in all patients receiving [MEDICATION(S)] [MEDICATION(S)] for Injection. 5.3 Ototoxicity Monitor for signs and symptoms of ototoxicity during therapy. Monitor serum [MEDICATION(S)] concentrations and renal function in all patients receiving [MEDICATION(S)] [MEDICATION(S)]. Record review of facility provided in-service, dated 05-10-2021, revealed the following in part: ISSUE: [MEDICATION(S)] being administered without obtaining orders and drawing trough levels. Nursing staff is to obtain orders from physician for trough levels. Before administering [MEDICATION(S)]. Nursing staff to obtain lab orders for all medications that have toxic capabilities upon receiving orders for the medication. The in-service sign-in sheet indicated that it was attended by DON, ADON, LVN B, LVN C, and LVN E in addition to other staff. Record review of facility provided standing order title [MEDICATION(S)] protocol, not dated, and implemented after the incident involving Resident # 1 but prior to the investigation, revealed in part: [MEDICATION(S)] Protocol All patients admitted to the facility with orders for IV [MEDICATION(S)] shall be placed on this protocol. 1. [MEDICATION(S)] trough before the first dose administered in the facility. Then, [MEDICATION(S)] trough shall be drawn prior to each fourth dose thereafter. 2. A BMP shall be drawn on each Monday and Thursday while the patient is on [MEDICATION(S)] to check the BUN and creatinine. 3. All laboratory levels shall be delivered to the provider directly in person or by speaking t the provider over the phone. Please do not fax results without direct verification of delivery. [name of MD A] It was determined these failures placed Resident # 1 in an IJ situation from 05/01/2021 through 05/09/2021. The facility took the following actions to correct the non-compliance on 05/10/2021: conducted a QA review of facility practices related to laboratory monitoring for [MEDICATION(S)] administration, acquired standing orders for [MEDICATION(S)] laboratory monitoring from facility medical director, developed a [MEDICATION(S)] monitoring form to be used during [MEDICATION(S)] administration that tracks dose administration and laboratory monitoring, audited residents' charts for laboratory order compliance and missing orders, and in-serviced facility charge nurses regarding [MEDICATION(S)] administration and monitoring.

Based on observation, interview and record review the facility failed to ensure [MEDICAL CONDITION] medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 13 of 16 residents (Resident #2, Resident #6, Resident #11, Resident # 16, Resident #18, Resident #19, Resident #20, Resident #23, Resident #24, Resident #25, Resident #33, Resident #35, and Resident #37) reviewed for unnecessary medications. -Resident #2 was receiving an antidepressant medication ([MEDICATION NAME]) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #6 was receiving an antipsychotic medication ([MEDICATION NAME]) and two antidepressant medications ([MEDICATION NAME] and [MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #11 was receiving an antidepressant medication ([MEDICATION NAME]) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #16 was receiving an antipsychotic medication ([MEDICATION NAME]), a sedative/antianxiety medication ([MEDICATION NAME]), and an antidepressant medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #18 was receiving an antidepressant medication ([MEDICATION NAME]) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #19 was receiving two antidepressant medications ([MEDICATION NAME] and [MEDICATION NAME]) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #20 was receiving an antidepressant medication (duloxetine) without adequate side effect or efficacy monitoring. -Resident #23 was receiving an antianxiety medication ([MEDICATION NAME]), two antipsychotic medications (paliperidone and aripiprazole), and an antidepressant medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #24 was receiving an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #25 was receiving an antidepressant medication ([MEDICATION NAME]), an antianxiety medication ([MEDICATION NAME]), and an antipsychotic medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #33 was receiving an antidepressant medication (duloxetine) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #35 was receiving two antidepressant medications ([MEDICATION NAME] and [MEDICATION NAME]) and an antianxiety medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. -Resident #37 was receiving an antidepressant medication ([MEDICATION NAME]) without adequate side effect or efficacy monitoring. This failure has the potential to affect residents at the facility by exposing them to unnecessary or unmonitored drug side effects, missed effects, and adverse reactions. Findings Include: Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male with a current admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score 05 out of 15, indicating severe cognitive impairment. The MDS indicated that he required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, and toilet use; and was totally dependent on staff for personal hygiene. Section N of the MDS indicated that Resident #2 received an antidepressant medication and an antianxiety medication on 7 out of 7 days during the look back period. Record review of Resident #2's physician orders [REDACTED]. Record review of Resident #2's comprehensive care plan revealed a focus area titled (Resident #2) requires antidepressant medication [MEDICATION NAME] with an intervention that read Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, [MEDICAL CONDITIONS]. Record review of Resident #2's comprehensive care plan revealed a focus area titled (Resident #2) has a PRN order for anti-anxiety medication [MEDICATION NAME] if needed with an intervention that read Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. Record review of Resident #2's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). Resident #6 Record review of Resident #6's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's MDS, dated [DATE], revealed a BIMS of 8 of 15 showing moderate cognitive impairment. Her functional status revealed she needed limited 1-person assistance with her ADLs. Section N of the MDS indicated that Resident #2 received an antidepressant medication and an antianxiety medication on 7 out of 7 days during the look back period. Record review of Resident #6's physician's orders [REDACTED]. Record review of Resident #6's comprehensive care plan revealed a focus area titled (Resident #6) requires [MEDICAL CONDITION] medications and a intervention that read Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #6's comprehensive care plan revealed a focus area titled (Resident #6) has potential for depression new admission misses family and an intervention that read Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #6's clinical record revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]). Resident #11 Record review of Resident #11's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #11's MDS dated [DATE] revealed a BIMS score 04 out of 15, indicating severe cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, and toilet use; and was totally dependent on staff for personal hygiene. Section N of the MDS indicated that Resident #11 received an antidepressant medication on 7 out of 7 days during the look back period. Record review of Resident #11's physician orders [REDACTED]. Record review of Resident #11's comprehensive care plan revealed a focus area titled (Resident #11) requires antidepressant medication for [DIAGNOSES REDACTED]. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, [MEDICAL CONDITIONS]. Record review of Resident #11's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). Resident #16 Record review of Resident #16's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Tubulo-Interstitial [MEDICAL CONDITION], Dementia With Behavioral Disturbance, [MEDICAL CONDITION] Not Due To A Substance or Known Physiological Condition, [MEDICAL CONDITION] Disorder, Anxiety Disorder, Noninfective Gastroenteritis and [MEDICAL CONDITIONS], and Major [MEDICAL CONDITION]. Record review of Resident #16's MDS, dated [DATE], revealed a BIMS of 7 of 17 showing moderate to severe cognitive impairment. Her functional status revealed she needed limited to extensive assistance with all ADLs. Section N of the MDS indicated that Resident #16 had received an antianxiety medication and an antidepressant medication 7 out of 7 days during the look back period. Record review of Resident #16's physician's orders [REDACTED]. Record review of Resident #16's comprehensive care plan revealed a focus area titled (Resident #16) uses anti-anxiety medications r/t Anxiety disorder with an intervention that read Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. Record review of Resident #16's comprehensive care plan revealed a focus area titled (Resident #16) behavior problem of picking at face and arms and causing sores d/t anxiety with an intervention that read Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #16's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]). Resident #18 Record review of Resident #18's face sheet revealed a [AGE] year-old male with a current admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #18's quarterly MDS dated [DATE] revealed a BIMS score 02 out of 15, indicating severe cognitive impairment. The MDS indicated that he required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Section N of the MDS indicated that Resident #18 received an antidepressant medication on 7 out of 7 days during the look back period. Record review of Resident #18's physician orders [REDACTED]. Record review of Resident #18's comprehensive care plan revealed a focus area titled (Resident #18) requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED]. Record review of Resident #18's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). Resident #19 Record review of Resident #19's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #19's MDS dated [DATE] revealed a BIMS score 08 out of 15, indicating moderate cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Section N of the MDS indicated that Resident #19 received an antidepressant medication and an antianxiety medication on 7 out of 7 days during the look back period. Record review of Resident #19's physician orders [REDACTED]. Record review of Resident #19's comprehensive care plan revealed a focus area titled (Resident #19) has a [DIAGNOSES REDACTED]. Monitor/document for side effects and effectiveness. Record review of Resident #19's comprehensive care plan revealed a focus area titled (Resident #19) requires [MEDICAL CONDITION] medications [MEDICATION NAME]. with interventions that read Administer medications as ordered. Monitor/document for side effects and effectiveness and Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [REDACTED]. Record review of Resident #19's comprehensive care plan revealed a focus area titled The resident requires antidepressant medication ([MEDICATION NAME]) for [DIAGNOSES REDACTED]. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, [MEDICAL CONDITIONS]. Record review of Resident #19's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). Resident #20 Record review of Resident #20's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #20's quarterly MDS dated [DATE] revealed a BIMS score 10 out of 15, indicating moderate cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Section N of the MDS indicated that Resident #20 received an antidepressant medication on 7 out of 7 days during the look back period. Record review of Resident #20's physician orders [REDACTED]. Record review of Resident #20's comprehensive care plan revealed a focus area titled (Resident #20) requires antidepressant medication [MEDICATION NAME] for [DIAGNOSES REDACTED]. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, [MEDICAL CONDITIONS]. Record review of Resident #20's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medication (duloxetine). Resident #23 Record review of Resident #23's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #23's MDS, dated [DATE], revealed a BIMS of 10 of 15 showing moderate cognitive impairment. Her functional status revealed she required supervision for all ADLs except walking, which she needed limited assistance. Section N of the MDS indicated Resident #23 had received an antipsychotic medication, and antianxiety medication, and an antidepressant medication 7 out of 7 days during the look back period. Record review of Resident #23's physician's orders [REDACTED]. day. Record review of Resident #23's comprehensive care plan revealed a focus area titled (Resident #23) The resident requires [MEDICAL CONDITION] medications [MEDICATION NAME] and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Monitor/document for side effects and effectiveness and Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol and Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [REDACTED]. Record review of Resident #23's comprehensive care plan revealed a focus area titled The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date with an intervention that read Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. The resident is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor (FREQ) for safety. Record review of Resident #23's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medication (aripiprazole, [MEDICATION NAME], paliperidone [MEDICATION NAME], and [MEDICATION NAME]). Resident #24 Record review of Resident #24's face sheet revealed a [AGE] year-old female with an admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #24's quarterly MDS dated [DATE] revealed a BIMS score 10 out of 15, indicating moderate cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Record review of Resident #24's physician orders [REDACTED]. Record review of Resident #24's comprehensive care plan revealed a focus area titled (Resident #24) requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED]. Monitor/document for side effects and effectiveness. Record review of Resident #24's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medication ([MEDICATION NAME]). Resident #25 Record review of Resident #25's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #25's quarterly MDS dated [DATE] revealed a BIMS score 04 out of 15, indicating severe cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Section N of the MDS indicated that Resident #25 received an antidepressant medication, antianxiety medication, and antipsychotic medication on 7 out of 7 days during the look back period. Record review of Resident #25's physician orders [REDACTED]. Record review of Resident #25's comprehensive care plan revealed a focus area titled The resident requires [MEDICAL CONDITION] medications [MEDICATION NAME] for [DIAGNOSES REDACTED]. Monitor/document for side effects and effectiveness. Record review of Resident #25's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]). Resident #33 Record review of Resident #33's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident 33's quarterly MDS dated [DATE] revealed a BIMS score 11 out of 15, indicating moderate cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility and personal hygiene; and limited assistance from staff with transfers, dressing, and toilet use. Section N of the MDS indicated that Resident #33 received an antidepressant medication on 7 out of 7 days during the look back period. Record review of Resident #33's physician orders [REDACTED]. Record review of Resident #33's comprehensive care plan revealed a focus area titled The resident requires antidepressant medication for [DIAGNOSES REDACTED]. Monitor/document for side effects and effectiveness and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Record review of Resident #33's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME] and duloxetine). Resident #35 Record review of Resident #35's face sheet revealed an [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident 35's quarterly MDS dated [DATE] revealed a BIMS score 07 out of 15, indicating severe cognitive impairment. The MDS indicated that she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Section N of the MDS indicated that Resident #35 received an antidepressant medication on 7 out of 7 days and an antianxiety medication on 6 out of 7 days during the look back period. Record review of Resident #35's physician orders [REDACTED]. Record review of Resident #35's clinical records revealed no evidence of staff monitoring for the potential side effects or the efficacy of the resident's prescribed [MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]). Resident #37 Record review of Resident #37's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED].