Every finding on record at Mescalero Care Center

Based on record review and interview, the facility failed to provide the required transfer information for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for transfers when staff failed to: 1. Notify R #8, R #9, and R #10 and their representative(s) of the residents' transfer to the hospital in writing and in a language and manner they understand.2. Ensure R #8, R #9, R #10 and their representative(s) receive a written notice of bed hold which indicated the duration the resident's bed would be held.These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the transfer, the location of the transfer, their rights to advocate and make informed decisions. The findings are:R #8A. Record review of R #8's admission Record, no date, revealed R #8 was admitted to the facility on [DATE]. B. Record review of R #8's nursing progress notes, revealed the following:1. On 03/21/26 R #8 was sent to the hospital due to altered mental status.2. On 05/29/26 R #8 was sent to the hospital due to nausea and vomiting. C. Record review of R #8's Bed Hold Notification, dated 03/21/26, revealed staff did not document the number of days the bed will be held, or the amount the bed hold would cost R #8 after the number of days held. D. Record review of R #8's medical record revealed staff did not complete the following:1. A Bed Hold Notification for R #8's transfer to the hospital on [DATE].2. A transfer notice to the hospital on [DATE] or 05/29/26. R #9E. Record review of R #9's admission Record, no date, revealed R #9 was admitted to the facility on [DATE]. F. Record review of R #9's nursing progress notes, revealed on 04/11/26 R #9 was sent to the hospital due to altered mental status. G. Record review of R #9's Bed Hold Notification, dated 04/11/26, revealed staff did not document the number of days the bed will be held, or the amount the bed hold would cost R #9 after the number of days held. H. Record review of R #9's medical record, no date, revealed staff did not complete a transfer notice to the hospital on [DATE]. R #10I. Record review of R #10's admission Record, no date, revealed R #10 was admitted to the facility on [DATE]. J. Record review of R #10's nursing progress notes, revealed R #10 was sent to the hospital due to dehydration on 05/30/26 K. Record review of R #10's medical record, no date, revealed staff did not complete the following:1. A Bed Hold Notification for R #10's transfer to the hospital on [DATE].2. A Transfer Notification for R #10's transfer to the hospital on [DATE]. L. On 06/10/26 at 9:21 AM, during an interview, the ADON confirmed that staff were not completing written transfer notices when residents are transferred from the facility. M. On 06/10/26 at 9:22 AM, during an interview, the DON confirmed that staff are not documenting the number of days a bed will be held or the amount the bed hold would cost the residents.

R #24A. Record review of R #24's admission documents, no date, revealed R #24 was admitted to the facility on [DATE]. B. Record review of an incident report for R #24 submitted to the state agency, dated 10/10/25, revealed the following: 1. Incident date 09/17/25.2. On 09/17/25, R #24 reported that Business Office Manager (BOM) #1 never let him know how much money he had in his account. C. Record review of R #24's personal fund transaction history, dated 01/01/25 to 11/30/25, revealed the following: 1. R #24's balance on 07/24/25 was $7,208.42.2. The last transaction documented in R #24's account was dated 07/24/25. 3. R #24 received monthly deposits for the same amount. 4. Staff did not document any deposits or withdrawals from R #24's account after 07/24/25. D. Record review of R #24's quarterly financial statement, dated 09/30/25, revealed the amount in R #24's account was $7,208.42 (the same as the amount listed on the financial history report that ended on 07/24/25). R #25E. Record review of R #25's personal fund transaction history, dated 01/01/25 to 12/05/25, revealed the following:1. R #25's balance on 07/28/25 was $299.38. 2. The last transaction documented in R #25's account was dated 07/28/25. 3. R #25 received monthly deposits each month. 4. R #25 had withdrawals for shopping and for salon services multiple times each month. 5. Staff did not document any deposits or withdrawals from R #25's account after 07/28/25. F. Record review of R #25's quarterly financial statement, dated 09/30/25, revealed the amount in R #25's account was $299.38 (the same as the amount listed on the financial history report that ended on 07/28/25). R #26G. Record review of R #26's personal fund transaction history, dated 01/01/25 to 12/05/25, revealed the following:1. R #26's balance on 07/24/25 was $476.02. 2. The last transaction documented in R #26's account was dated 07/24/25. 3. R #26 received monthly deposits each month. 4. R #26 had withdrawals for shopping and for salon services multiple times each month. 5. Staff did not document any deposits or withdrawals from R #26's account after 07/24/25. H. Record review of R #26's quarterly financial statement, dated 09/30/25, revealed the amount in R #26's account was $476.02 (the same as the amount listed on the financial history report that ended on 07/24/25). I. On 12/4/25 at 8:18 AM during an interview with R #26, she stated BOM #1 was doing something with her money. BOM #1 made R #26 feel uncomfortable and R #26 doesn't trust her. BOM #1 would not want to give R #26 when she asked for statements (she was not sure of the dates she had requested the statements). R #28J. Record review of R #28's personal fund transaction history, dated 01/01/25 to 12/05/25, revealed the following:1. R #28's balance on 07/28/25 was $1,981.24. 2. The last transaction documented in R #28's account was dated 07/28/25. 3. R #28 received monthly deposits each month. 4. R #28 had withdrawals for shopping and for salon services multiple times each month. 5. Staff did not document any deposits or withdrawals from R #28's account after 07/28/25. K. Record review of R #28's quarterly financial statement, dated 09/30/25, revealed the amount in R #28's account was $1,981.24 (the same as the amount listed on the financial history report that ended on 07/28/25). L. On 12/05/25 at 10:48 AM, during an interview, BOM #2 stated the following:1. The BOM deposits resident funds into the bank. 2. She stated the bank does not give the facility statements regarding the resident financial accounts that are through the facility. 3. She was not able to determine how much money each resident actually had in their account. 4. The facility tries to keep a record of each resident's account, but since she cannot look at the bank statements, she is unable to determine how much money each resident actually have.5. Each resident's financial account should be manually updated by the BOM with deposits and withdrawals.6. She confirmed that R #24, R #25, R #26, and R #28 accounts had not been updated with deposits and withdrawals since July 2025.7. The statements residents were given on 09/30/25 were not accurate because they did not include any transactions that occurred after the last date listed in the transaction history for each resident.8. She was not sure if residents or their representatives were provided with quarterly statements prior to 09/30/25.9. She confirmed the BOM was expected to provide residents with accurate financial statements at least quarterly and if requested by the resident or representative.10. She became the BOM in September 2025.11. She stated that multiple residents had reported that the previous BOM did not provide them with financial statements and had stated they didn't know how much money they had.

Based on record review and interview, the facility failed to protect residents from abuse, neglect, and exploitation for 3 (Anonymous R #1, Anonymous R #2, and R #24) of 5 (Anonymous R #1 and Anonymous R #2, R #24, R #25, R #26) residents sampled for abuse, neglect, and exploitation for the following:1. The Business Office Manager (BOM) #1 attempted to exploit R #24's resident funds in the amount of $7208.42. 2. BOM #1 was witnessed on two separate occurrences in the front lobby and in resident common area yelling at other staff members. 3. Anonymous R #1, Anonymous R #2 are fearful of retaliation (getting kicked out of the facility) for speaking out against BOM #1 who is directly related to the tribal leadership. These deficient practices could result in facility not maintaining a safe environment for residents' psychosocial wellbeing, residents could experience feeling powerless, violated, fearful, and unsure of how to regain control over their lives and continue to trust staff and feel safe in their home. The findings are: R #24 A. Record review of R #24's administration record, no date revealed R #24's admission date of 01/15/25. B. Record review of R #24's quarterly MDS dated [DATE], revealed the following BIMS score of 15. C. Record review of R #24's initial incident report submitted to the state agency, dated 10/10/25, revealed the following: 1. Incident date 09/17/25 2. On 09/17/25, R #24's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) attempted to withdrawal R #24's money from his facility account (see finding D). D. Record review of R #24's follow-up report submitted to the state agency, dated 10/13/25, revealed the following 1. R #24's POA (who was also BOM #1) was an employee of the facility at the time she tried to take R #24's money from his facility account. 2. The amount of money R #24's POA tried to remove was $7208.42 from his account. The facility prevented her from doing so. E. On 12/04/25 at 2:03 PM, during an interview, the Administrator confirmed the following: 1. R #24's POA was the BOM #1 for the facility. 2. The incident with R #24's POA occurred on 09/17/25. 3. R #24 was informed that the BOM #1 was attempting to take his money and he did not want BOM #1 to take his money. 4. R #24 BIMS score was 15 and was able to make financial decisions.5. Staff did not allow the BOM #1 to take R #24's $7208.42. BOM #1 yelling at staff in front of residentsF. Record review of Anonymous R #1quarterly MDS dated [DATE], revealed the following BIMS score of 13. G. On 12/04/25 at 1:30 PM, during an interview, Anonymous R #1 stated she witnessed BOM #1 yelling at other staff members in the front lobby area coming out of her office. She stated that there were other residents sitting in wheelchairs in the lobby area (Anonymous R #1 couldn't recall the specific date or specific residents). H. Record review of Anonymous R #2 quarterly MDS dated [DATE], revealed the following BIMS score of 15. I. On 12/04/25 at 7:30 AM, during an interview, Anonymous R #2 stated BOM #1 yelled at staff members in the hallway in common resident area by nurse's station. Anonymous R #2 stated there were several other residents who were in the area with him (Anonymous R #2 couldn't recall the specific date or specific residents). J. On 12/3/25 at 1:22 PM during a dual interview with the Administrator and BOM #2 confirmed the following:1. The BOM #1 had a history of yelling at staff. Some of those incidents happened in front of residents. The Administrator gave the following examples: a. BOM #1 was yelling at BOM #2 and the Administrator when she was attempting to get R #24's funds of $7208.42. BOM #1 entered the Administrator's personal space in an aggressive manner. b. BOM #1 was heard yelling in front lobby area by the Administrator and other residents (the Administrator could not recall what residents) when he entered the BOM office two family members (two women related to R #26), huddled together and Social Services worker (SSW) was sitting in the corner, and all appeared scared. It was reported to the State Agency. BOM #1's employment was terminated by the facility. That decision is in appeal with K. On 12/05/25 at 10:06 AM, during an interview, the Ombudsman stated BOM #1 walked intentionally into her shoulder in an effort to intimidate her in the front lobby area (approximately June or July 2025). BOM #1 stated to the ombudsman light weight. Ombudsman stated she was afraid of BOM #1 and had not been to the facility since the incident. Fearful of RetaliationL. On 12/04/25 at 1:30 PM, during an interview with Anonymous R #1 revealed the following:1. Anonymous R #1 stated she's afraid of BOM #1 because she knows a lot of very important people in the [NAME]. Anonymous R #1 thinks BOM #1 would do something to get her kicked out of the nursing home. Anonymous R #1 doesn't want to go anywhere because this is her home.2. Anonymous R #1 stated she does not want BOM #1 back. Anonymous R #1 stated BOM #1 is not a good person for this facility. Anonymous R #1 stated BOM #1 is a horrible person and shouldn't be working with elderly people. 3. Anonymous R #1 did not report this to anyone for fear of retaliation. M. On 12/04/25 at 7:30 AM, during an interview with Anonymous R #2 revealed the following:1. Anonymous R #2 stated he does not want BOM #1 at the facility because she would make him uncomfortable. 2. Anonymous R #2 stated BOM #1 might do something with his money or his stay at the facility. Anonymous R #2 is worried they might get kicked out of the facility for speaking against BOM #1. 3. Anonymous R #@ did not report this to anyone for fear of retaliation. N. On 12/03/25 at 1:22 PM during an interview with the Administrator confirmed that everyone (residents and staff) is afraid of her and her family ties. They fear retaliation.

Based on observation and interview, the facility failed to meet professional standards of practice for medication administration for 5 (R #16, R #17, R #18, R #19, and R #25) of 8 (R #16, R #17, R #18, R #19, R #21, R #22, R #23, and R #25) residents reviewed for medication administration when staff failed to ensure medications were prepared immediately before medication administration for each resident.This deficient practice could likely lead to the residents receiving the incorrect medications and could cause adverse effects (an undesired harmful effect resulting from a medication or other intervention). The findings are: A. On 12/04/24 at 7:27 AM, during an observation of medication administration revealed the following: 1. LPN #16's medication cart had five (5) medicine cups with pills in them.2. Four (4) of the medication cups had initials on them.3. One of the medication cups with initials had one (1) pill in it.4. One of the medication cups with initials had five (5) pills in it.5. One of the medication cups with initials had two (2) pills in it6. One of the medication cups with initials had eight (8) pills in it.7. One (1) of the medication cups did not have initials on it and had ten (10) pills in it. B. On 12/04/24 at 7:30 AM, during an interview, LPN #16 revealed the following: 1. She prepared the residents' medications early to try to administer them to the residents quickly. 2. She stated she had written the resident's initials on the sides of the cups so she would know who they were for. 3. She stated the medication cup with one (1) pill was for R #16. 4. She stated the medication cup with five (5) pills was for R #17. 5. She stated the medication cup with two (2) pills was for R #18. 6. She stated the medication cup with eight (8) pills was for R #25. 7. She confirmed one of the medication cups had no initials on it. 8. She stated the medication cup with no initials and ten (10) pills was for R #19. 9. She stated that staff were not supposed to pre-pour (a type of workaround, described as a delay between preparation and administration of a medication or the preparation of multiple medications for different clients) medications for residents. C. On 12/04/24 at 7:47 AM, during a joint interview, the DON and ADON confirmed the following:1. Staff were not allowed to pre-pour medications for residents.2. Staff were expected to prepare each resident's medication and administer the medication to the residents immediately after preparation.3. Pre-pouring medications could likely result in staff administering medications to the incorrect residents and could lead to medication errors.

Based on record review and interview, the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of the allegation for 1 (R #24) of 5 (R #24, R #25, R #26, R #27, and R #28) residents reviewed for misappropriation of property. If the facility fails to report allegations of misappropriation of property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their belongings are not being protected. The findings are: A. Record review of R #24 admission documents, no date, revealed R #24 was admitted to the facility on [DATE]. B. Record review of the initial incident report submitted to the state agency, dated 10/10/25, revealed the following: 1. Incident date 09/17/25 (incident submitted on 10/10/25, not within 24 hours of incident on 09/17/25). 2. On 09/17/25, R #24's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) attempted to withdrawal R #24's money from his facility account. C. Record review of the follow-up report submitted to the state agency, dated 10/13/25, revealed the following 1. R #24's POA was an employee of the facility at the time she tried to take R # 24's money from his facility account. 2. The amount of money R #24's POA attempted to remove from R #24's resident account was $7208.42. D. On 12/04/25 at 2:03 PM, during an interview, the administrator confirmed the following: 1. R #24's POA was the Business Office Manager (BOM) for the facility. 2. The incident with R #24's POA occurred on 09/17/25. 3. The facility did not report the allegations of misappropriation of R #24's money to the state agency until 10/10/25, which was not within 24 hours of the incident on 09/17/25.

Based on an interviews the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. This failure could potentially affect all 29 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 05/12/25). If the facility fails to employ qualified dietary staff, residents nutritional needs may not be met and they could likely suffer adverse outcomes. The findings are: A. On 05/12/25 at 1:36 PM, during an interview, Dietary Staff #16 revealed that the facility did not have a dietary manager (DM). B. On 05/12/25 at 1:38 PM, during an interview, [NAME] #16 revealed the following: 1. The facility did not have a DM. 2. They had not had a DM for approximately a month. 3. He was not sure if the facility had a dietitian. C. On 05/15/25 at 12:17 PM, during an interview, the Administrator confirmed the following: 1. The dietitian works at the facility one day a week. 2. The facility had not had a DM since 04/18/25. 3. The facility hired a DM that was expected to start on 05/23/25.

Recite from [DATE] Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 29 residents in the facility (residents were identified by resident matrix provided by the Administrator on [DATE]) who eat food or drinks stored in the nutrition refrigerator or freezer when staff failed to: 1. Maintain refrigerator temperatures in the nutrition refrigerators (refrigerator near the nursing station that contains drinks and snacks for residents). 2. Food stored in the nutrition refrigerator was not expired. 3. Food stored in the nutrition refrigerator or freezer had an expiration date. 4. Food that was supposed to be frozen was not thawed in the refrigerator. If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On [DATE] at 11:53 AM, during an observation of the nourishment room refrigerator revealed there was no temperature log for the refrigerator or freezer. B. On [DATE] at 11:54 AM, during an interview, RN #16 stated that the kitchen staff take the temperatures in the nourishment room refrigerator. C. On [DATE] at 12:05 PM, during an interview, Dietary Aide (DA) #16 stated she was unsure where the nourishment room temperature log was. D. On [DATE] at 12:21 PM, during an observation of the nutrition refrigerator and freezer revealed the following: 1. A sandwich was in the refrigerator with a date written on it of [DATE]. 2. A bag of shredded cheese in the refrigerator with an expiration date of [DATE]. 3. Several individually packaged peanut butter and jelly sandwiches in the refrigerator with no date and no expiration date. The wrappers stated thaw and serve (should be stored in the freezer until ready to serve). E. On [DATE] at 12:24 PM, during an interview, the DON confirmed the following: 1. The sandwich in the nutrition room refrigerator was expired. 2. The cheese in the nutrition room refrigerator was expired. 3. The individually packaged peanut butter and jelly sandwiches did not have a date that they would expire. 4. The individually packaged peanut butter and jelly sandwiches should have had a date that they expired written on them and should have been stored in the freezer and not the refrigerator. 5. There was no refrigerator or freezer temperature log in the nutrition room. 6. She was unsure if anyone had been checking the temperature of the nutrition room refrigerator or freezer. 7. Kitchen staff were responsible for the following in the nourishment room: a. Taking temperatures of the refrigerator and freezer. b. Stocking refrigerator and freezer and other snacks in the room. c. Removing expired items. F. On [DATE] at 12:38 PM, during an interview, DA #16 confirmed the kitchen staff had not been checking temperatures for the nutrition room refrigerator and freezer. She was unable to determine the last time the nutrition room refrigerator and freezer temperatures had been checked.

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #26) of 2 (CNA #26 and CNA #28), CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of CNA #26's employee files revealed the following: 1. CNA #26's hire date was 07/18/11. 2. CNA #26's last performance review was 02/20/24. B. On 05/19/25 at 2:48 PM during an interview, the Human Resource Manager confirmed that the last performance evaluation for CNA #26 was 02/20/24.

Based on record review, observation, and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary for 6 (R #9, R #10, R #11, R #118, R #119, and R #130) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to: 1. Psychotropic medications for R #118 and R #119 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Psychotropic medications that were ordered to be given as needed (PRN) for R #119 were not prescribed for longer than 14 days without a rationale from the provider for why the medication was needed for longer than 14 days. 3. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). 4. R #130 received psychotropic medications causing excessive sedation (state of calm or sleep induced by the administration of medication). These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: Diagnosis and PRN Orders R #118 A. Record review of R #118's admission record, no date, revealed R #118 was admitted to the facility on [DATE]. B. Record review of R #118's physician's orders revealed an order dated 04/03/25 for hydroxyzine (medication that can be used to treat anxiety) 25 mg at bedtime for restlessness or anxiety. C. Record review of R #118's MAR, dated 05/01/25 through 05/12/25, revealed the following: 1. On 05/01/25, R #118 received hydroxyzine 25 mg in the evening. 2. On 05/02/25, R #118 received hydroxyzine 25 mg in the evening. 3. On 05/03/25, R #118 refused hydroxyzine 25 in the evening. 4. On 05/04/25, R #118 refused hydroxyzine 25 mg in the evening. 5. On 05/05/25, R #118 received hydroxyzine 25 mg in the evening. 6. On 05/06/25, R #118 received hydroxyzine 25 mg in the evening. 7. On 05/07/25, R #118 received hydroxyzine 25 mg in the evening. 8. On 05/08/25, R #118 received hydroxyzine 25 mg in the evening. 9. On 05/09/25, R #118 received hydroxyzine 25 mg in the evening. 10. On 05/10/25, R #118 received hydroxyzine 25 mg in the evening. 11. On 05/11/25, R #118 received hydroxyzine 25 mg in the evening. 12. On 05/12/25, R #118 refused hydroxyzine 25 mg in the evening. D. Record review of R #118's entire medical record, no date, revealed R #118 did not have a diagnosis of anxiety. E. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118 had an order for hydroxyzine for restlessness or anxiety. 2. R #118 did not have a diagnosis of anxiety. 3. Staff are expected to ensure that medications are ordered to treat a diagnosed condition. R #119 F. Record review of R #119's admission record, no date, revealed the following: 1. R #119 was admitted to the facility on [DATE]. 2. R #119 did not have a psychiatric diagnosis. G. Record review of R #119's physician's orders revealed an order dated 04/29/25, for trazadone (antidepressant medication) 25 mg as needed (PRN) for sleep related to systolic (congestive) heart failure (CHF, occurs when the heart's left ventricle cannot contract effectively, leading to insufficient blood being pumped to the body), ordered for indefinite time period (no end date). H. Record review of R #119's MAR's, dated April and May 2025, revealed that R #119 received PRN trazadone on 05/07/25 at 9:34 PM. I. Record review of R #119's entire medical record, no date, revealed the provider did not document a rationale for why R #119 needed to have a PRN order for trazadone for longer than 14 days. J. On 05/19/25 at 2:12 PM, during an interview, the DON confirmed the following: 1. R #119 had an order for trazadone for sleep related to CHF. 2. R #119 did not have a psychiatric diagnosis for the use of trazadone. 3. R #119's PRN order for trazadone was ordered indefinitely. 4. Staff are expected to ensure there is a psychiatric diagnosis for the psychotropic medications that are ordered. 5. PRN psychotropic medications are not supposed to be ordered for longer than 14 days without a rationale for why it is needed. Gradual Dose Reduction R #9 K. Record review of R #9's admission record, no date revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of Anxiety disorder (mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life). L. Record review of R #9's physician's orders revealed an order for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) give 50 mg by mouth one time a day for anxiety. Start date: 09/16/24. M. Record review of R #9's MAR, dated 05/01/25 through 05/19/25, revealed the following: 1. On 05/01/25, R #9 received sertraline 50 mg in the morning. 2. On 05/02/25, R #9 received sertraline 50 mg in the morning. 3. On 05/03/25, R #9 received sertraline 50 mg in the morning 4. On 05/04/25, R #9 received sertraline 50 mg in the morning. 5. On 05/05/25, R #9 received sertraline 50 mg in the morning. 6. On 05/06/25, R #9 received sertraline 50 mg in the morning. 7. On 05/07/25, R #9 received sertraline 50 mg in the morning. 8. On 05/08/25, R #9 received sertraline 50 mg in the morning. 9. On 05/09/25, R #9 received sertraline 50 mg in the morning. 10. On 05/10/25, R #9 received sertraline 50 mg in the morning. 11. On 05/11/25, R #9 received sertraline 50 mg in the morning. 12. On 05/12/25, R #9 received sertraline 50 mg in the morning. 13. On 05/13/25, R #9 received sertraline 50 mg in the morning. 14. On 05/14/25, R #9 received sertraline 50 mg in the morning. 15. On 05/15/25, R #9 received sertraline 50 mg in the morning. 16. On 05/16/25, R #9 received sertraline 50 mg in the morning. 17. On 05/17/25, R #9 received sertraline 50 mg in the morning. 18. On 05/18/25, R #9 received sertraline 50 mg in the morning. 19. On 05/19/25, R #9 received sertraline 50 mg in the morning. N. Record review of R #9's Note to attending physician/prescriber (form that documents pharmacist recommendation regarding residents' medication(s)) to the physician/prescriber dated 03/03/25, revealed the following: 1. R #9 has been taking the antidepressant sertraline 50 mg once daily for anxiety since 09/17/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Resident with good response, maintain the current dose and Disagree marked. 3. The medical director (clinician who oversees and guides the care provider to nursing home residents) did not provide rationale with patient specific information as to why R #10 needed to remain on the medication. 4. The form was signed by the medical director and dated 03/23/25. O. On 05/19/25 at 3:50 PM during an interview, the DON confirmed the following: 1. R #9 has not had a GDR for sertraline. 2. The medical director did not provide a rationale for not performing a GDR for R #9's sertraline. R #10 P. Record review of R #10's admission record, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had the following psychiatric diagnoses: a. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). b. Restlessness and agitation (feelings of irritability, nervousness and mental distress). Q. Record review of R #10's physician's orders, multiple dates, revealed the following: 1. Order dated 04/11/24 and discontinued 11/26/24, for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) 50 mg, give 1 tablet by mouth in the morning related to depression. 2. Order dated 11/27/24 for sertraline tablet 50 mg, give 1 tablet by mouth in the morning for depression as evidenced by sadness. 3. Order dated 04/08/24 and discontinued 11/26/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep). 4. Order dated 11/27/24 for trazodone tablet give 50 mg by mouth at bedtime for insomnia. 5. Order dated 06/09/24 and discontinued 11/26/24, for escitalopram tablet (antidepressant medication used to treat anxiety and depression disorders) 10 mg, give 2 tablets by mouth in the morning for depression. 6. Order dated 11/27/24 for escitalopram tablet 10 mg, give 2 tablets by mouth in the morning for depression as evidenced by social isolation. 7. Order dated 04/22/24 and discontinued 11/26/24, hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 10 mg, give 1 tablet by mouth two times a day for anxiety related to restlessness and agitation. 8. Order dated 11/27/24 hydroxyzine tablet 10 mg, give 1 tablet by mouth two times a day for anxiety as evidenced by restlessness and agitation. R. Record review of R #10's MAR, dated 05/01/25 through 05/19/25, revealed the following: Sertraline 1. On 05/01/25, R #10 received sertraline 50 mg in the morning. 2. On 05/02/25, R #10 received sertraline 50 mg in the morning. 3. On 05/03/25, R #10 received sertraline 50 mg in the morning 4. On 05/04/25, R #10 received sertraline 50 mg in the morning. 5. On 05/05/25, R #10 received sertraline 50 mg in the morning. 6. On 05/06/25, R #10 received sertraline 50 mg in the morning. 7. On 05/07/25, R #10 received sertraline 50 mg in the morning. 8. On 05/08/25, R #10 received sertraline 50 mg in the morning. 9. On 05/09/25, R #10 received sertraline 50 mg in the morning. 10. On 05/10/25, R #10 received sertraline 50 mg in the morning. 11. On 05/11/25, R #10 received sertraline 50 mg in the morning. 12. On 05/12/25, R #10 received sertraline 50 mg in the morning. 13. On 05/13/25 R #10 received sertraline 50 mg in the morning. 14. On 05/14/25, R #10 received sertraline 50 mg in the morning. 15. On 05/15/25, R #10 received sertraline 50 mg in the morning. 16. On 05/16/25, R #10 received sertraline 50 mg in the morning. 17. On 05/17/25, R #10 received sertraline 50 mg in the morning. 18. On 05/18/25, R #10 received sertraline 50 mg in the morning. 19. On 05/19/25, R #10 received sertraline 50 mg in the morning. Trazodone 20. On 05/01/25, R #10 received trazodone 50 mg in the evening. 21. On 05/02/25, R #10 received trazodone 50 mg in the evening. 22. On 05/03/25, R #10 received trazodone 50 mg in the evening. 23. On 05/04/25, R #10 received trazodone 50 mg in the evening. 24. On 05/04/25, R #10 received trazodone 50 mg in the evening. 25. On 05/06/25, R #10 received trazodone 50 mg in the evening. 26. On 05/07/25, R #10 received trazodone 50 mg in the evening. 27. On 05/08/25, R #10 received trazodone 50 mg in the evening. 28. On 05/09/25, R #10 received trazodone 50 mg in the evening. 29. On 05/10/25, R #10 received trazodone 50 mg in the evening. . 30. On 05/11/25, R #10 received trazodone 50 mg in the evening. 31. On 05/12/25 R #10 received trazodone 50 mg in the evening. 32. On 05/13/25, R #10 received trazodone 50 mg in the evening. 33. On 05/14/25, R #10 received trazodone 50 mg in the evening. 34. On 05/15/25, R #10 received trazodone 50 mg in the evening. 35. On 05/16/25, R #10 received trazodone 50 mg in the evening. 36. On 05/17/25, R #10 received trazodone 50 mg in the evening. 37. On 05/18/25, R #10 received trazodone 50 mg in the evening. Escitalopram 38. On 05/01/25, R #10 received escitalopram 20 mg in the morning. 39. On 05/02/25, R #10 received escitalopram 20 mg in the morning. 40. On 05/03/25, R #10 received escitalopram 20 mg in the morning. 41. On 05/04/25, R #10 received escitalopram 20 mg in the morning. 42. On 05/05/25, R #10 received escitalopram 20 mg in the morning. 43. On 05/06/25, R #10 received escitalopram 20 mg in the morning. 44. On 05/07/25, R #10 received escitalopram 20 mg in the morning. 45. On 05/08/25, R #10 received escitalopram 20 mg in the morning. 46. On 05/09/25, R #10 received escitalopram 20 mg in the morning. 47. On 05/10/25, R #10 received escitalopram 20 mg in the morning. 48. On 05/11/25, R #10 received escitalopram 20 mg in the morning. 49. On 05/12/25, R #10 received escitalopram 20 mg in the morning. 50. On 05/13/25 R #10 received escitalopram 20 mg in the morning. 51. On 05/14/25, R #10 received escitalopram 20 mg in the morning. 52. On 05/15/25, R #10 received escitalopram 20 mg in the morning. 53. On 05/16/25, R #10 received escitalopram 20 mg in the morning. 54. On 05/17/25, R #10 received escitalopram 20 mg in the morning. 55. On 05/18/25, R #10 received escitalopram 20 mg in the morning. 56. On 05/19/25, R #10 received escitalopram 20 mg in the morning. Hydroxyzine 57. On 05/01/25, R #10 received hydroxyzine 10 mg twice daily. 58. On 05/02/25, R #10 received hydroxyzine 10 mg twice daily. 59. On 05/03/25, R #10 received hydroxyzine 10 mg twice daily. 60. On 05/04/25, R #10 received hydroxyzine 10 mg twice daily. 61. On 05/05/25, R #10 received hydroxyzine 10 mg twice daily. 62. On 05/06/25, R #10 received hydroxyzine 10 mg twice daily. 63. On 05/07/25, R #10 received hydroxyzine 10 mg twice daily. 64. On 05/08/25, R #10 received hydroxyzine 10 mg twice daily. 65. On 05/09/25, R #10 received hydroxyzine 10 mg twice daily. 66. On 05/10/25, R #10 received hydroxyzine 10 mg twice daily. 67. On 05/11/25, R #10 received hydroxyzine 10 mg twice daily. 68. On 05/12/25, R #10 received hydroxyzine 10 mg twice daily. 69. On 05/13/25, R #10 received hydroxyzine 10 mg twice daily. 70. On 05/14/25, R #10 received hydroxyzine 10 mg twice daily. 71. On 05/15/25, R #10 received hydroxyzine 10 mg twice daily. 72. On 05/16/25, R #10 received hydroxyzine 10 mg twice daily. 73. On 05/17/25, R #10 received hydroxyzine 10 mg twice daily. 74. On 05/18/25, R #10 received hydroxyzine 10 mg twice daily. S. Record review of R #10's Recommendation Summary for DON and medical director dated 02/03/25, revealed the following: 1. R #10 has a history of chronic depression and has been receiving the current dose sertraline 50 mg every morning since 04/11/24, trazodone 50 mg at bedtime since 04/08/24, and escitalopram 20 mg every morning since 06/09/24 2. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested. 3. The form had Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the residents function and or cause psychiatric instability. Please elaborate with patient specific information marked. 4. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the medications. 5. The form was signed by the medial director and dated 03/23/25. T. Record review of R #10's Note to attending physician/prescriber dated 04/01/25, revealed the following: 1. R #10 has been taking the anxiolytic (class of medications used to prevent or treat anxiety symptoms or disorders) hydroxyzine 10 mg twice daily for anxiety since 04/22/24. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose marked. 3. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the same dose of hydroxyzine. 4. The form was signed by the medical director and dated 04/03/25. U. On 05/19/25 at 3:57 PM, during an interview, the DON confirmed the following: 1. R #10 has not had a GDR for sertraline, trazodone, escitalopram, and hydroxyzine. 2. The medical director did not provide a rationale for not performing GDR's for R #10's medications. R #11 V. Record review of R #11's admission record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following psychiatric diagnoses: a. Major Depressive Disorder (MDD, mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) b. Panic disorder [Episodic Paroxysmal Anxiety] (mental and behavioral disorder, specifically an anxiety disorder characterized by recurring unexpected panic attacks). c. Psychotic Disorder with Hallucinations due to known physiological condition (a condition when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)). d. Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). W. Record review of R #11's physician's orders, multiple dates, revealed the following: 1. Order dated 04/29/24 and discontinued 11/26/24, for buspirone (medication that can treat anxiety) 5 mg tablet, one tablet twice a day for anxiety. 2. Order dated 11/26/24, for buspirone 5 mg tablet, one tablet twice a day for anxiety. 3. Order dated 09/29/23 and discontinued 11/26/24, for lorazepam 0.5 mg tablet, one tablet twice a day for anxiety. 4. Order dated 11/26/24, for lorazepam (medication that can treat anxiety) 0.5 mg tablet, one tablet twice a day for anxiety. 5. Order dated 07/07/23 and discontinued 10/01/23, for trazadone 50 mg, one tablet in the evening for insomnia. 6. Order dated 10/01/23 and discontinued 11/26/24, for trazadone 50 mg, one tablet in the evening for depression, MDD, insomnia. 7. Order dated 11/26/24, for trazadone 50 mg tablet, one tablet in the evening for depression, MDD, insomnia. 8. Order dated 08/03/23 and discontinued 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression. 9. Order dated 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression. 10. Order dated 06/30/23, for Nuplazid 34 mg, give one capsule at bedtime for hallucinations related to Parkinson's disease (psychotic disorder with hallucinations due to known physiological condition). X. Record review of R #11's MAR, dated May 2025, revealed the following: 1. R #11 received Lorazepam 0.5 mg twice a day as ordered. 2. R #11 received buspirone 5 mg twice a day as ordered. 3. R #11 received trazadone 50 mg in the evening as ordered. 4. R #11 received mirtazapine 7.5 mg in the evening as ordered. 5. R #11 received Nuplazid 34 mg in the evening as ordered. Y. Record review of of the Psychotropic & Sedative/Hypnotic Utilization By Resident report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 05/02/25, revealed the following: 1. R #11 had an order for buspirone 5 mg twice a day since 04/29/24, and a GDR was declined in February 2025. 2. R #11 had an order for lorazepam 0.5 mg twice a day since 09/29/23, and a GDR was declined in September 2024. 3. R #11 had an order for mirtazapine (antidepressant medication) 7.5 mg in the evening for depression since 08/03/23, and a GDR was declined in September 2024. 4. R #11 had an order for Nuplazid 34 mg at bedtime since 06/30/23, and a GDR was recommended in April 2025. 5. R #11 had an order for trazadone 50 mg at bedtime since 10/01/23, and a GDR was declined in October 2024. Z. Record review of R #11's pharmacist recommendation, dated 08/03/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 08/03/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form had agree selected with a provider signature and date of 09/15/24. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. AA. Record review of R #11's pharmacist recommendation, dated 09/03/24, revealed the following: 1. R #11 has been taking the anxiolytic lorazepam 0.5 mg twice daily since 09/28/23. Please evaluate the current dose and consider a dose reduction. 2. The form had agree selected with a signature and date of 09/09/24. 3. The form had a note dated 09/16/24, verbal order to continue med. Per order by [Doctor Name]. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. BB. Record review of R #11's pharmacist recommendation, dated 10/04/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of trazadone 50 mg at bedtime for depression since 10/01/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a note, dated 10/14/24, [Name of nurse practitioner] verbal continue of this dose. CC. Record review of R #11's pharmacist recommendation, dated 02/03/25, revealed the following: 1. R #11 has been taking the anxiolytic buspirone 5 mg since 04/29/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Condition stable: Attempt dose reduction to discontinue this medication, Resident with good response, maintain the current dose, and Disagree marked. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a comment dated 02/19/25, MD intended to keep resident on current dose, verified by [DON signature]. DD. Record review of R #11's pharmacist recommendation, dated 04/05/25, revealed the following: 1. R #11 has been taking the antipsychotic Nuplazid 34 mg at bedtime for psychotic disorder with hallucinations related to Parkinson's Disease since 06/30/23. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose. 3. The form had agree selected with a signature and date of 05/09/25. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. EE. On 05/19/25 at at 2:34 during an interview, the DON confirmed the following: 1. R #11 has not had a GDR for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. 2. The provider did not provide a rationale for why she did not perform a GDR for R #11 for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. R #118 FF. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. 2. An order dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. GG. Record review of R #118's MAR, dated 05/01/25 through 05/12/25, revealed the following: 1. On 05/01/25, R #118 received mirtazapine 7.5 mg in the evening. 2. On 05/02/25, R #118 received mirtazapine 7.5 mg in the evening. 3. On 05/03/25, R #118 refused mirtazapine 7.5 mg in the evening. 4. On 05/04/25, R #118 refused mirtazapine 7.5 mg in the evening. 5. On 05/05/25, R #118 received mirtazapine 7.5 mg in the evening. 6. On 05/06/25, R #118 received mirtazapine 7.5 mg in the evening. 7. On 05/07/25, R #118 received mirtazapine 7.5 mg in the evening. 8. On 05/08/25, R #118 received mirtazapine 7.5 mg in the evening. 9. On 05/09/25, R #118 received mirtazapine 7.5 mg in the evening. 10. On 05/10/25, R #118 received mirtazapine 7.5 mg in the evening. 11. On 05/11/25, R #118 received mirtazapine 7.5 mg in the evening. 12. On 05/12/25, R #118 refused mirtazapine 7.5 mg in the evening. HH. Record review R #118's pharmacist recommendation, dated 05/02/25, revealed the following: 1. R #118 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 07/15/24. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form a provider signature and date of 05/09/25. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. II. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118 has not had a GDR for mirtazapine. 2. The provider did not provide a rationale for why she did not perform a GDR for R #118 for mirtazapine. Excessive Sedation R #130 JJ. Record review of R #130's admission record, no date, revealed the following: 1. R #130 was admitted to the facility on [DATE]. 2. R #130 had the following psychiatric diagnoses: a. Other specified anxiety disorder (diagnosis that applies to individuals who have symptoms characteristic of an anxiety disorder such as excessive fear, worry, and anxiety that interfere with daily life but do not meet the criteria for a specific anxiety disorder). b. Depression, unspecified (diagnosis used when someone displays depressive symptoms such as feelings of sadness or loss of interest but there is not enough information for a specific diagnosis) KK. On 05/13/25 at 10:04 AM, during an interview, R #130 stated that she was very sleepy, and she did not know why. R #130 stated she slept well last night. LL. On 05/14/25 at 9:44 AM, during an observation of the common area (TV room), R #130 was asleep in her wheelchair. MM. On 05/14/25 at 2:15 PM, during an observation of R #130, she was asleep on her recliner in her room. NN. On 05/15/25 at 1:30 PM, during an observation of R #130, she was asleep on her recliner in her room. R #130's lunch tray was on the bathroom counter and appeared to be untouched. OO. On 05/15/25 at 1:32 PM, during an interview, R #130's POA (power of attorney) stated the following: 1. R #130 was asleep since she arrived at 11:00 AM. 2. R #130 was slumped over in her wheelchair asleep in the common area. 3. She asked the facility staff to assist her in taking R #130 to her room and assist her into her recliner. 4. She and R #130's other family members have noticed that R #130 has been sleeping more during the daytime hours. 5. R #130 was too sleepy and did not eat any of her lunch. 6. She was not aware that R #130 was taking her Xanax (name brand of antianxiety medication alprazolam; medication primarily used to treat anxiety disorders and anxiety associated with depression) three times daily and was not aware that R #130 was also taking hydroxyzine (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) twice daily. 7. R #130 was only taking Xanax as needed prior to her admission to the facility, R #130's POA stated she usually gave R #130 Xanax in the morning and sometimes at 1:00 PM. PP. Record review of R #130's admission referral dated 04/08/25 revealed the following: 1. Diagnosis; anxiety, depression. 2. Alprazolam 0.25 mg give one tablet by mouth three times daily as needed for anxiety. QQ. Record review of R #130's physician's orders revealed the following: 1. An order for alprazolam (generic for Xanax) 0.25 mg, give 1 tablet by mouth three times daily (7:00 AM, 1:00 PM, and 8:00 PM) for anxiety and restlessness. Start date 04/16/25. 2. An order for hydroxyzine tablet 25 mg, give one tablet by mouth two times daily related to anxiety. Start date: 04/19/25 RR. Record review of R #130's MAR, dated 05/01/25 through 05/18/25, revealed the following: Alprazolam 1. On 05/01/25, R #130 received alprazolam 0.25 mg three times daily. 2. On 05/02/25, R #130 received alprazolam 0.25 mg three times daily. 3. On 05/03/25, R #130 received alprazolam 0.25 mg three times daily. 4. On 05/04/25, R #130 received alprazolam 0.25 mg three times daily. 5. On 05/05/25, R #130 received alprazolam 0.25 mg three times daily. 6. On 05/06/25, R #130 received alprazolam 0.25 mg three times daily. 7. On 05/07/25, R #130 received alprazolam 0.25 mg three times daily. 8. On 05/08/25, R #130 received alprazolam 0.25 mg three times daily. 9. On 05/09/25, R #130 received alprazolam 0.25 mg three times daily. 10. On 05/10/25, R #130 received alprazolam 0.25 mg three times daily. 11. On 05/11/25, R #130 received alprazolam 0.25 mg three times daily. 12. On 05/12/25, R #130 received alprazolam 0.25 mg three times daily. 13. On 05/13/25 R #130 received alprazolam 0.25 mg three times daily. 14. On 05/14/25, R #130 received alprazolam 0.25 mg three times daily. 15. On 05/15/25, R #130 received alprazolam 0.25 mg three times daily. 16. On 05/16/25, R #130 received alprazolam 0.25 mg three times daily. 17. On 05/17/25, R #130 received alprazolam 0.25 mg three times daily. 18. On 05/18/25, R #130 received alprazolam 0.25 mg three times daily. Hydroxyzine 19. On 05/01/25, R #130 received hydroxyzine 25 mg twice daily. 20. On 05/02/25, R #130 received hydroxyzine 25 mg twice daily. 21. On 05/03

Based on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representative(s) in writing for 3 (R #8, R #11, and R #119) of 3 (R #8, R #11, and R #119) residents sampled for hospitalization s or discharge when staff failed to: 1. Notify the resident and the resident's representative of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #8. 2. Complete a discharge summary for R #8 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status including an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. c. A reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) 3. Notify the residents and resident's representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #11 and R #119. 4. Ensure the transfer or discharge notice for R #8, R #11, and R #119 included: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 5. Send a written copy of the Discharge or Transfer Notices to the Ombudsman for R #8, R #11, and R #119. 6. Ensure R #119 or his representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer or discharge, the location of the transfer or discharge their rights to advocate and make informed decisions regarding the resident's healthcare, the services that the resident received while at the facility, the resident's current health status, or the resident's current medications leading to adverse outcomes for the resident. The findings are: Discharge Notices R #8 A. Record review of R #8's medical record, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 was discharged from the facility on 03/14/25. B. Record review of R #8's progress note, dated 03/14/25, revealed the following: 1. R #8 was discharged home with family. 2. R #8 was given her medications and copies of her paperwork. 3. R #8 and her family were educated on how to take her medications and what they were for. 4. R #8's vital signs were normal and she had no pain. C. Record review of R #8's entire medical record, no date, revealed staff did not document the following: 1. A discharge notice for R #8's discharge from the facility on 03/14/25. 2. A discharge summary for R #8. D. On 05/15/25 at 2:40 PM, during an interview, RN #16 stated the following regarding discharging residents: 1. They complete an assessment on the resident. 2. She stated they do not complete a discharge summary or a recapitulation of the resident's stay. 3. The nurses educate the resident and their family about medications that the resident was taking in the facility and give them a printout of facility medications. 4. They educate the resident and family about any upcoming appointments. E. On 05/15/25 at 3:14 PM, during an interview, the Ombudsman stated that she did not receive a discharge notice for R #8's discharge on 03/14/25. F. On 05/19/25 at 2:27 PM, during an interview, the DON confirmed the following: 1. R #8 discharged to her home on 3/14/25. 2. R #8's medical record did not contain documentation of discharge summary, discharge notification, recapitulation of stay, or medication reconciliation. 3. The facility did not send a written copy of a discharge notification for R #8 to the Ombudsman. Transfer and Behold Notices R #11 G. Record review of R #11's medical record revealed the following: 1. On 04/16/25, R #11 was sent to the hospital after a fall. 2. The medical record did not contain a written transfer notice for R #11's transfer to the hospital on 04/16/25. R #119 H. Record review of R #119's medical record revealed the following: 1. On 05/08/25, R #119 was sent to the hospital after a fall. 2. The medical record did not contain a written transfer notification for R #119's transfer to the hospital on 05/08/25. 3. The medical record did not contain a written bed hold notification for R #119's transfer to the hospital on 05/08/25. I. On 05/16/25 at 10:34 AM, during an interview, the Business Office Manager (BOM), stated the following: 1. She does not complete transfer notices. 2. She is responsible for completing bed hold notifications for residents. 3. She did not complete a bed hold notification for R #119's transfer to the hospital on 05/08/25. J. On 05/16/25 at 10:58 AM, during an interview, the DON confirmed the following: 1. Staff were not completing written transfer or discharge notices when residents transfer or discharge from the facility. 2. Staff were not providing a copy of written transfer or discharge notices to the ombudsman. 3. The BOM is expected to complete bed hold notifications when residents are transferred to the hospital.

Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment were accurate for 3 (R #9, R #118 and R #121) of 9 (R #1, R #4, R #9, R #10, R #118, R #119, R #121, R #130 and R #131) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #9 A. Record review of R #9's admission record revealed R #9 was admitted on [DATE]. B. Record review of R #9's physician's orders revealed an order for Smaglutide (non-insulin medication used to help improve blood sugar control) subcutaneous (fatty tissue layer just beneath the skin) solution, inject 1 mg every Sunday for diabetes mellitus type 2 (DM 2; chronic disease characterized by high levels of sugar in the blood). Start date: 12/08/24. C. Record review of R #9's Quarterly MDS dated [DATE] revealed the following: 1. Section N0350, Insulin (hormone that helps lower blood sugar levels) a. Staff documented R #9 received 1 insulin injection in the last 7 days. D. Record review of R #9's MAR for March 2025 revealed the following: 1. R #9 received semaglutide injection on 03/09/25 2. R #9 did not receive any insulin injections. E. On 05/19/25 at 2:27 PM, during an interview, the MDS Coordinator confirmed that R #9 did receive semaglutide injection but did not receive any insulin injections. The MDS coordinator confirmed that R #9's Quarterly MDS was not accurate because R #9 did not receive any insulin injections. R #118 F. Record review of R #118's admission documents revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had a diagnosis of muscle weakness. G. Record review of R #118's physician's order, dated 12/06/24, revealed R #118 had an order for Restorative Nursing Program (RNP), for bilateral (right and left side) arm and leg strengthening exercises once a day five days a week as tolerated. H. Record review of R #118's quarterly MDS assessment, dated 02/19/25, revealed staff documented the following: 1. Section O- Special Treatments, Procedures, and Programs. O0500. Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily): a. Range of Motion (passive)- 0 bragged of Motion (active)- 0 c. Splint of brace assistance- 0 I. Record review of R #118's survey documentation report (report that includes documentation regarding activities of daily living, RNP, and other care areas provided for residents), dated February 2025, revealed R #118 received active range of motion (AROM, resident moves joints on their own) and passive range of motion (PROM, resident receives assistance with moving joints) as follows: 1. 02/01/25, 5 minutes of AROM and 5 minutes of PROM. 2. 02/02/25, 5 minutes of AROM and 5 minutes of PROM. 3. 02/03/25, 10 minutes of AROM and 10 minutes of PROM. 4. 02/04/25, 10 minutes of AROM and 10 minutes of PROM. 5. 02/05/25, 15 minutes of AROM and 15 minutes of PROM. 6. 02/06/25, 15 minutes of AROM and 15 minutes of PROM. 7. 02/07/25, 10 minutes of AROM and 10 minutes of PROM. 8. 02/08/25, 5 minutes of AROM and 5 minutes of PROM. 9. 02/09/25, 5 minutes of AROM and 5 minutes of PROM. 10. 02/10/25, 5 minutes of AROM and 5 minutes of PROM. 11. 02/11/25, 15 minutes of AROM and 15 minutes of PROM. 12. 02/12/25, 15 minutes of AROM and 15 minutes of PROM. 13. 02/13/25, 0 minutes of AROM and 15 minutes of PROM. 14. 02/14/25, 5 minutes of AROM and 5 minutes of PROM. 15. 02/17/25, 15 minutes of AROM and 15 minutes of PROM. 16. 02/18/25, 15 minutes of AROM and 15 minutes of PROM. 17. 02/19/25, 5 minutes of AROM and 5 minutes of PROM. J. On 05/19/25 at 12:50 PM, during an interview, the MDS coordinator confirmed the following: 1. R #118 had received RNP services within the 7 days prior to the MDS assessment. 2. R #118's quarterly MDS, dated [DATE], showed that R #119 did not receive RNP services during the 7 days prior to the MDS assessment. 3. She should have included R #118's RNP services on the MDS assessment. R #121 K. Record review of R #121's admission documents revealed the following: 1. R #121 was admitted to the facility on [DATE]. 2. R #121 had a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of unspecified toe. L. Record review of R #121's skin assessment, dated 04/16/25, revealed the following: 1. R #121 had an open blister on her lower left leg. 2. R #121 had newly diagnosed cellulitis and was taking antibiotics. 3. R #121 had wound care orders. 4. R #121 did not have any pressure wounds. M. Record review of R #121's physician's orders, dated 04/16/25, revealed an order for wound care to left lower leg blister every day and as needed until healed. N. Record review of R #121's quarterly MDS assessment, dated 04/17/25, revealed Section M- Skin Conditions: M0300- Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage- B. Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister, staff documented that R #121 had one stage 2 pressure ulcer. O. On 05/19/25 at 12:39 PM, during an interview, the MDS Coordinator confirmed the following: 1. R #121 did not have any pressure ulcers. 2. R #121's quarterly MDS, dated [DATE], indicated that R #121 had a stage 2 pressure ulcer. 3. R #121's quarterly MDS was inaccurate because she did not have a pressure wound. 49313

Recite from 05/22/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 4 (R #9, R #11, R #118, and R #130) of 6 (R #9, R #11, R #118, R #119, R #121, and R #130) residents when the staff failed to revise the care plan with the most current resident information. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #9 A. Record review of R #9's Admission Record (no date) revealed R #9 was admitted to the facility on [DATE]. B. Record review of R #9's CNA shower review forms dated 02/03/25 through 05/15/25 revealed the following: 1. R #9 was offered showers twenty-three times. 2. R #9 refused her showers eleven of the twenty-three times showers were offered to her. C. Record review of R #9's care plan dated 09/17/24 revealed the following: 1. R #9 requires partial/limited assistance with bathing/showering. 2. R #9's care plan was not revised to include residents refusal of showers and what actions staff could take to encourage her to shower. D. On 05/19/25 at 4:19 PM, during an interview, the MDS Coordinator confirmed that R #9's care plan was not revised to include her refusal of care (refusing to shower) and actions that staff could take to assist her to agree to shower. R #11 E. Record review of R #11's admission documents, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following diagnoses: a. Lack of coordination. b. Muscle weakness. c. History of falling. F. Record review of R #16's progress note dated 04/16/25 revealed R #11 fell and was sent to the hospital. G. Record review of the facility's follow-up report, dated 04/18/24, revealed the facility implemented increased monitoring and redirection as interventions to prevent R #11 from falling again. H. Record review of R #11 care plan, revised 04/02/25, revealed staff did not revise R #11's care plan after she fell on [DATE]. I. On 05/19/25 at 2:31 PM, during an interview, the DON confirmed the following: 1. R #11 fell on [DATE]. 2. Close monitoring and redirection are interventions that are in place to prevent R #11 from falling. 3. R #11's care plan was not revised to include these interventions. 4. R #11's care plan should have been revised to include these interventions. R #118 J. Record review of R #118's admission documents, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had the following diagnoses: a. History of falling. b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). K. On 05/12/25 at 3:47 PM, during an interview with R #118's family member (FM) #1 the following was revealed: 1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date). 2. R #118 tried to get out of bed on her own. 3. The facility placed a fall mat and R #118's bed in lowest position when she is in bed. 4. The provider ordered hydroxyzine to be added to R #118's medications to help with anxiety. L. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order dated 03/15/25, for a fall mat and bed to be in lowest position when R #118 is in bed. 2. An order dated 04/03/25, for hydroxyzine 25 mg at bedtime for anxiety and restlessness. M. Record review of R #118's care plan, revised 03/24/25, revealed the following: 1. R #118's care plan was not revised to include a fall mat next to her bed or the bed to be in lowest position when she is in bed. 2. R #118's care plan was not revised to include R #118's order for hydroxyzine for anxiety or restlessness. N. On 05/14/25 at 10:27 AM, during an interview, the DON confirmed the following: 1. R #118's care plan was not revised to include a fall mat next to R #118's bed and the bed to be in lowest position when she was in bed. 2. She confirmed that resident care plans are expected to be revised with any interventions in place to prevent them from falling. R #130 O. Record review of R #130's Admission Record (no date) revealed R #130 was admitted to the facility on [DATE]. P. Record review of R #130's physician's orders revealed the following: 1. Alprazolam (generic for Xanax; medication primarily used to treat anxiety disorders and anxiety associated with depression) 0.25 mg, give 1 tablet by mouth three times daily for anxiety (mental health condition characterized by excessive fear, and worry that interfere with daily life) and restlessness (feelings of irritability, nervousness and mental distress). Start date 04/16/25. 2. Hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 25 mg, give one tablet by mouth two times daily related to anxiety. Start date: 04/19/25. Q. Record review of R #130's care plan revised on 04/30/25 revealed the following: 1. R #130 uses anti-anxiety medications (Xanax) related to anxiety disorder. 2. R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety. R. On 05/19/25 at 2:20 PM, during an interview, the MDS Coordinator confirmed that R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety. 49313

Based on observation, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #1 and R #121) of 2 (R #1 and R #121) residents reviewed for unnecessary medication use and wound care when staff failed to: 1. Notify the physician about R #1's elevated blood pressure as indicated on physician's order. 2. Obtain wound care orders prior to performing wound care on R #121's right leg. If the facility is not providing care per physician's orders and care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #1's physician orders revealed an order for Amlodipine (high blood pressure primarily used to treat high blood pressure and chest pain by relaxing blood vessels which lowers blood pressure and decreases the hears workload) tablet 10 mg, give 1 tablet by mouth in the morning for high blood pressure (HTN; hypertension medical term for high blood pressure) hold (do not give medication) and call doctor if systolic blood pressure (SBP, top number of blood pressure reading ) is less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) is less than 50 and/or pulse (heart rate, beats per minute) is less than 50. Administer (give medication) and call doctor if SBP is greater than 180, DBP is greater than 100 and/or Pulse is greater than 100. C. Record review of R #1's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/01/25 staff documented bp 195/63 and administered amlodipine. 2. On 04/05/25 staff documented bp 181/64 and administered amlodipine. 3. On 04/08/25 staff documented pulse 47 and administered amlodipine. 4. On 04/08/25 staff documented pulse 43 and administered amlodipine. 5. On 04/09/25 staff documented bp 184/81 and administered amlodipine. 6. On 04/12/25 staff documented bp 189/78 and administered amlodipine. D. Record review of R #1's MAR dated May 2025, revealed staff documented the following: 1. On 05/04/25 staff documented bp 190/82 and administered amlodipine. 2. On 05/05/25 staff documented bp 198/74 and administered amlodipine. 3. On 05/06/25 staff documented bp 189/73 and administered amlodipine. 4. On 05/07/25 staff documented bp 185/76 and administered amlodipine. 5. On 05/10/25 staff documented bp 185/79 and administered amlodipine. 6. On 05/11/25 staff documented bp 217/92 and administered amlodipine. 7. On 05/13/25 staff documented bp 185/79 and administered amlodipine. 8. On 05/14/25 staff documented bp 182/70 and administered amlodipine. 9. On 05/15/25 staff documented bp 215/74 and administered amlodipine. E. Record review of R #1's progress notes for March and April 2025, revealed staff did not document that they notified the physician of R #1's elevated blood pressure (SBP higher than 180) or low pulse (heart rate less than 50). F. On 05/19/25 at 3:19 PM, during an interview, the DON confirmed the following: 1. R #1's blood pressure was elevated, and her pulse was low. 2. R #1's order indicates that staff are to call physician when blood pressure is greater than 180 and heart rate is less than 50. 3. Facility staff did not call the physician as indicated on the order and staff are expected to follow the physician's order. R #121 G. Record review of R #121's admission record (no date) revealed the following: 1. R #121 was admitted to the facility on [DATE]. 2. R # 121 had a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of unspecified toe. H. On 05/12/25 at 2:18 PM, during an interview and observation of R #121, the following was revealed: 1. R #121 stated she had cellulitis in both legs. 2. Her right leg was worse than her left leg. 3. She stated that the nurses were performing wound care on both of her legs. 4. She had bandages to both legs. 5. She stated she was on antibiotics for the cellulitis. 6. The provider ordered for her to see the wound care specialist, but she didn't know the date of the scheduled appointment. I. Record review of R #121's physician orders, multiple dates, revealed the following: 1. An order dated 04/16/25, for dry dressing and kerlix (bandage roll that provides absorbency and aeration) wrap to left lower leg blister every day and as needed until healed. 2. R #121's medical record did not have orders for wound care for R #121's right leg. J. Record review of R #121's TAR for May 2025 revealed the following: 1. dry dressing and kerlix wrap to left lower leg blister every day and as needed until healed. 2. Staff documented treatment was administered as ordered. K. On 05/15/25 at 12:27 PM, during an interview with RN #17, the following was revealed: 1. R #121 has wounds on both of her legs. 2. R #121's right leg wounds were worse than her left. 3. She performed wound care on both of R #121's legs. 4. For wound care, she washed R #121's wounds with wound care solution or normal saline (a mixture of water and salt with a salt concentration of .9%). Then put a non-adhesive (non-stick) dressing over the wounds and wrapped with kerlix. 5. She confirmed that R #121 had wound care orders for her left leg. 6. She confirmed that R #121 did not have orders for wound care to her right leg. 7. She stated that R #121's wounds on both legs were healing. 8. She confirmed R #121 had an appointment scheduled with the wound care specialist on 05/19/25. L. On 05/19/25 at 2:24 PM, during an interview, the DON confirmed the following: 1. R #121 had cellulitis in both legs. 2. Staff were performing wound care on both of R #121's legs. 3. R #121 did not have physician's orders for wound care for R #121's right leg. 4. Staff were expected to get orders for wound care for R #121's right leg prior to performing wound care on the right leg. 49313

Based on record review and interview the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 1 (R #4) of 1 (R #4) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: A. Record review of R #4's Admission record no date revealed an admitted [DATE]. B. Record review of R #4's Annual MDS assessment dated [DATE] revealed R #4's personal preferences for activities. C. Record review of R #4's care plan dated 09/30/24 revealed R #4's care plan did not include her personal preferences from the MDS Annual Assessment. D. Record review of R #4's Activity Individual Participation Record dated March 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. E. Record review of R #4's Activity Individual Participation Record dated April 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. F. Record review of R #4's Activity Individual Participation Record dated May 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. G. On 05/14/25 at 9:12 AM, during an interview, R #4 stated she was not offered activities in her room. R #4 stated no one comes in and watches tv with me, no talking or conversing. R #4 stated she would like a prayer, or bible study regarding Catholic religion, and likes all music, games, arts/crafts, gardening, any activity would be nice because she was not offered them by staff. H. On 05/14/25 at 9:26 AM, during an interview with the Activities Director, she confirmed the following: 1. R #4's Annual MDS assessment dated [DATE] is accurate and reflects resident's personal preferences for activities. 2. The Activities Director (AD) confirmed that she doesn't document everything for R #4 in the chart but is offering R #4 activities (contradicting R #4's statement). The AD will start documenting.

Recite from 05/22/24 Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 4 (R #1, R #9, R #10, and R #118) of 5 (R #1, R #9, R #10, R #118, and R #130) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: R #1 A. Record review of R #1's Electronic Medical Record (EMR) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 was seen by the Medical Director (clinician who oversees and guides the care provider to nursing home residents) on 12/29/24. 3. R #1 was seen by the Medical Director on 05/10/25. B. On 05/19/25 at 3:13 PM, during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days. R #9 C. Record review of R #9's EMR revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 was seen by the Medical Director on 09/24/24. 3. R #9 was seen by the Medical Director on 05/02/25. D. On 05/19/25 at 3:44 PM during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days. R #10 E. Record review of R #10's EMR revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 was seen at the local medical clinic on 07/24/24. 3. R #10 was seen by the Medical Director on 04/03/25. F. On 05/19/25 at 3:52 PM during an interview, the DON confirmed that R #10 was not seen by the provider every 60 days. R #118 G. Record review of R #118's EMR revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. Last physician visit was on 07/12/24. H. On 05/14/25 at 12:42 PM, during an interview, the DON stated the following: 1. The physician went to the facility weekly. 2. The physician saw all new residents during her weekly visits. 3. The physician saw all residents receiving skilled services weekly. 4. The physician saw any resident who had a specific need to be seen. 5. The physician saw all residents annually. 6. The DON confirmed that R #118 had not been seen by the physician since 07/12/24. 49313

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #9, R #10, R #11 and R #118) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #9 A. Record review of R #9's admission record, no date, revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had the following psychiatric diagnoses: a. Anxiety disorder (mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life). B. Record review of R #9's physician's orders revealed an order for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) give 50 mg by mouth one time a day for anxiety. Start date: 09/16/24. C. Record review of R #9's MAR, dated 05/01/25 through 05/19/25, revealed the following: 1. On 05/01/25, R #9 received sertraline 50 mg in the morning. 2. On 05/02/25, R #9 received sertraline 50 mg in the morning. 3. On 05/03/25, R #9 received sertraline 50 mg in the morning 4. On 05/04/25, R #9 received sertraline 50 mg in the morning. 5. On 05/05/25, R #9 received sertraline 50 mg in the morning. 6. On 05/06/25, R #9 received sertraline 50 mg in the morning. 7. On 05/07/25, R #9 received sertraline 50 mg in the morning. 8. On 05/08/25, R #9 received sertraline 50 mg in the morning. 9. On 05/09/25, R #9 received sertraline 50 mg in the morning. 10. On 05/10/25, R #9 received sertraline 50 mg in the morning. 11. On 05/11/25, R #9 received sertraline 50 mg in the morning. 12. On 05/12/25, R #9 received sertraline 50 mg in the morning. 13. On 05/13/25, R #9 received sertraline 50 mg in the morning. 14. On 05/14/25, R #9 received sertraline 50 mg in the morning. 15. On 05/15/25, R #9 received sertraline 50 mg in the morning. 16. On 05/16/25, R #9 received sertraline 50 mg in the morning. 17. On 05/17/25, R #9 received sertraline 50 mg in the morning. 18. On 05/18/25, R #9 received sertraline 50 mg in the morning. 19. On 05/19/25, R #9 received sertraline 50 mg in the morning. D. Record review of R #9's Note to attending physician/prescriber (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 03/03/25 revealed the following: 1. R #9 has been taking the antidepressant sertraline 50 mg once daily for anxiety since 09/17/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Resident with good response, maintain the current dose and Disagree marked. 3. The medical director (clinician who oversees and guides the care provider to nursing home residents) did not provide rationale with patient specific information as to why R #10 needed to remain on the medication. 4. The form was signed by the medical director and dated 03/23/25. E. On 05/19/25 at 3:50 PM, during an interview, the DON confirmed the following: 1. The pharmacist recommendation for R #9 was not implemented by the medical director. 2. The medical director did not provide a rationale for not performing a GDR for R #9's sertraline. R #10 F. Record review of R #10's admission record, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had the following psychiatric diagnoses: a. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). b. Restlessness and agitation (feelings of irritability, nervousness and mental distress). G. Record review of R #10's physician's orders, multiple dates, revealed the following: 1. Order dated 04/11/24 and discontinued 11/26/24, for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) 50 mg, give 1 tablet by mouth in the morning related to depression. 2. Order dated 11/27/24, for sertraline tablet 50 mg, give 1 tablet by mouth in the morning for depression as evidenced by sadness. 3. Order dated 04/08/24 and discontinued 11/26/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep). 4. Order dated 11/27/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia. 5. Order dated 06/09/24 and discontinued 11/26/24, for escitalopram tablet (antidepressant medication used to treat anxiety and depression disorders) 10 mg, give 2 tablets by mouth in the morning for depression. 6. Order dated 11/27/24, for escitalopram tablet 10 mg, give 2 tablets by mouth in the morning for depression as evidenced by social isolation. 7. Order dated 04/22/24 and discontinued 11/26/24, hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 10 mg, give 1 tablet by mouth two times a day for anxiety related to restlessness and agitation. 8. Order dated 11/27/24, hydroxyzine tablet 10 mg, give 1 tablet by mouth two times a day for anxiety as evidenced by restlessness and agitation. H. Record review of R #10's MAR, dated 05/01/25 through 05/19/25, revealed the following: Sertraline 1. On 05/01/25, R #10 received sertraline 50 mg in the morning. 2. On 05/02/25, R #10 received sertraline 50 mg in the morning. 3. On 05/03/25, R #10 received sertraline 50 mg in the morning 4. On 05/04/25, R #10 received sertraline 50 mg in the morning. 5. On 05/05/25, R #10 received sertraline 50 mg in the morning. 6. On 05/06/25, R #10 received sertraline 50 mg in the morning. 7. On 05/07/25, R #10 received sertraline 50 mg in the morning. 8. On 05/08/25, R #10 received sertraline 50 mg in the morning. 9. On 05/09/25, R #10 received sertraline 50 mg in the morning. 10. On 05/10/25, R #10 received sertraline 50 mg in the morning. 11. On 05/11/25, R #10 received sertraline 50 mg in the morning. 12. On 05/12/25, R #10 received sertraline 50 mg in the morning. 13. On 05/13/25 R #10 received sertraline 50 mg in the morning. 14. On 05/14/25, R #10 received sertraline 50 mg in the morning. 15. On 05/15/25, R #10 received sertraline 50 mg in the morning. 16. On 05/16/25, R #10 received sertraline 50 mg in the morning. 17. On 05/17/25, R #10 received sertraline 50 mg in the morning. 18. On 05/18/25, R #10 received sertraline 50 mg in the morning. 19. On 05/19/25, R #10 received sertraline 50 mg in the morning. Trazodone 20. On 05/01/25, R #10 received trazodone 50 mg in the evening. 21. On 05/02/25, R #10 received trazodone 50 mg in the evening. 22. On 05/03/25, R #10 received trazodone 50 mg in the evening. 23. On 05/04/25, R #10 received trazodone 50 mg in the evening. 24. On 05/04/25, R #10 received trazodone 50 mg in the evening. 25. On 05/06/25, R #10 received trazodone 50 mg in the evening. 26. On 05/07/25, R #10 received trazodone 50 mg in the evening. 27. On 05/08/25, R #10 received trazodone 50 mg in the evening. 28. On 05/09/25, R #10 received trazodone 50 mg in the evening. 29. On 05/10/25, R #10 received trazodone 50 mg in the evening. . 30. On 05/11/25, R #10 received trazodone 50 mg in the evening. 31. On 05/12/25 R #10 received trazodone 50 mg in the evening. 32. On 05/13/25, R #10 received trazodone 50 mg in the evening. 33. On 05/14/25, R #10 received trazodone 50 mg in the evening. 34. On 05/15/25, R #10 received trazodone 50 mg in the evening. 35. On 05/16/25, R #10 received trazodone 50 mg in the evening. 36. On 05/17/25, R #10 received trazodone 50 mg in the evening. 37. On 05/18/25, R #10 received trazodone 50 mg in the evening. Escitalopram 38. On 05/01/25, R #10 received escitalopram 20 mg in the morning. 39. On 05/02/25, R #10 received escitalopram 20 mg in the morning. 40. On 05/03/25, R #10 received escitalopram 20 mg in the morning. 41. On 05/04/25, R #10 received escitalopram 20 mg in the morning. 42. On 05/05/25, R #10 received escitalopram 20 mg in the morning. 43. On 05/06/25, R #10 received escitalopram 20 mg in the morning. 44. On 05/07/25, R #10 received escitalopram 20 mg in the morning. 45. On 05/08/25, R #10 received escitalopram 20 mg in the morning. 46. On 05/09/25, R #10 received escitalopram 20 mg in the morning. 47. On 05/10/25, R #10 received escitalopram 20 mg in the morning. 48. On 05/11/25, R #10 received escitalopram 20 mg in the morning. 49. On 05/12/25, R #10 received escitalopram 20 mg in the morning. 50. On 05/13/25 R #10 received escitalopram 20 mg in the morning. 51. On 05/14/25, R #10 received escitalopram 20 mg in the morning. 52. On 05/15/25, R #10 received escitalopram 20 mg in the morning. 53. On 05/16/25, R #10 received escitalopram 20 mg in the morning. 54. On 05/17/25, R #10 received escitalopram 20 mg in the morning. 55. On 05/18/25, R #10 received escitalopram 20 mg in the morning. 56. On 05/19/25, R #10 received escitalopram 20 mg in the morning. Hydroxyzine 57. On 05/01/25, R #10 received hydroxyzine 10 mg twice daily. 58. On 05/02/25, R #10 received hydroxyzine 10 mg twice daily. 59. On 05/03/25, R #10 received hydroxyzine 10 mg twice daily. 60. On 05/04/25, R #10 received hydroxyzine 10 mg twice daily. 61. On 05/05/25, R #10 received hydroxyzine 10 mg twice daily. 62. On 05/06/25, R #10 received hydroxyzine 10 mg twice daily. 63. On 05/07/25, R #10 received hydroxyzine 10 mg twice daily. 64. On 05/08/25, R #10 received hydroxyzine 10 mg twice daily. 65. On 05/09/25, R #10 received hydroxyzine 10 mg twice daily. 66. On 05/10/25, R #10 received hydroxyzine 10 mg twice daily. 67. On 05/11/25, R #10 received hydroxyzine 10 mg twice daily. 68. On 05/12/25, R #10 received hydroxyzine 10 mg twice daily. 69. On 05/13/25, R #10 received hydroxyzine 10 mg twice daily. 70. On 05/14/25, R #10 received hydroxyzine 10 mg twice daily. 71. On 05/15/25, R #10 received hydroxyzine 10 mg twice daily. 72. On 05/16/25, R #10 received hydroxyzine 10 mg twice daily. 73. On 05/17/25, R #10 received hydroxyzine 10 mg twice daily. 74. On 05/18/25, R #10 received hydroxyzine 10 mg twice daily. I. Record review of R #10's Recommendation Summary for DON and medical director (pharmacist recommendation to the DON and medical director regarding residents' medications) dated 02/03/25, revealed the following: 1. R #10 has a history of chronic depression and has been receiving the current dose sertraline 50 mg every morning since 04/11/24, trazodone 50 mg at bedtime since 04/08/24, and escitalopram 20 mg every morning since 06/09/24 2. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested. 3. The form had Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the residents function and or cause psychiatric instability. (Please elaborate with patient specific information marked. 4. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the medications. 5. The form was signed by the medial director and dated 03/23/25. J. Record review of R #10's Note to attending physician (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 04/01/25, revealed the following: 1. R #10 has been taking the anxiolytic (class of medications used to prevent or treat anxiety symptoms or disorders) hydroxyzine 10 mg twice daily for anxiety since 04/22/24. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose marked. 3. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the same dose of hydroxyzine. 4. The form was signed by the medical director and dated 04/03/25. K. On 05/19/25 at 3:57 PM, during an interview, the DON confirmed the following: 1. The pharmacist recommendation for R #10 was not implemented by the medical director. 2. The medical director did not provide a rationale for not performing GDR's for R #10's medications. R #11 L. Record review of R #11's admission record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following psychiatric diagnoses: a. Major Depressive Disorder (MDD, mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) b. Panic disorder [Episodic Paroxysmal Anxiety] (mental and behavioral disorder, specifically an anxiety disorder characterized by recurring unexpected panic attacks). c. Psychotic Disorder with Hallucinations due to known physiological condition (a condition when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)). d. Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). M. Record review of R #11's physician's orders, multiple dates, revealed the following: 1. Order dated 04/29/24, and discontinued 11/26/24, for buspirone (medication that can treat anxiety) 5 mg tablet, one tablet twice a day for anxiety. 2. Order dated 11/26/24, for buspirone 5 mg tablet, one tablet twice a day for anxiety. 3. Order dated 09/29/23 and discontinued 11/26/24, for lorazepam 0.5 mg tablet, one tablet twice a day for anxiety. 4. Order dated 11/26/24, for lorazepam (medication that can treat anxiety) 0.5 mg tablet, one tablet twice a day for anxiety. 5. Order dated 07/07/23 and discontinued 10/01/23, for trazadone 50 mg, one tablet in the evening for insomnia. 6. Order dated 10/01/23 and discontinued 11/26/24, for trazadone 50 mg, one tablet in the evening for depression, MDD, insomnia. 7. Order dated 11/26/24, for trazadone 50 mg tablet, one tablet in the evening for depression, MDD, insomnia. 8. Order dated 08/03/23 and discontinued 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression. 9. Order dated 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression. 10. Order dated 06/30/23, for Nuplazid 34 mg, give one capsule at bedtime for hallucinations related to Parkinson's disease, psychotic disorder with hallucinations due to known physiological condition. N. Record review of R #11's MAR, dated May 2025, revealed the following: 1. R #11 received Lorazepam 0.5 mg twice a day as ordered. 2. R #11 received buspirone 5 mg twice a day as ordered. 3. R #11 received trazadone 50 mg in the evening as ordered. 4. R #11 received mirtazapine 7.5 mg in the evening as ordered. 5. R #11 received Nuplazid 34 mg in the evening as ordered. O. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 05/02/25, revealed the following: 1. R #11 had an order for buspirone 5 mg twice a day since 04/29/24, and a GDR was declined in February 2025. 2. R #11 had an order for lorazepam 0.5 mg twice a day since 09/29/23, and a GDR was declined in September 2024. 3. R #11 had an order for mirtazapine (antidepressant medication) 7.5 mg in the evening for depression since 08/03/23, and a GDR was declined in September 2024. 4. R #11 had an order for Nuplazid 34 mg at bedtime since 06/30/23, and a GDR was recommended in April 2025. 5. R #11 had an order for trazadone 50 mg at bedtime since 10/01/23, and a GDR was declined in October 2024. P. Record review of R #11's pharmacist recommendation, dated 08/03/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 08/03/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form had agree selected with a provider signature and date of 09/15/24. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. Q. Record review of R #11's pharmacist recommendation, dated 09/03/24, revealed the following: 1. R #11 has been taking the anxiolytic lorazepam 0.5 mg twice daily since 09/28/23. Please evaluate the current dose and consider a dose reduction. 2. The form had agree selected with a signature and date of 09/09/24. 3. The form had a note dated 09/16/24, verbal order to continue med. Per order by [Doctor Name]. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. R. Record review of R #11's pharmacist recommendation, dated 10/04/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of trazadone 50 mg at bedtime for depression since 10/01/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a note, dated 10/14/24, [Name of nurse practitioner] verbal continue of this dose. S. Record review of R #11's pharmacist recommendation, dated 02/03/25, revealed the following: 1. R #11 has been taking the anxiolytic buspirone 5 mg since 04/29/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Condition stable: Attempt dose reduction to discontinue this medication, Resident with good response, maintain the current dose, and Disagree marked. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a comment dated 02/19/25, MD intended to keep resident on current dose, verified by [DON signature]. T. Record review of R #11's pharmacist recommendation, dated 04/05/25, revealed the following: 1. R #11 has been taking the antipsychotic Nuplazid 34 mg at bedtime for psychotic disorder with hallucinations related to Parkinson's Disease since 06/30/23. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose. 3. The form had agree selected with a signature and date of 05/09/25. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. U. On 05/19/25 at 2:34 PM, during an interview, the DON confirmed the following: 1. R #11 has not had a GDR for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. 2. The provider did not provide a rationale for why she did not perform a GDR for R #11 for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. R #118 V. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order, dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. 2. An order, dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. W. Record review of R #118's MAR, dated 05/01/25 to 05/12/25, revealed the following: 1. On 05/01/25, R #118 received mirtazapine 7.5 mg in the evening. 2. On 05/02/25, R #118 received mirtazapine 7.5 mg in the evening. 3. On 05/03/25, R #118 refused mirtazapine 7.5 mg in the evening. 4. On 05/04/25, R #118 refused mirtazapine 7.5 mg in the evening. 5. On 05/05/25, R #118 received mirtazapine 7.5 mg in the evening. 6. On 05/06/25, R #118 received mirtazapine 7.5 mg in the evening. 7. On 05/07/25, R #118 received mirtazapine 7.5 mg in the evening. 8. On 05/08/25, R #118 received mirtazapine 7.5 mg in the evening. 9. On 05/09/25, R #118 received mirtazapine 7.5 mg in the evening. 10. On 05/10/25, R #118 received mirtazapine 7.5 mg in the evening. 11. On 05/11/25, R #118 received mirtazapine 7.5 mg in the evening. 12. On 05/12/25, R #118 refused mirtazapine 7.5 mg in the evening. X. Record review R #118's pharmacist recommendation, dated 05/02/25, revealed the following: 1. R #118 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 07/15/24. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form a provider signature and date of 05/09/25. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. Y. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118 has not had a GDR for mirtazapine. 2. The provider did not provide a rationale for why she did not perform a GDR for R #118 for mirtazapine. 49313

Recite from 05/22/24 Based on record review and interview the facility failed to ensure residents obtained dental services for 3 (R #9, R #10 and R #123) of 4 (R #9, R #10, R #121 and R #123) residents sampled for dental services, when staff failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #9 A. On 05/12/25 at 2:15 PM, during an interview, R #9 stated that she needed to have her dentures checked because they were loose. B. Record review of R #9's Admission Record, no date, revealed an admitted [DATE]. C. Record review of R #9's physician's order dated 09/16/24 revealed Dental consult as needed. D. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #9 had not been seen by a dentist since her admission. R #10 E. On 05/13/25 at 10:22 AM, during an interview, R #10's Power of Attorney (POA; legal document that appoints someone as a representative and allows them to act on one's behalf) stated that R #10 had a dental filling that fell out approximately 6 months ago. R #10's POA stated she asked for the facility to schedule an appointment, but she is unsure if she was seen by a dentist. F. Record review of R #10's physician's order dated 05/20/24 revealed Dental consult as needed. G. Record review of R #10's Weekly Oral/Dental Assessment, dated 11/29/24 revealed Upper gums red, irritated. Currently using medicated mouthwash for treatment. Resident broke her silver cap off a tooth yesterday 11/28/24. Transportation noted to make resident dentist appointment. Passed on in nursing report and nursing staff. H. Record review of R #10's progress notes revealed Social Service Note dated 12/13/24 at 1:57 PM: POA reported that her filling fell out of her mouth, she did report it to nurse. POA request that she needs to be taken to a dentist. I. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #10 had not been seen by a dentist after 11/28/24. R #123 J. Record review of R #123's face sheet, no date, revealed an admitted [DATE]. K. On 05/13/25 at 2:23 PM, during an interview, R #123 stated he had toothache, and he has not been to the dentist since his admission to the facility. L. Record review of R #123's treatment administration record dated 05/01/25 revealed dental consultation as needed. M. On 05/14/25 11:19 AM during an interview, DON stated she did not know that R #123 had a tooth ache. DON confirmed that R #123 did not have a monthly dental assessment in his record, and R #123 has been at the facility since 05/06/25 and has not seen a dentist in this time. 52223

Recite from 05/22/24 Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #9 and R #118) of 6 (R #1, R #9, R #10, R #118, R #130 and R #131) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #9 A. Record review of R #9's physician orders revealed the following: 1. An order dated 11/25/24 for acetaminophen (Tylenol; analgesic medication used to treat mild to moderate pain) tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for pain. B. Record review of R #9's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/06/25 at 3:01 AM, staff documented acetaminophen was given for a pain level of 5 (pain scale 1-10, 10 highest). 2. On 04/08/25 at 1:30 PM, staff documented acetaminophen was given for a pain level of 4. 3. On 04/16/25 at 11:15 PM, staff documented acetaminophen was given for a pain level of 4. 4. On 04/30/25 at 4:25 AM, staff documented acetaminophen was given for a pain level of 6. C. Record review of R #9's MAR dated May 2025, revealed staff documented the following: 1. On 05/09/25 at 4:54 AM, staff documented acetaminophen was given for a pain level of 6. 2. On 05/09/25 at 9:46 PM, staff documented acetaminophen was given for a pain level of 5. 3. On 05/13/25 at 2:45 AM, staff documented acetaminophen was given for a pain level of 3. 4. On 05/14/25 at 3:00 AM, staff documented acetaminophen was given for a pain level of 5. 5. On 05/16/25 at 5:46 AM, staff documented acetaminophen was given for a pain level of 5. 6. On 05/17/25 at 5:45 AM, staff documented acetaminophen was given for a pain level of 5. 7. On 05/17/25 at 5:08 PM, staff documented acetaminophen was given for a pain level of 5. 8. On 05/18/25 at 3:33 AM, staff documented acetaminophen was given for a pain level of 5. D. Record review of R #9's progress notes dated April 2025 and May 2025 revealed the following: 1. On 04/08/25 staff documented acetaminophen was given for throat pain. 2. Staff did not document the reason acetaminophen was given for any other dates in April or May. E. On 05/19/25 at 3:47 PM, during an interview with the DON, she confirmed the following: 1. Facility staff did not document the reason R #9 was given acetaminophen. 2. Facility staff did not document whether the acetaminophen was effective in treating R #9's complaints of pain. 3. She expects staff to document the location of the pain and whether the pain medication helped relieve the pain. 4. Documenting the pain location and effectiveness helps the facility staff and physician know if there needs to be additional treatment for complaints of pain or if medication changes are necessary. R #118 F. Record review of R #118's admission record, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 did not have any mental health diagnoses. G. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine (antidepressant to treat major depressive disorder) 7.5 mg in the evening for appetite and depression. 2. An order dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. H. Record review of R #118's provider's progress note, dated 07/12/24, revealed R #118 had a diagnosis of major depressive disorder (MDD, mood disorder that causes a persistent feeling of sadness and loss of interest). I. Record review of R #118's medical record, no date, revealed staff did not update R #118's medical diagnoses to include her diagnosis of MDD. J. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118's did not have a diagnosis of depression in her list of diagnoses in the medical record. 2. R #118's provider progress note, dated 07/12/24, listed MDD as one of R #118's diagnoses. 3. Staff did not update R #118's electronic medical record (EMR) with the diagnosis of MDD. 4. Staff were expected to update resident EMR's with all new diagnoses 49313

Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory Effective Communication training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of RN #24's Online Training Transcript, no date revealed effective communication training was not completed. B. Record review of LPN #25's Online Training Transcript, no date revealed effective communication training was not completed. C. Record review of CNA #26's Online Training Transcript, no date revealed effective communication training was not completed. D. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that Effective Communication Training has not been completed for RN #24, LPN #25, and CNA #26.

Based on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and heart rate outside of set parameters) for 1 (R #1) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to notify the provider that R #1's blood pressure was high and R #1's pulse was low. This deficient practice could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #1's physician orders revealed the following: 1. Amlodipine (high blood pressure primarily used to treat high blood pressure and chest pain by relaxing blood vessels which lowers blood pressure and decreases the hears workload) tablet 10 mg, give 1 tablet by mouth in the morning for high blood pressure (HTN; hypertension medical term for high blood pressure) hold (do not give medication) and call doctor if systolic blood pressure (SBP, top number of blood pressure reading ) is less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) is less than 50 and/or pulse (heart rate, beats per minute) is less than 50. Administer (give medication) and call doctor if SBP is greater than 180, DBP is greater than 100 and/or Pulse is greater than 100. C. Record review of R #1's Medication Administration Record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/01/25 staff documented bp 195/63 and administered amlodipine. 2. On 04/05/25 staff documented bp 181/64 and administered amlodipine. 3. On 04/08/25 staff documented pulse 47 and administered amlodipine. 4. On 04/08/25 staff documented pulse 43 and administered amlodipine. 5. On 04/09/25 staff documented bp 184/81 and administered amlodipine. 6. On 04/12/25 staff documented bp 189/78 and administered amlodipine. D. Record review of R #1's MAR dated May 2025, revealed staff documented the following: 1. On 05/04/25 staff documented bp 190/82 and administered amlodipine. 2. On 05/05/25 staff documented bp 198/74 and administered amlodipine. 3. On 05/06/25 staff documented bp 189/73 and administered amlodipine. 4. On 05/07/25 staff documented bp 185/76 and administered amlodipine. 5. On 05/10/25 staff documented bp 185/79 and administered amlodipine. 6. On 05/11/25 staff documented bp 217/92 and administered amlodipine. 7. On 05/13/25 staff documented bp 185/79 and administered amlodipine. 8. On 05/14/25 staff documented bp 182/70 and administered amlodipine. 9. On 05/15/25 staff documented bp 215/74 and administered amlodipine. E. Record review of R #1's progress notes for March and April 2025, revealed staff did not notify the physician of R #1's elevated blood pressure (SBP higher than 180) or low pulse (heart rate less than 50). F. On 05/19/25 at 3:19 PM, during an interview, the DON confirmed the following: 1. R #1's blood pressure was elevated, and her pulse was low. 2. R #1's order indicated that staff are to call physician when blood pressure is greater than 180 and heart rate is less than 50. 3. Facility staff did not call the physician as indicated.

The following deficient practices were found during an annual/complaint survey that were Immediate Jeopardy: 1) CNA #1 was still working with the residents after a few residents told previous administrative individuals of the possible abusive incidents that happened in (YEAR) and their fears. Former members of the Administration were made aware of one of the abusive incidents toward residents by CNA #1 on 08/14/17. 2) The incidents that happened in (YEAR) were not thoroughly investigated by the former administrative staff nor were they reported to the State Agency (SA) when the former administrative staff were made aware of the incidents. 3) The most recent former Administrator had investigated the incident when he became aware of them in (MONTH) (YEAR). He decided that with at least one resident still fearful of CNA #1, he would not bring back CNA #1. He reported to the SA on 03/24/18 that he would not rehire CNA #1. 4) The facility had no documentation of when the staff were last taught about how, when, and to whom to report abuse/neglect/exploitation. 5) Current administration did not know where to locate the policies and procedures regarding abuse/neglect/exploitation and therefore did not implement them. This resulted in an Immediate Jeopardy that was called on 07/10/18 at 5:50 pm. The Final Plan of Removal was accepted on 07/12/18 at 8:30 am. PLAN OF REMOVAL 1. 7/10/18- (Name of CNA #1) was placed on suspension pending investigation upon notification of an Immediate Jeopardy call by the (SA) State Survey Team. (Name of CNA #1) is aware she is not to return to the facility or have contact with facility employees until the conclusion of this investigation. At the conclusion of the investigation, (Name of CNA #1) will be notified of investigation results in the presence of (Tribal) HR (Human Resources) Administrator and (Name of facility) Director of Nursing Services. 2. 7/11/18 - a second allegation of abuse was presented by the NM State Survey Team. (Name of CNA #1) is already on suspension. 3. A full investigation will be conducted for each allegation. 4. (Name of SA) report will be prepared and transmitted to SA for each allegation. 5. A 5-Day follow-up report will be completed and transmitted to SA for each allegation. 6. Employees will be provided abuse and neglect education prior to the start of their scheduled shift until 100% of scheduled and PRN (on-call) personnel have documented education on file. Employee education packet includes: 1. A written narrative of definitions of abuse and neglect; as well as, possible signs of abuse/neglect that might be demonstrated by a resident suffering from abuse/neglect; 2. Abuse/Neglect state reporting requirements and timeframes for completion. This information is posted at the nurse's station as well for quick references, 3. Post-test with passing score of 75%. A sign-in-sheet for education is attached signifying 100% completion. 7. All contract services personnel who provide resident services will complete abuse/neglect education requirements. 8. All new employees will attend New Employee Orientation where each will receive abuse/neglect education prior to providing care for residents at (Name of facility). 9. Abuse/Neglect education will be provided to all employees and contract service employees on a yearly basis. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 07/12/18 at 11:56 am. This resulted in the scope and severity reduced from a L to an F. Based on record review, observation, and interview, the facility failed to keep residents safe from abuse when the facility allowed a CNA (#1), that residents had been complained about in (MONTH) (YEAR) and were still fearful, to return to work with the residents. This deficient practice could impact all 34 residents (as listed on the Resident Census and Condition provided by the DON on 07/09/18). This failed practice could place residents at risk of abuse, fear, and intimidation. The findings are: A. Record review of an undated investigative report for R #37 completed by the previous Administrator revealed the following: Brief summary of the incident: Resident (#37) stated that former staff member (Name of CNA #1) was verbally abusive towards her and proceeded to tell the Social Services Director and Activities Director that (CNA #1) had been rough with another resident and was verbally inappropriate to another . (Name of R #37) stated that she had previously informed former DON (Name of former DON) in writing. (Name of R #37) did provide another incident that she has not turned in. Conclusion: (Name of R #37) stated that she if (sic) fearful of having (Name of CNA #1) return because she does not know what (name of CNA #1) would do if a resident fails to follow (name of CNA #1)'s direction (i.e., (sic) verbally, physically hurtful to a frail and elderly population) . Based on her fears, it is my recommendation that (name of CNA #1) not return to the facility for employment. B. Record review of a letter written by R #37 dated 08/14/17 revealed an incident that happened on 08/13/17 in the evening. R #37 described that CNA #1 started yelling at R #37's roommate at the time (R #25) to get her nightgown on. When R #37 put on the call light to ask for a gown, and CNA #1 was curt with her. CNA #1 the went on to yell about how another CNA was leaving work for her to do and was slamming doors. The letter is is incomplete and stops there. The rest of the letter could not be found. C. Record review of a typed letter dated 03/22/18 revealed that R #37 was talking about an incident that happened with CNA #1 in (MONTH) (YEAR). Letter read, (Name of R #37) than (sic) stated, 'That (name of CNA #1) was verbally abusive towards her roommate, (name of R #25) . Then the CNA roughly pushed (name of R #25) to the sink and began helping her with face washing and tooth brushing. The next day (08/14/17), R #37 report the incident to a former DON. The letter continued, (Name of R #37) is afraid that if this CNA were to be employed again here, that there would be a physical confrontation. (Name of R #37) expressed that she id fearful of this CNA. She was very shocked and afraid when she heard that (name of CNA #1) was coming back, She expressed her fear with the care planning team . This letter is signed by the care planning team. D. Record review of a typed note dated 03/22/18 revealed information provided by R #3 to the Social Services Director (SSD). The SSD wrote that R #3 told her about a time that she was sick and CNA #1 had thrown her around as a rag doll, she (R #3) kept yelling, 'Ouch, ouch. You are hurting me.' CNA #1 replied that, 'I know what I'm doing.' (Name of R #3) is afraid of her and requested that (name of CNA #1) not attend to her. This is signed by the SSD and R #3. E. During an interview on 07/10/18 at 3:00 pm, the SSD stated that in (MONTH) (YEAR) the DON asked her to collect anything that she had about CNA #1. She collected the previously mentioned information and provided the DON her opinion that CNA #1 should not be working with the residents. F. Record review of the CNA Schedule for 07/08/18 through 07/21/18 revealed that CNA #1 was scheduled to work in the evening on 07/10/18. G. On 07/10/18 at 4:00 pm, CNA #1 was seen in the common room while working with different residents. H. During an interview on 07/10/18 at 5:05 pm, R #3 was asked about CNA #1. R #3 stated that CNA #1 was not to attend to her, but she occasionally does. When asked if she is fearful of her, she stated, Yes. She would not provide any more information. I. During an interview on 07/10/18 at 5:50 pm, the DON stated that she was also asked to investigate this in (MONTH) (YEAR). She stated that CNA #1 was let go in (MONTH) of (YEAR) because of not showing up to work. CNA #1 was to return in (MONTH) (YEAR) and that the SSD had issues about this. No documentation of any previous incidents were found until until (MONTH) (YEAR). On the day (03/21/18) that she was hired back, she was immediately placed on paid leave until the end of the investigation. CNA #1 did return (no specified date), but has had no complaints about her since her return. J. During an interview on 07/10/18 at 5:50 pm, the DON stated that R #37 could not be interviewed because she was not longer in the facility. K. During an interview on 07/11/18 at 9:00 am, R #25 could not remember any problems or issues with any staff. L. During an interview on 07/11/18 at 10:45 am, the SSD stated that R #37 had told her in (MONTH) (YEAR) that she has many incident in (YEAR) with CNA #1 and reported them to the previous DON. When asked about R #3, the SSD stated that she does not know when this happened. R #3 reported that she was not feeling well and had nausea and had both vomited and diarrhea. When CNA #1 had come to clean her up, CNA #1 was rough with her. And because of this, R #3 did not want CNA #1 to work with her. When asked about R #25 and R #37, she stated that R #25 has a poor memory, but that R #37 has a good memory. M. During an interview on 07/09/18 at 2:00 pm, R #20 stated that CNA #1 and CNA #9 have been rough with her. When she was asked if she reported to staff, R #20 stated that she has told therapy and SSD. N. Record review of a posted note attached to resident council meeting minutes dated 04/26/17 revealed that R #20 had stated that CNA #1 and CNA #9 are often rough with her. O. During an interview on 07/11/15 at 10:15 am, the SA Complaints Section confirmed that no complaints or investigations were send in about the incidents in (YEAR). They further confirmed that no requests to place a CNA on the Nurse Aide Registry had been made by the facility recently. P. Record review of a Grievance/Complaint report dated 05/10/18 that the SSD had revealed that R #11 had fallen and a CNA had helped her up. She received bruises on both of wrists and they both hurt. Further review revealed that the DON written that she had counseled the CNA about proper lift techniques and use of mechanical lift . Q. During an interview on 07/11/18 at 10:45 am, the SSD was asked if any of the incidents found in the Grievance notebook or resident council meeting minutes had been reported to the SA or fully investigated, She stated that none had been reported to the SA or investigated for abuse. R. Record review of the facility's Abuse Investigations binder revealed Abuse Investigations policies and procedures that were last reviewed in (YEAR). 1. Review of them revealed nothing about not employing someone that the facility has determined that abused/neglected/exploited a resident of the facility. Further the policies and procedures do not indicate if the the facility does substantiate abuse/neglect/exploitation, the facility will make a recommendation to the SA to place the person on the Nurse Aide Registry. 2. Review of the facility's policy and procedure titled, Reporting Abuse to Facility Management, undated, revealed that if abuse is seen or could be assumed, then this was to be reported promptly to the facility administration to be investigated. The SA is to be notified within 24 hours. A thorough investigations is the be completed and sent to the SA on or before day five. S. During on interview on 07/10/18 at 5:50 pm, the DON was asked if she knew of any policies and procedure about abuse/neglect/exploitation. She stated that she did not know if the facility had any. She was then given the Abuse Investigations binder.

During an annual survey, the following deficient practice was found to be an Immediate Jeopardy: 1) A nurse had administered humalog insulin to R #185 on 07/02/18 when his blood sugar was 418. The sliding scale revealed: 350-399 mg/dl give 4 units and call MD. 2) The nurse attempted to contact the MD about this incident, but was unable to get a response from him until 07/08/18 because he was out of town and did not get coverage. 3) On 07/09/18, a nurse gave R #185 [MEDICATION NAME] 5/325 when his order was for [MEDICATION NAME] 10/325. The resident is now fearful and anxious of medications he is presented with and feels like he must examine each one. The nurse did not the notify the MD about the error. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 6:49 pm. An acceptable Plan of Removal was submitted on 07/27/18 at 11:00 am and approved. The plan was: 1. Nurses giving insulin without having orders for 2 different residents. Nurses not notifying the MD for elevated blood sugars. * Interventions: A. Nurse will be in-serviced prior to working on the floor regarding diabetes management. (i.e., disease process, medication management; assessment and monitoring; and hypo and [MEDICAL CONDITION], and implications to residents' health and intervention.) B. Nurses will be education prior to working on the floor regarding following physician orders [REDACTED]. * Date of Completion: 07/30/18 As of 07/31/18 at 11:58 am, the IJ plan of removal was accepted and the IJ was lifted based on verfication. This resulted in a change of scope and serverity from a L to a E. Based on record review and interview, the facility failed to ensure that the physician was notified of elevated blood sugars for 2 (R #185 and R #20) of 2 (R #185 and R #20) residents reviewed for insulin. Further, a nurse failed to notify the physician when she gave the wrong opioid pain medication and to R #185 (reviewed for complaint of medication error). This deficient practice can likely result the physician being unaware significant events of the resident and the opportunity to make decisions regarding the care of the resident in a timely fashion that can result in a delay in treatment that could result in illness and death. The findings are: R #185 A. Record review of the (Name of facility) admission orders [REDACTED]. B. Record review of a faxed order for R #185, fax confirmation date 06/26/18 revealed: Humalog (a type of insulin) sliding scale (amount of insulin to be given based on the results of blood glucose (sugar)) AC (before meals) & HS (at bedtime). Call if less than 100 Less than 150 mg (milligram)/dl (deciliter) 0 units (give no insulin) 150-199 mg/dl 1 unit 200-249 mg/dl 2 units 250-299 mg/dl 3 units 300-349 mg/dl 4 units 350-399 mg/dl 4 units and call MD (medical doctor) Call if greater than 400 06/26/2018 Open ended (no end date for the order) C. Record review of the blood glucose log for R #185 for (MONTH) (YEAR) revealed: 07/02/18 blood sugar was 418. D. Record review of the skilled daily nurse notes dated 07/02/18 for R #185 revealed: Blood sugar at 1100 (11 am) was 418. Covered with Humalog 6 units. attempted to contact doctor on home phone with no success. Informed via fax. E. Record review of fax from RN #1 to MD regarding R #185, dated 07/02/18 revealed: Resident's blood sugar was 418. Covered w/(with) Humalog 6 units. Resident A & O (Alert and oriented). Doctor's response OK cont. (continue) sliding scale dated 07/08/18. Noted (date received and noted as read by staff) on 07/09/18. F. On 07/11/18 at 2:46 pm, during an interview, the DON stated, I know the nurse contacted the doctor on 07/02/18 to notify him of the elevated blood sugar by fax. He was out of town, but the order does say greater than 400 blood sugar he should be contacted. I don't believe the doctor had anyone to cover for him. If he did, he did not tell us. If they couldn't get a hold of the doctor, they should call me. If it is an emergency, they have to call me and I would decide to send them to the ER (emergency room or not). I do not have a written protocol. G. On 07/11/18 at 5:10 pm, during an interview with the MD (Medical Doctor), who is also the medical director, when asked about 24 hours emergency coverage for the residents, he stated, I would always be available, but I am not always available to just snap to right away. I am the coverage and I have not found anyone to help. If he (the resident) was clinically stable, there would be no need. Nurses can decide what they think is best. The MD affirmed that a nurse could send a resident to the emergency room if the nurse resident was not clinically stable. R #20 H. Record review of the Physician order [REDACTED].#20, dated 07/01/18 to 07/31/18 revealed the Diagnoses: [REDACTED]. are attacked by its own immune system), and [MEDICAL CONDITION] arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). I. Record review of the PRN Medication flow sheet for R #20, dated 06/01/2018 - 06/30/2018 revealed: 1. 06/15/18 at 4:30 pm - blood sugar 400 2. 06/16/18 at 11:30 am - blood sugar 462 3. 06/25/18 at 11:30 am - blood sugar 419 4. 06/27/18 at 11:30 am - blood sugar 413 J. Record review of the Order dated 05/01/18 revealed: Humalog (Insulin [MEDICATION NAME]) solution 100 units/ml Amount to be administrated (sic) per sliding scale 150-200 give 2 units 201-250 give 4 units 251-300 give 6 units 301-350 give 8 units 351-400 give 10 units Call MD only when less than 70 or greater than 400 05/01/18 K. Record review of Nurse's Notes for R #20 revealed one nursing note in (MONTH) (YEAR) regarding a blood draw for a potassium level on 06/27/18. There was no other documentation recorded for that month, nothing regarding notification of the physician for the elevated blood sugars. L. On 07/16/18 at 11:46 am, during an interview with RN #4 regarding the elevated blood sugars for R #20 in June; when asked, she stated, Yes, the blood sugars were not reported. I was caring for her her on (MONTH) 16th and 25, The blood sugar was over 400. But if she tells me she had a snack, I would not notify the doctor. By the order, I should have called the doctor; but I do not call if she has had a snack. M, On 07/16/18 at 2:16 pm, during an interview with the DON regarding the unreported high blood sugars; she stated, The nurses should have called on the high sugars. N. On 07/19/18 at 1:27 pm, during an interview, the DON was asked about the lack of timely notification of the physician about high blood sugars. She stated, Possible outcome to patient is [DIAGNOSES REDACTED] (low blood sugar) or even death by Diabetic Ketoacidosis (a life-threatening complication diabetes that occurs when the body produces high levels of [MEDICATION NAME] due to lack of insulin). R #185 Wrong Pain Medication O. On 07/10/18 at 3:28 pm, during an interview, RN #3 was asked about a medication error with R #185. She stated, I would say it it would have on 07/04/18. I would have to look at the narcotic sign out sheet. (Name of R #185)'s family member said he needed something for pain. I got R #184's pain medication -from a bottle of 5 mg (a metric unit of measure)/325 mg [MEDICATION NAME] (an opioid pain medication). I took it in him (R #185) at same time I was helping to pass trays, feeding another resident in dining room, and passing meds (medications). R #185 said, 'It's white (a different color than he was used to).' He didn't have to swallow it if he had questions. He started getting woozy and he complained. I wondered if I gave him right thing. He (R #185) said it really knocked him out. I went and talked to him. The family member said he was slurring his speech--but I saw he was alert and joking around. When I looked at pills, I thought I made an error. Remember, all these guys (new admissions) were called the same nickname. When I looked at the pills, I knew I made a mistake. I went an apologize to (Name of R #185). I just kept an eye on him. No special vital signs or anything else. I did not notify doctor or my supervisor. He (R #185) went to bed he was fine. The DON came to me or the wife went to her, I don't remember. The DON asked me about the error. There is a medication error form, but I did not do one because I was not asked to do one. I did not document (the error) on his (R #185's) drug log or document it in his chart. I think I signed it out on the control drug sheet for R #184. After reviewing the control drug logs, RN #3 said she was unsure of the date it happened, or if she had signed it out. I can't really read it (the documentation). P. On 07/10/18 at 5:29 pm, during an interview with the DON regarding the opioid administration error. The DON said when she found out about the error she did not notify the physician either.

The following deficient practices were found during an annual/complaint survey that were Immediate Jeopardy: 1) CNA #1 was still working with the residents after a few residents told previous administrative individuals of the possible abusive incidents that happened in (YEAR) and their fears. Former members of the Administration were made aware of one of the abusive incidents toward residents by CNA #1 on 08/14/17. 2) The incidents that happened in (YEAR) were not thoroughly investigated by the former administrative staff nor were they reported to the State Agency (SA) when the former administrative staff were made aware of the incidents. 3) The most recent former Administrator had investigated the incident when he became aware of them in (MONTH) (YEAR). He decided that with at least one resident still fearful of CNA #1, he would not bring back CNA #1. He reported to the SA on 03/24/18 that he would not rehire CNA #1. 4) The facility had no documentation of when the staff were last taught about how, when, and to whom to report abuse/neglect/exploitation. 5) Current administration did not know where to locate the policies and procedures regarding abuse/neglect/exploitation and therefore did not implement them. This resulted in an Immediate Jeopardy that was called on 07/10/18 at 5:50 pm. The Final Plan of Removal was accepted on 07/12/18 at 8:30 am. PLAN OF REMOVAL 1. 7/10/18- (Name of CNA #1) was placed on suspension pending investigation upon notification of an Immediate Jeopardy call by the (SA) State Survey Team. (Name of CNA #1) is aware she is not to return to the facility or have contact with facility employees until the conclusion of this investigation. At the conclusion of the investigation, (Name of CNA #1) will be notified of investigation results in the presence of (Tribal) HR (Human Resources) Administrator and (Name of facility) Director of Nursing Services. 2. 7/11/18 - a second allegation of abuse was presented by the NM State Survey Team. (Name of CNA #1) is already on suspension. 3. A full investigation will be conducted for each allegation. 4. (Name of SA) report will be prepared and transmitted to SA for each allegation. 5. A 5-Day follow-up report will be completed and transmitted to SA for each allegation. 6. Employees will be provided abuse and neglect education prior to the start of their scheduled shift until 100% of scheduled and PRN (on-call) personnel have documented education on file. Employee education packet includes: 1. A written narrative of definitions of abuse and neglect; as well as, possible signs of abuse/neglect that might be demonstrated by a resident suffering from abuse/neglect; 2. Abuse/Neglect state reporting requirements and timeframes for completion. This information is posted at the nurse's station as well for quick references, 3. Post-test with passing score of 75%. A sign-in-sheet for education is attached signifying 100% completion. 7. All contract services personnel who provide resident services will complete abuse/neglect education requirements. 8. All new employees will attend New Employee Orientation where each will receive abuse/neglect education prior to providing care for residents at (Name of facility). 9. Abuse/Neglect education will be provided to all employees and contract service employees on a yearly basis. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 07/12/18 at 11:56 am. This resulted in the scope and severity reduced from a L to an F. Based on record review, observation, and interview, the facility failed fully develop and implement the facility's Abuse/Neglect/Exploitation policies and procedures to protect the residents when the facility allowed a CNA (#1), that residents had complained about in (MONTH) (YEAR) and were still fearful, to return to work with the residents. Further, the facility failed to thoroughly investigate and report to the State Agency (SA) the incident when staff became aware of the incidents on 08/14/17. This deficient practice could impact all 34 residents (as listed on the Resident Census and Condition provided by the DON on 07/09/18). This failed practice could place residents at risk of abuse, fear, and intimidation. The findings are: A. Record review of the facility's Abuse Investigations binder revealed Abuse Investigations policies and procedures that were last reviewed in (YEAR). 1. Review of them revealed nothing about not employing someone that the facility has determined that abused/neglected/exploited a resident of the facility. Further the policies and procedures do not indicate if the the facility does substantiate abuse/neglect/exploitation, the facility will make a recommendation to the SA to place the person on the Nurse Aide Registry. 2. Review of the facility's policy and procedure titled, Reporting Abuse to Facility Management, undated, revealed that if abuse is senn or could be assumed, then this was to be reported promptly to the facility administration to be investigated. The SA is to be notified within 24 hours. A thorough investigations is the be completed and sent to the SA on or before day five. B. During on interview on 07/10/18 at 5:50 pm, the DON was asked if she knew of any policies and procedure about abuse/neglect/exploitation. She stated that she did not know if the facility had any. She was then given the Abuse Investigations binder. C. Record review of an undated investigative report for R #37 completed by the previous Administrator revealed the following: Brief summary of the incident: Resident (#37) stated that former staff member (Name of CNA #1) was verbally abusive towards her and proceeded to tell the Social Services Director and Activities Director that (CNA #1) had been rough with another resident and was verbally inappropriate to another . (Name of R #37) stated that she had previously informed former DON (Name of former DON) in writing. (Name of R #37) did provide another incident that she has not turned in. Conclusion: (Name of R #37) stated that she if (sic) fearful of having (Name of CNA #1) return because she does not know what (name of CNA #1) would do if a resident fails to follow (name of CNA #1)'s direction (i.e., (sic) verbally, physically hurtful to a frail and elderly population) . Based on her fears, it is my recommendation that (name of CNA #1) not return to the facility for employment. D. Record review of a letter written by R #37 dated 08/14/17 revealed an incident that happened on 08/13/17 in the evening. R #37 described that CNA #1 started yelling at R #37's roommate at the time (R #25) to get her nightgown on. When R #37 put on the call light to ask for a gown, and CNA #1 was curt with her. CNA #1 the went on to yell about how another CNA was leaving work for her to do and was slamming doors. The letter is is incomplete and stops there. The rest of the letter could not be found. E. Record review of a typed letter dated 03/22/18 revealed that R #37 was talking about an incident that happened with CNA #1 in (MONTH) (YEAR). Letter read, (Name of R #37) than (sic) stated, 'That (name of CNA #1) was verbally abusive towards her roommate, (name of R #25) . Then the CNA roughly pushed (name of R #25) to the sink and began helping her with face washing and tooth brushing. The next day (08/14/17), R #37 report the incident to a former DON. The letter continued, (Name of R #37) is afraid that if this CNA were to be employed again here, that there would be a physical confrontation. (Name of R #37) expressed that she id fearful of this CNA. She was very shocked and afraid when she heard that (name of CNA #1) was coming back, She expressed her fear with the care planning team . This letter is signed by the care planning team. F. Record review of a typed note dated 03/22/18 revealed information provided by R #3 to the Social Services Director (SSD). The SSD wrote that R #3 told her about a time that she was sick and CNA #1 had thrown her around as a rag doll, she (R #3) kept yelling, 'Ouch, ouch. You are hurting me.' CNA #1 replied that, 'I know what I'm doing.' (Name of R #3) is afraid of her and requested that (name of CNA #1) not attend to her. This is signed by the SSD and R #3. G. During an interview on 07/10/18 at 3:00 pm, the SSD stated that in (MONTH) (YEAR) the DON asked her to collect anything that she had about CNA #1. She collected the previously mentioned information and provided the DON her opinion that CNA #1 should not be working with the residents. H. Record review of the CNA Schedule for 07/08/18 through 07/21/18 revealed that CNA #1 was scheduled to work in the evening on 07/10/18. I. On 07/10/18 at 4:00 pm, CNA #1 was seen in the common room while working with different residents. J. During an interview on 07/10/18 at 5:05 pm, R #3 was asked about CNA #1. R #3 stated that CNA #1 was not to attend to her, but she occasionally does. When asked if she is fearful of her, she stated, Yes. She would not provide any more information. K. During an interview on 07/10/18 at 5:50 pm, the DON stated that she was also asked to investigate this in (MONTH) (YEAR). She stated that CNA #1 was let go in (MONTH) of (YEAR) because of not showing up to work. CNA #1 was to return in (MONTH) (YEAR) and that the SSD had issues about this. No documentation of any previous incidents were found until until (MONTH) (YEAR). On the day (03/21/18) that she was hired back, she was immediately placed on paid leave until the end of the investigation. CNA #1 did return (no specified date), but has had no complaints about her since her return. L. During an interview on 07/10/18 at 5:50 pm, the DON stated that R #37 could not be interviewed because she was not longer in the facility. M. During an interview on 07/11/18 at 9:00 am, R #25 could not remember any problems or issues with any staff. N. During an interview on 07/11/18 at 10:45 am, the SSD stated that R #37 had told her in (MONTH) (YEAR) that she has many incident in (YEAR) with CNA #1 and reported them to the previous DON. When asked about R #3, the SSD stated that she does not know when this happened. R #3 reported that she was not feeling well and had nausea and had both vomited and diarrhea. When CNA #1 had come to clean her up, CNA #1 was rough with her. And because of this, R #3 did not want CNA #1 to work with her. When asked about R #25 and R #37, she stated that R #25 has a poor memory, but that R #37 has a good memory. O. During an interview on 07/09/18 at 2:00 pm, R #20 stated that CNA #1 and CNA #9 have been rough with her. When she was asked if she reported to staff, R #20 stated that she has told therapy and SSD. P. Record review of a posted note attached to resident council meeting minutes dated 04/26/17 revealed that R #20 had stated that CNA #1 and CNA #9 are often rough with her. Q. During an interview on 07/11/15 at 10:15 am, the SA Complaints Section confirmed that no complaints or investigations were send in about the incidents in (YEAR). They further confirmed that no requests to place a CNA on the Nurse Aide Registry had been made by the facility recently. R. Record review of a Grievance/Complaint report dated 05/10/18 that the SSD had revealed that R #11 had fallen and a CNA had helped her up. She received bruises on both of wrists and they both hurt. Further review revealed that the DON written that she had counseled the CNA about proper lift techniques and use of mechanical lift . S. During an interview on 07/11/18 at 10:45 am, the SSD was asked if any of the incidents found in the Grievance notebook or resident council meeting minutes had been reported to the SA or fully investigated, She stated that none had been reported to the SA or investigated for abuse.

The following deficient practices were found during an annual/complaint survey that were Immediate Jeopardy: 1) CNA #1 was still working with the residents after a few residents told previous administrative individuals of the possible abusive incidents that happened in (YEAR) and their fears. Former members of the Administration were made aware of one of the abusive incidents toward residents by CNA #1 on 08/14/17. 2) The incidents that happened in (YEAR) were not thoroughly investigated by the former administrative staff nor were they reported to the State Agency (SA) when the former administrative staff were made aware of the incidents. 3) The most recent former Administrator had investigated the incident when he became aware of them in (MONTH) (YEAR). He decided that with at least one resident still fearful of CNA #1, he would not bring back CNA #1. He reported to the SA on 03/24/18 that he would not rehire CNA #1. 4) The facility had no documentation of when the staff were last taught about how, when, and to whom to report abuse/neglect/exploitation. 5) Current administration did not know where to locate the policies and procedures regarding abuse/neglect/exploitation and therefore did not implement them. This resulted in an Immediate Jeopardy that was called on 07/10/18 at 5:50 pm. The Final Plan of Removal was accepted on 07/12/18 at 8:30 am. PLAN OF REMOVAL 1. 7/10/18- (Name of CNA #1) was placed on suspension pending investigation upon notification of an Immediate Jeopardy call by the (SA) State Survey Team. (Name of CNA #1) is aware she is not to return to the facility or have contact with facility employees until the conclusion of this investigation. At the conclusion of the investigation, (Name of CNA #1) will be notified of investigation results in the presence of (Tribal) HR (Human Resources) Administrator and (Name of facility) Director of Nursing Services. 2. 7/11/18 - a second allegation of abuse was presented by the NM State Survey Team. (Name of CNA #1) is already on suspension. 3. A full investigation will be conducted for each allegation. 4. (Name of SA) report will be prepared and transmitted to SA for each allegation. 5. A 5-Day follow-up report will be completed and transmitted to SA for each allegation. 6. Employees will be provided abuse and neglect education prior to the start of their scheduled shift until 100% of scheduled and PRN (on-call) personnel have documented education on file. Employee education packet includes: 1. A written narrative of definitions of abuse and neglect; as well as, possible signs of abuse/neglect that might be demonstrated by a resident suffering from abuse/neglect; 2. Abuse/Neglect state reporting requirements and timeframes for completion. This information is posted at the nurse's station as well for quick references, 3. Post-test with passing score of 75%. A sign-in-sheet for education is attached signifying 100% completion. 7. All contract services personnel who provide resident services will complete abuse/neglect education requirements. 8. All new employees will attend New Employee Orientation where each will receive abuse/neglect education prior to providing care for residents at (Name of facility). 9. Abuse/Neglect education will be provided to all employees and contract service employees on a yearly basis. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 07/12/18 at 11:56 am. This resulted in the scope and severity reduced from a L to an F. Based on record review, observation, and interview, the facility failed to thoroughly investigate and report to the State Agency (SA) the possible abuse by CNA #1 when staff became aware of the incidents on 08/14/17. This deficient practice could impact all 34 residents (as listed on the Resident Census and Condition provided by the DON on 07/09/18). This failed practice could place residents at risk of abuse, fear, and intimidation. The findings are: A. Record review of an undated investigative report for R #37 completed by the previous Administrator revealed the following: Brief summary of the incident: Resident (#37) stated that former staff member (Name of CNA #1) was verbally abusive towards her and proceeded to tell the Social Services Director and Activities Director that (CNA #1) had been rough with another resident and was verbally inappropriate to another . (Name of R #37) stated that she had previously informed former DON (Name of former DON) in writing. (Name of R #37) did provide another incident that she has not turned in. Conclusion: (Name of R #37) stated that she if (sic) fearful of having (Name of CNA #1) return because she does not know what (name of CNA #1) would do if a resident fails to follow (name of CNA #1)'s direction (i.e., (sic) verbally, physically hurtful to a frail and elderly population) . Based on her fears, it is my recommendation that (name of CNA #1) not return to the facility for employment. B. Record review of a letter written by R #37 dated 08/14/17 revealed an incident that happened on 08/13/17 in the evening. R #37 described that CNA #1 started yelling at R #37's roommate at the time (R #25) to get her nightgown on. When R #37 put on the call light to ask for a gown, and CNA #1 was curt with her. CNA #1 the went on to yell about how another CNA was leaving work for her to do and was slamming doors. The letter is is incomplete and stops there. The rest of the letter could not be found. C. Record review of a typed letter dated 03/22/18 revealed that R #37 was talking about an incident that happened with CNA #1 in (MONTH) (YEAR). Letter read, (Name of R #37) than (sic) stated, 'That (name of CNA #1) was verbally abusive towards her roommate, (name of R #25) . Then the CNA roughly pushed (name of R #25) to the sink and began helping her with face washing and tooth brushing. The next day (08/14/17), R #37 report the incident to a former DON. The letter continued, (Name of R #37) is afraid that if this CNA were to be employed again here, that there would be a physical confrontation. (Name of R #37) expressed that she id fearful of this CNA. She was very shocked and afraid when she heard that (name of CNA #1) was coming back, She expressed her fear with the care planning team . This letter is signed by the care planning team. D. Record review of a typed note dated 03/22/18 revealed information provided by R #3 to the Social Services Director (SSD). The SSD wrote that R #3 told her about a time that she was sick and CNA #1 had thrown her around as a rag doll, she (R #3) kept yelling, 'Ouch, ouch. You are hurting me.' CNA #1 replied that, 'I know what I'm doing.' (Name of R #3) is afraid of her and requested that (name of CNA #1) not attend to her. This is signed by the SSD and R #3. E. During an interview on 07/10/18 at 3:00 pm, the SSD stated that in (MONTH) (YEAR) the DON asked her to collect anything that she had about CNA #1. She collected the previously mentioned information and provided the DON her opinion that CNA #1 should not be working with the residents. F. Record review of the CNA Schedule for 07/08/18 through 07/21/18 revealed that CNA #1 was scheduled to work in the evening on 07/10/18. G. On 07/10/18 at 4:00 pm, CNA #1 was seen in the common room while working with different residents. H. During an interview on 07/10/18 at 5:05 pm, R #3 was asked about CNA #1. R #3 stated that CNA #1 was not to attend to her, but she occasionally does. When asked if she is fearful of her, she stated, Yes. She would not provide any more information. I. During an interview on 07/10/18 at 5:50 pm, the DON stated that she was also asked to investigate this in (MONTH) (YEAR). She stated that CNA #1 was let go in (MONTH) of (YEAR) because of not showing up to work. CNA #1 was to return in (MONTH) (YEAR) and that the SSD had issues about this. No documentation of any previous incidents were found until until (MONTH) (YEAR). On the day (03/21/18) that she was hired back, she was immediately placed on paid leave until the end of the investigation. CNA #1 did return (no specified date), but has had no complaints about her since her return. J. During an interview on 07/10/18 at 5:50 pm, the DON stated that R #37 could not be interviewed because she was not longer in the facility. K. During an interview on 07/11/18 at 9:00 am, R #25 could not remember any problems or issues with any staff. L. During an interview on 07/11/18 at 10:45 am, the SSD stated that R #37 had told her in (MONTH) (YEAR) that she has many incident in (YEAR) with CNA #1 and reported them to the previous DON. When asked about R #3, the SSD stated that she does not know when this happened. R #3 reported that she was not feeling well and had nausea and had both vomited and diarrhea. When CNA #1 had come to clean her up, CNA #1 was rough with her. And because of this, R #3 did not want CNA #1 to work with her. When asked about R #25 and R #37, she stated that R #25 has a poor memory, but that R #37 has a good memory. M. During an interview on 07/09/18 at 2:00 pm, R #20 stated that CNA #1 and CNA #9 have been rough with her. When she was asked if she reported to staff, R #20 stated that she has told therapy and SSD. N. Record review of a posted note attached to resident council meeting minutes dated 04/26/17 revealed that R #20 had stated that CNA #1 and CNA #9 are often rough with her. O. During an interview on 07/11/15 at 10:15 am, the SA Complaints Section confirmed that no complaints or investigations were send in about the incidents in (YEAR). They further confirmed that no requests to place a CNA on the Nurse Aide Registry had been made by the facility recently. P. Record review of a Grievance/Complaint report dated 05/10/18 that the SSD had revealed that R #11 had fallen and a CNA had helped her up. She received bruises on both of wrists and they both hurt. Further review revealed that the DON written that she had counseled the CNA about proper lift techniques and use of mechanical lift . Q. During an interview on 07/11/18 at 10:45 am, the SSD was asked if any of the incidents found in the Grievance notebook or resident council meeting minutes had been reported to the SA or fully investigated, She stated that none had been reported to the SA or investigated for abuse. R. Record review of the facility's Abuse Investigations binder revealed Abuse Investigations policies and procedures that were last reviewed in (YEAR). 1. Review of them revealed nothing about not employing someone that the facility has determined that abused/neglected/exploited a resident of the facility. Further the policies and procedures do not indicate if the the facility does substantiate abuse/neglect/exploitation, the facility will make a recommendation to the SA to place the person on the Nurse Aide Registry. 2. Review of the facility's policy and procedure titled, Reporting Abuse to Facility Management, undated, revealed that if abuse is senn or could be assumed, then this was to be reported promptly to the facility administration to be investigated. The SA is to be notified within 24 hours. A thorough investigations is the be completed and sent to the SA on or before day five. S. During on interview on 07/10/18 at 5:50 pm, the DON was asked if she knew of any policies and procedure about abuse/neglect/exploitation. She stated that she did not know if the facility had any. She was then given the Abuse Investigations binder.

The following deficient practices were found during an annual/complaint survey that were Immediate Jeopardy: 1) Staff did not follow doctor's orders when R #20 and R #185 received doses of insulin beyond the sliding scale order parameters and did not notify the physician when blood sugars were elevated above 400 mg (milligram)/dl (deciliter) per doctor's orders for R #20 and R #185. The nurse attempted to call the physician about the elevated blood sugar for R #185, but the physician was out of town and the DON stated there was no emergency coverage when the physician is out of town. 2) On 07/09/18 a nurse gave R #185 [MEDICATION NAME] (a narcotic pain reliever and [MEDICATION NAME]-tylenol) 5/325 mg (milligram) when his order was for [MEDICATION NAME] (a narcotic pain reliever) 10/325 mg. The resident is now fearful and anxious of medications he is presented with and feels like he must examine each one. The nurse further did not assess the resident after this, failed to document the medication error, and did not notify the MD and DON (Director of Nurses) about the error. The error was discovered because the family member complained about 2 medication errors in 2 weeks. 3) On 06/29/18 the staff gave an anti-psychotic medication ([MEDICATION NAME]) to R #185 as a sleeping medication without questioning the physician about the order. The was resident reviewed for resident complaint of receiving the wrong medication and oversedation. 4) The Staff Administered [MEDICATION NAME]from a MAR (medication administration record) that listed two different doses of insulin without clarifying the order for R#185. 5) Staff administed [MEDICATION NAME] without clarifying the order for [MEDICATION NAME] (a short acting form ) or [MEDICATION NAME] (a delayed time release formulation) for 2 (R #24 and R #25. 6) Staff failed to perform controlled medication (A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by the government) accountability when one of the two nurses counting the medications was distracted doing paperwork and not looking at the actual count. Also, the nurse that gave the wrong narcotic to R #185 was unsure she had accounted for that narcotic. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 6:49 pm. An acceptable Plan of Removal was submitted on 07/27/18 at 11:00 am and approved. The plan was: 1. Nurses giving insulin without having orders for 2 different residents. Nurses not notifying the MD for elevated blood sugars. * Interventions: A. Nurse will be in-serviced prior to working on the floor regarding diabetes management. (i.e., disease process, medication management; assessment and monitoring; and hypo and [MEDICAL CONDITION], and implications to residents' health and intervention.) B. Nurses will be education prior to working on the floor regarding following physician orders [REDACTED]. * Date of Completion: 07/30/18 2. Nurses were giving medications (insulin and [MEDICATION NAME] vs [MEDICATION NAME]) from incomplete or ambiguous orders and/or MARs without clarification. * Interventions: Nurses will be in-serviced on the necessary components of a medication order; taking an order; and the process of transcribing; placing the order on the MAR; verifying, clarifying PRN; and administering the medication. (Verifying the resident and clarifying the MAR PRN.) * Date of Completion: 07/27/18 3. Nurses were giving wrong opioid medication, not assessing the resident after this incident, not documenting the wrong medication, and not notifying the DON or the MD. * Interventions: A. Nurses will be in-serviced on medication administration (Right resident, etc.). B. Nurses will be in-serviced regarding assessing the resident for the effectiveness and side-effects of the medications. C. Nurses will be in-serviced on the procedure for medication errors (notifying the physician, the DON, and documentation). * Date of Completion: 07/30/18 4. MD was writing orders for anti-psychotic for PRN for sleep. The Nurse did not seek clarification from the MD prior to giving the medication. * Interventions: A. Nurses will be in-serviced on the use of anti-psychotic medications including indications for use, the new PRN regulations and time frames, and contacting the physician with questions and concerns. B. Facility will review the orders for other residents that might be similarly impacted. * Date of Completion: 07/30/18 5. Physician coverage not available 24 hours for emergencies. * Interventions: A. Nurses will be in-serviced regarding the new plan for covering emergencies. (A policy and procedure covering each eventuality and transport.) B. Nurses will be in-serviced regarding the documentation the inability to contact the physician on the Notice of Physician Unavailability form, complete incident report, and notify DON immediately for further direction. DON will report all incidents of physician unavailability to the Tribal Administrator for further action(s). (DON is interim facility Administrator, Tribal Administrator is next in chain of command.) * Date of Completion: 07/27/18 The IJ was lifted after the Plan of Removal was implemented and verified on 07/31/18 at 12:58 pm. This resulted in a lowering of the scope and severity from a L to a H. Based on record review, interview, and observation, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice to maintain or attain their highest practicable well-being when the staff 1) Failed to follow doctor's orders when residents received doses of insulin without an order and failed to notify a physician when blood sugars were elevated above 400 mg/dl in compliance with doctor's orders for 2 (R #20, and R #185) of 2 (R #20, and R #185) residents reviewed for insulin administration, and 2) Administered the wrong narcotic pain reliever medication to R #185 and then failed to perform an assessment on the resident and notify the physician and DON of the error. 3) Gave an anti-psychotic medication as a sleeping medication without questioning the physician about the order for for 1 (R#185) of 1 (R#185) resident reviewed for resident complaint of receiving the wrong medication, 4) Administered insulin from a MAR (medication administration record) that listed two different doses of insulin without clarifying the order for 1(R #185) of 2 (R #20, and R #185) residents reviewed for insulin administration, 5) Administering [MEDICATION NAME] without clarifying the order for [MEDICATION NAME] (a short acting form ) or [MEDICATION NAME] (a delayed time release formulation) for 2 (R #24 and R #25) of 7 (R #2, R #8, R #23, R #24, R #25, R #184, and R #185) reviewed for medication orders, and 6) Failed to perform controlled medication (A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by the government) accountability that could affect all 34 residents as listed in the census list provided by the DON on 07/09/18. The result of these deficient practices resulted in staff giving insulin in dosages that were not ordered, giving the wrong medication, not reporting blood sugars as specified by the physician orders [REDACTED]. The result of not following basic rules of medication administration can result in over or under treatment, unnecessary side effects, risk of adverse reactions and death. The result of these deficient practices caused unnecessary fear, worry and anxiety of a resident (R #185) when he was being given medication. The result of the deficient practice of not reconciling controlled medication can result in no accountability for the use of controlled medication, no safeguard of the recording of controlled medication and use and increases the possibility of drug diversion. The findings are: R #185 Humalog Insulin A. Record review of the (Name of facility) admission orders [REDACTED]. B. Record review of a faxed order for R #185, fax confirmation date 06/26/18 revealed: Humalog (a type of insulin) sliding scale (amount of insulin to be given based on the results of blood glucose (sugar)). AC (before meals) & HS (at bedtime). Call if less than 100. Less than 150 mg (milligram)/dl (deciliter) - 0 units (give no insulin) 150-199 mg/dl - 1 unit 200-249 mg/dl - 2 units 250-299 mg/dl - 3 units 300-349 mg/dl - 4 units 350-399 mg/dl - 4 units and call MD (medical doctor) Call if greater than 400 06/26/2018 - Open ended (no end date for the order) C. Record of of the MAR (medication administration record) for R #185 dated as generated 06/26/18 revealed: Humalog 100 units/ml Injection Amount to administer: sliding scale; subcutaneous (to be given as injection under the skin and into the fatty tissue) Before Meals and at Bedtime Call MD if less than 100 or greater than 400 (blood sugar) Dx: Diabetes mellitus due to underling condition with diabetic [MEDICAL CONDITION] (nerve damage from elevated blood sugar) 150-199 - 1 unit 200-249 - 2 units 350-299 - 3 units 300-349 - 4 units 350-399 - 5 units Further review of the same MAR revealed: 1. On 06/29/18, R #185 blood sugar was 400 and 5 units of Humalog insulin was given (actual order was for 4 units and there was no higher coverage indicated) 2. On 06/30/18, resident had a blood sugar of 419 and there is no notation of insulin given R #185 Notification of Elevated Blood Glucose D. Record review of the blood glucose log for R #185 for (MONTH) (YEAR) revealed on 07/02/18 had a blood sugar of 418. E. Record review of the skilled daily nurse notes 07/02/18 for R #185 revealed: Blood sugar at 1100 (11:00 am) was 418. Covered with Humalog 6 units. attempted to contact doctor on home phone with no success. Informed via fax. F. Record review of fax from RN #1 to MD regarding R #185, dated 07/02/18 revealed: Resident's blood sugar was 418. Covered w/(with) Humalog 6 units. Resident A & O (Alert and oriented). Doctor's response OK cont. (continue) sliding scale dated 07/08/18. Noted (date received and noted as read by staff) on 07/09/18. G. On 07/11/18 at 2:46 pm, during an interview, the DON stated, I know the nurse contacted him, the doctor, on 07/02/18 to notify him of the elevated blood sugar by fax. He was out of town. But the order does say greater than 400 blood sugar, he should be contacted. I don't believe the doctor had anyone to cover for him, if he did he did not tell us. If they couldn't get a hold of the doctor, they should call me. If it is an emergency, they have to call me and I would decide to send them to the ER (emergency room ) or not. I do not have a written protocol. When asked about the discrepancy between the MAR and orders on 06/26/18, the DON stated, The nurse should have clarified the order. And after talking with the doctor, the MAR should have been yellowed out (with a yellow marker to indicate it is not a current order) and the order should have been rewritten. The nurse shouldn't try to guess the doctor probably wanted (for a dose) and write a 5 (on the sliding scale)when that is not what the order says. H. On 07/12/18 at 10:52 am, during an interview, RN #1 affirmed the order for the sliding scale insulin dated 06/26/18 and the MAR written on 06/26/18 does not agree. RN #1 stated she does not know why they do not agree, and does not know who wrote the MAR. R #185 [MEDICATION NAME] (a long acting insulin) Administration I. Record review of discharge orders from a local Hospital dated 06/26/18 revealed: Medications to Continue Taking: Insulin [MEDICATION NAME] ([MEDICATION NAME] 100 units/ml subcutaneous solution) 30 units every day J. Record review of a telephone order for R #185, dated 06/30/18 revealed: Insulin [MEDICATION NAME] Sub Q (subcutaneous) 40 units once a day (morning) Dx (diagnosis): Diabetes K. Record review of the MAR for R #185 dated 07/01/218-07/31/2018 revealed: insulin [MEDICATION NAME] subcutaneous infection: 30 units (printed and marked out with a dark line and rewritten by hand 30 units) Amount to Administer: 40 units sq:subcutaneous Once a Day L. Record review of an order for [REDACTED].? (second digit was illegible) that is overwritten repeatedly in pencil to indicate 30 units. Insulin [MEDICATION NAME] give (Printed number is obliterated by a written over 30) units once daily in the morning 06/30/18-open ended M. Record review of the Diabetic Flowsheet for R #185 dated 07/01/2018-07/31/2018 revealed: Insulin [MEDICATION NAME] subcutaneous Injection 30 units, Amount to administer 40 units sq (subcutaneous) Once a Day. Insulin [MEDICATION NAME] give 30 units once daily in the morning. Time: 08:00 and initials are present (signifying when insulin was given on 07/01/18 to 07/18/18 on a daily basis) N. On 07/19/18 at 8:27 am, during an interview with RN #1 was asked about the discrepancy on (MONTH) (YEAR) MAR for R #185 that showed 2 different dosages for [MEDICATION NAME]with in the same MAR entry. She stated, I gave 30 units, that is the order. The wife came in after admission and said the order for 40 units was wrong--the doctor wrote an order on 6/30/18 for 40 units. His wife came in and brought an order dated 7/3/18 from his specialist that says 30 units. RN #1 stated, It reads as 30 units and she further stated, This note is from the specialist and it always overrides other orders . I just gave what was on the MAR. O. On 07/19/18 at 01:27 pm, during an interview with the DON regarding the MAR that had 2 different doses under on entry for [MEDICATION NAME], she stated, The nurses should have verified the 30 units I know the doctor said to give the 30 units. I heard him, but we did not write an order. I am not sure what the nurses gave during that month for the [MEDICATION NAME]. R #185 Wrong pain medication and wrong indication for anti-psychotic medication P. On 07/0918 at 4:13 pm, during an interview, the family member of R #185 stated, (Name of R #185) has received the wrong medication for the second time in two weeks. The medication dispensing worries me. They gave him a sleeping pill and it was wrong and (Name of DON) said they were looking into it. He got the wrong pain medication too. You can talk to him about it. There is no specific person to talk to here. Q. On 07/10/18 08:46 am, during an interview, R #185 stated, Yesterday, they gave me a sleeping pill instead of a pain pill. Yesterday, I couldn't wake up and when they took me for breakfast and I could not hold my head up. The nursing staff needs the beejesus scared out of them because they are not real careful with the pills. In the evening, I had asked for pain pill; they gave me two pills and one was sleeping pill. One of the nurses told me yesterday after they woke me up and told me that a mistake had been made. Now, I have to watch pills carefully. I am worried. Another time, I asked for pain pill. I noticed the pill was not the same shape--it was round, not oblong. The nurse said it was same thing, different shape when I asked her why it looked different. It made me incoherent into the next day. The nurse then fessed (confessed) up she gave me the wrong pill. R. On 07/10/18 at 1:10 pm, during an interview, the DON was asked about the two medication errors that R #185 had indicated he had received. She stated, I know of one error--a nurse was gave him (R #185) [MEDICATION NAME] instead of [MEDICATION NAME]. I believe it was on 4th or 5th of July, I am not sure of the date. He got (Name of R #184's) medication. There was no incident report, or drug error report. The DON confirmed she heard about the medication from R #185's family member, then confronted RN #3 sometime after (MONTH) 4 and asked the nurse to write it up but had not received the documentation yet. When the DON was shown the order for [MEDICATION NAME] 50 mg prn (as needed) for sleep, the DON stated, I would have hoped the nurses would clarify the order. It is a anti-psychotic and not given for sleep. Electronic orders and hand-written orders don't always coincide. Nobody is verifying anything against (confirming with) the chart. S. Record review of the admission orders [REDACTED]. T. Record review of R #184's controlled drug record revealed: [MEDICATION NAME] (an opioid pain medication) /APAP (generic for Tylenol) (A.K.A.) [MEDICATION NAME] 5/325 mg take one tablet by mouth q (every) 6 hrs as needed. U. On 07/10/18 at 3:28 pm, during an interview, RN #3 was asked about a medication error with R #185. She stated, I would say it it would have on 07/04/18. I would have to look at the narcotic sign out sheet. (Name of R #185)'s family member said he needed something for pain. I got R #184's pain medication -from a bottle of 5 mg (a metric unit of measure)/325 mg [MEDICATION NAME] (an opioid pain medication). I took it in him (R #185) at same time I was helping to pass trays, feeding another resident in dining room, and passing meds (medications). R #185 said, 'It's white (a different color than he was used to).' He didn't have to swallow it if he had questions. He started getting woozy and he complained. I wondered if I gave him right thing. He (R #185) said it really knocked him out. I went and talked to him. The family member said he was slurring his speech--but I saw he was alert and joking around. When I looked at pills, I thought I made an error. Remember, all these guys (new admissions) were called the same nickname. When I looked at the pills, I knew I made a mistake. I went an apologize to (Name of R #185). I just kept an eye on him. No special vital signs or anything else. I did not notify doctor or my supervisor. He (R #185) went to bed he was fine. The DON came to me or the wife went to her, I don't remember. The DON asked me about the error. There is a medication error form, but I did not do one because I was not asked to do one. I did not document (the error) on his (R #185's) drug log or document it in his chart. I think I signed it out on the control drug sheet for R #184. After reviewing the control drug logs, RN #3 said she was unsure of the date it happened, or if she had signed it out. I can't really read it (the documentation). V. On 07/10/18 at 5:29 pm, during an interview with the DON regarding the opioid administration error that involved RN #3 and the lack of an assessment by RN #3 after the error was discovered, the DON stated, I talked to (Name of RN #3) about the error. I did not notify the physician either. I have a concern that she did not report or document the error. I was going to make a plan of action with her about the error but had not done it yet because you guys (surveyors) walked thought the door. She apologized to the resident. She (RN #3) did not know she made an error until I told her. She (RN #3) didn't make an assessment because she didn't know at the time. It was explained to her (DON) recall of what she knew of the incident did not match what RN #3 stated in the interview. The DON said she did not know what to say about the differences. W. Record review of the physician order [REDACTED]. X. Record review of the MAR for R #185, dated 07/01/2018 - 07/31/2018 revealed: [MEDICATION NAME] 50 mg 1 tab (tablet) PO Q HS PRN sleep was given on 07/09/2018 Y. On 07/10/18 at 12:47 pm, during an interview, RN #1 was asked about the resident complaint about receiving a medicine for sleep. She stated, Yesterday, he (R #185) was very sleepy, but the night before he had [MEDICATION NAME] for sleep. I checked blood sugar and it was normal and he was given [MEDICATION NAME]. When we get new admission we put in orders with diagnosis. That (the [MEDICATION NAME] order) carried over from the hospital. If I had input the information in with that order for [MEDICATION NAME] for sleep, I would have contacted the doctor for clarification since [MEDICATION NAME] is not a sleeping medication. Z. On 07/11/18 at 2:46 pm, during an interview with the DON regarding the administration of [MEDICATION NAME] on 07/09/18 to R #185 for sleep, she stated, I know [MEDICATION NAME] cannot be given on as as needed basis and it is not appropriate for sleep or for his anxiety and depression. The risk to the resident is over sedation. R #20 INSULIN AND REPORTING OF HIGH BLOOD SUGARS AA. Record review of the Physician order [REDACTED].#20, dated 07/01/18 to 07/31/18 revealed: Diagnoses: [REDACTED]. are attacked by its own immune system), and [MEDICAL CONDITION] arthritis(a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). Order: Humalog (insulin [MEDICATION NAME]) solution 100 unit/ml; amt (amount): per Sliding Scale If Blood Sugar is less than 149, call MD If Blood Sugar 82 150 to 200, give 2 units If Blood Sugar is 201 to 250, give 4 units If Blood Sugar is 251 to 300, give 8 units If Blood Sugar is greater than 300, call MD. subcutaneous Before Meals and At Bedtime; 07:00, 11:30, 16:30 (4:30 pm), 20:00 (8:00 pm) BB. Record review of the PRN Medication flow sheet for R #20, dated 06/01/2018 - 06/30/2018 revealed: 1. 06/15/18 at 4:30 pm - blood sugar 400 2. 06/16/18 at 11:30 am - blood sugar 462 3. 06/25/18 at 11:30 am - blood sugar 419 4. 06/27/18 at 11:30 am - blood sugar 413 Order: Humalog (Insulin [MEDICATION NAME]) solution 100 units/ml Amount to be administrated (sic) per sliding scale 150-200 give 2 units 201-250 give 4 units 251-300 give 6 units 301-350 give 8 units 351-400 give 10 units Call MD only when less than 70 or greater than 400 05/01/18 CC. Record review of Nurse's Notes for R #20 revealed: One nursing note in (MONTH) regarding a blood draw for a potassium level on 06/27/18. There was no other documentation recorded for that month, nothing regarding notification of the physician for the elevated blood sugars. DD. On 07/16/18 at 11:46 am, during an interview with RN #4 regarding the elevated blood sugars for R #20 in (MONTH) (YEAR) she stated, Yes, the blood sugars were not reported. I was caring for her her on (MONTH) 16th and 25th, The blood sugar was over 400 but if she tells me she had a snack I would not notify the doctor. By the order I should have called the doctor, but I do not call if she has had a snack. EE. On 07/16/18 at 12:39 pm, during an interview with RN #4 regarding the orders for R #20 and the recapitulation orders (summary of orders)dated 07/01/18 - 07/31/18 for sliding scale coverage doesn't match the MAR for (MONTH) (YEAR) or (MONTH) (YEAR) she stated, I don't know why they don't match; they should match. For a while, not all the nurses had passwords to get in and enter the orders in the computer and not all orders were put in the computer. The orders in the computer are not always up to date. RN #4 confirmed she looked for the order for the sliding scale insulin that would have matched the MAR but could not find it. FF. On 07/16/18 at 1:08 pm, RN #2 stated, I wrote the (MONTH) (YEAR) MAR for the sliding scale insulin, that is my handwriting. There was period of time I could not get into electronic record to enter orders for a month. Today I cannot get in either. I cannot find the order for the 05/03/18 order for (name of R #20). GG. On 07/16/18 at 2:16 pm, during an interview with the DON regarding the unreported high blood sugars and discrepancy between the MAR and the recapitulation orders for R #20, she stated, When an order comes in, I don't think any nurse does it the same. The order should go into electronic record. The DON confirmed there were no nurses notes regarding the physician notice of the high blood sugars in (MONTH) (YEAR), and that the staff told her they were unable to find the supporting orders for the MARS. She stated, All nurses have access to electronic records, but it is not user friendly. I have made it clear, verbally they do both (write an order and also enter the order into the electronic records). Yes, the electronic record and MAR should match. The nurse should be using the physician order [REDACTED]. I was aware of this from when I worked the floor-- maybe (MONTH) 3rd (2018). The nurses should have called the doctor on the high sugars. HH. On 07/17/18 at 4:00 pm, the DON brought a documented and stated, This is the missing order for the correct sliding scale for R#20. It was found in the very back of the chart. The document was a fax response to a nurse inquiry dated 05/03/18 for R #20. The document revealed: Resident (R #20) has standard sliding scale for her BG (blood glucose) levels but it stops at 300 with orders to call MD over 300 or under 149. Would it be possible to broaden the range adding: 301-350 8 units 351-400 10 units and direction to call MD only when less than 70 or greater than 400? Please advise The doctors response: OK was dated 05/03/18. II. On 07/19/18 at 1:27 pm, during an interview, the Director of Nurses was asked about possible outcomes for the residents from the unclear insulin orders, nurses guessing at sliding scale insulin coverage, and lack of timely notification to the physician about high blood sugars. She stated, Possible outcome to patient is [DIAGNOSES REDACTED] (low blood sugar) or even death by Diabetic Ketoacidosis (a life-threatening complication diabetes that occurs when the body produces high levels of [MEDICATION NAME] due to lack of insulin). R #24 and R #25 [MEDICATION NAME] orders R #24 JJ. Record review of the physician orders [REDACTED]. KK. Record review of the MAR (medication administration record) for R #24, dated 07/01/2018 - 07/31/2018 revealed: [MEDICATION NAME] tablet; 25 mg (milligram-a metric unit of measure) one half tablet: oral Twice a Day LL. On 07/17/18 at 5:34 pm, during medication pass observation, RN #3 administered [MEDICATION NAME] 25 mg 1/2 tablet PO (by mouth) to Resident #24. MM. On 07/17/18 at 5:36 pm, during an interview, RN #3 confirmed that she did not know if the order was for [MEDICATION NAME] (short acting) or [MEDICATION NAME] (long acting) from the MAR and did not stop and confirm which medication the physician wanted her to give to the resident. R #25 NN. Record review of the facility admission orders [REDACTED]. OO. Record Review of a physician order, dated 06/01/2018 - 06/30/20 for R #25 revealed: [MEDICATION NAME] titrate tablet extended release 24 hour, 25 mg tablet po PP. Record review of the MAR for R #25, dated 07/01/18 to 07/31/18 revealed: [MEDICATION NAME] titrate extended release 24 hr; 25 mg; amt; 1 tablet po twice a day. QQ. On 07/18/18 at 11:26 am, during an interview, the DON was asked the about order for R #25 dated 03/06/18 for [MEDICATION NAME] titrate extended release. The DON agreed the admitting nurse should have called for clarification of which [MEDICATION NAME] was ordered and [MEDICATION NAME] titrate could be confused with [MEDICATION NAME]. She stated, The MAR is unclear as [MEDICATION NAME] titrate extended release. RR. Record review of Audrey Berman PhD, RN, Geralyn Frandsen EdD, RN, Shirlee J. Snyder EdD, RN. (YEAR). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice - 10th Ed. Upper Saddle River, NJ. Pearson Education, Inc. ISBN 10: 0-13- 6-7, ISBN 13: 978-0-13- 6-2. eISBN-10: 0-13- 4-5, eISBN-13: 978-0-13- 4-6. STAT!Ref Online Electronic Medical Library. http://online.statref.com/Document.aspx?docAddress=G4VciehnhuDTXOk5ttJ-uQ!!. 7/24/2018 5:38:19 PM CDT (UTC -05:00). Essential Parts of a Drug Order: · Full name of the client · Date and time the order is written · Name of the drug to be administered · Dosage of the drug · Frequency of administration · Route of administration · Signature of the person writing the order Ten Rights of Medication Administration RIGHT MEDICATION · The medication given was the medication ordered. RIGHT DOSE · The dose ordered is appropriate for the client. · Double-check calculations that appear questionable. · Know the usual dosage range of the medication. · Question a dose outside of the usual dosage range. RIGHT TIME · Give the medication at the right frequency and at the time ordered according to agency policy. · Medications should be given within the agency guidelines. RIGHT ROUTE · Give the medication by the ordered route. · Make certain that the route is safe and appropriate for the client. RIGHT CLIENT · Medication is given to the intended client. · Check the client's identification band with each administration of a medication. · Know the agency's name alert procedure when clients with the same or similar last names are on the nursing unit. RIGHT CLIENT EDUCATION · Explain information about the medication to the client (e.g., why receiving, what to expect, any precautions). RIGHT D[NAME]UMENTATION · Document medication administration after giving it, not before. · If time of administration differs from prescribed time, note the time on the MAR and explain the reason and follow-through activities (e.g., pharmacy states medication will be available in 2 hours) in nursing notes. · If a medication is not given, follow the agency's policy for documenting the reason why. RIGHT TO REFUSE · Adult clients have the right to refuse any medication. · The nurse's role is to ensure that the client is fully informed of the potential consequences of refusal and to communicate the client's refusal to the health care provider. RIGHT ASSESSMENT · Some medications require specific assessments prior to administration (e.g., apical pulse, blood pressure, lab results). · Medication orders may include specific parameters for administration (e.g., do not give if pulse less than 60 or systolic blood pressure less than 100). RIGHT EVALUATION · Conduct appropriate follow-up (e.g., was the desired effect achieved or not? Did the client experience any side effects or adverse reactions CONTROLLED MEDICATION RECONCILIATION SS. On 07/10/18 at 3:28 pm, during an interview, RN #3 was asked about a medication error with R #185. She stated, I would say it it would have on 07/04/18. I would have to look at the narcotic sign out sheet. (Name of R #185)'s family member said he needed something for pain. I got R #184's pain medication -from a bottle of 5 mg (a metric unit of measure)/325 mg [MEDICATION NAME] (an opioid pain medication). RN #3 when talking about giving the wrong opioid to R #185, after she reviewed the control drug logs said she was unsure of the date it happened, or (TRUNCATED)

During an annual survey, the following deficient practice was found at Immediate Jeopardy: 1) A nurse had administered humalog insulin to R #185 on 07/02/18 when his blood sugar was 418. The sliding scale revealed: 350-399 mg/dl give 4 units and call MD, that was the top of parameters. The nurse gave 5 units of insulin. 2) The nurse attempted to contact the MD about this incident, but was unable to get a response from him until 07/08/18 because he was out on vacation and did not get coverage. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 6:49 pm. A acceptable Plan of Removal was submitted on 07/27/18 at 11:00 am and approved. The plan was: Physician coverage not available 24 hours for emergencies. * Interventions: A. Nurses will be in-serviced regarding the new plan for covering emergencies. (A policy and procedure covering each eventuality and transport.) B. Nurses will be in-serviced regarding the documentation the inability to contact the physician on the Notice of Physician Unavailability form, complete incident report, and notify DON immediately for further direction. DON will report all incidents of physician unavailability to the Tribal Administrator for further action(s). (DON is interim facility Administrator, Tribal Administrator is next in chain of command.) * Date of Completion: 07/27/18 The IJ was lifted after the Plan of Removal was implemented and verified on 07/31/18 at 12:58 pm. This resulted in a lowering of the scope and severity from a L to a F. Based on record review and interview, the facility failed to ensure for the provision of physician services 24 hours a day, in case of emergency when the physician was unable to be reached for 1 (R #185) of 2 (R #20 and R #185) residents reviewed for insulin when the staff could not reach the doctor to report an elevated blood sugar. The results of this deficient practice result in the physician being unaware of situations that might require the expertise and possible intervention of a medical doctor and could result in a delay of treatment that could have negative effects of a resident. The findings are: A. Record review of the (Name of facility) admission orders [REDACTED] B. Record review of a faxed order for R #185, fax confirmation date 06/26/18 revealed: Humalog (a type of insulin) sliding scale (amount of insulin to be given based on the results of blood glucose (sugar)) AC (before meals) & HS (at bedtime). Call if less than 100 Less than 150 mg (milligram)/dl (deciliter) 0 units (give no insulin) 150-199 mg/dl 1 unit 200-249 mg/dl 2 units 250-299 mg/dl 3 units 300-349 mg/dl 4 units 350-399 mg/dl 4 units and call MD (medical doctor) Call if greater than 400 06/26/2018 Open ended (no end date for the order) C. Record review of the blood glucose log for R #185 for (MONTH) revealed: 07/02/18 - blood sugar was 418. D. Record review of the skilled daily nurse notes for R #185 revealed: Blood sugar at 1100 was 418. Covered with Humalog 6 units, attempted to contact doctor on home phone with no success. Informed via fax. E. Record review of fax from RN #1 to MD regarding R #185, dated 07/02/18 revealed: Resident's blood sugar was 418. Covered w/(with) Humalog 6 units. Resident A & O (Alert and oriented). Doctor's response OK cont. (continue) sliding scale dated 07/08/18. Noted (date received and noted as read by staff) on 07/09/18. F. On 07/11/18 at 2:46 pm, during an interview, the DON stated, I know the nurse contacted him the doctor on 07/02/18 to notify him of the elevated blood sugar by fax. He was out of town. But the order does say greater than 400 blood sugar, he should be contacted. I don't believe the doctor had anyone to cover for him; if he did he not tell us. If they couldn't get a hold of the doctor, they should call me. If it is an emergency, they have to call me and I would decide to send them to the ER (emergency room ) or not. I do not have a written protocol. G. On 07/11/18 at 5:10 pm, during an interview with the MD (Medical Doctor) who is also the medical director, when asked about 24 hours emergency coverage for the residents, he stated, I would always be available, but I am not always available to just snap to right away. I am the coverage and I have not found anyone to help. If he (the resident) was clinically stable, there would be no need. Nurses can decide what's best. The MD said that a nurse could send a resident to the emergency room if the nurse resident was not clinically stable.

During an annual survey the following deficient practice was found to be Immediate Jeopardy: 1) R #17 had developed 2 facility acquired (developed in the facility) one that healed and one that progressed to a stage 4 pressure ulcer on her sacral (bony structure that is located at the base of the lumbar vertebrae) both discovered on 03/24/18. 2) Record review of R #17's care plan dated 03/22/18 revealed no interventions for her pressure ulcers, or her refusal to be laid in bed to relieve pressure on her wound. 3) Record review of a fax to R #17's Medical Doctor (MD) dated 04/21/18 requesting a Treatment Order for Santyl (Wound Care drug used to remove dead, damaged, or infected tissue to improve the healing potential) to treat R #17's stage 4 pressure ulcer. MD responded back on 04/23/17. There were 5 attempts to get Santyl from the Pharmacy 04/23/18, 04/27/18, 05/06/18, 05/22/18, and 05/25/18. 4) On 07/11/18 at 9:00 am, during an interview the DON confirmed that the facility had Santyl in the treatment cart but that it did not get used for R #17 until 05/26/18. 5) Record review of a fax to R #17's MD dated 05/30/18 requesting an air mattress for R #17's stage 4 pressure ulcer. No response from MD was documented. 6) Observation of R #17's wound care showed several deficiencies in wound care and infection control practices. 7) No documentation of residents repositioning could be found. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 1:35 pm. A Plan of Removal were submitted on 07/12/18 at 1:01 pm and approved. Plan of Removal 1. Wound care by staff nurses is immediately suspended. Staff informed verbally. 2. Certified Wound Care Nurse (DON) will complete and document all aspects of resident wound care. Resident wound care, by nurses, may resume only after wound care protocols, education, wound care competencies, and ongoing training are complete/established. 3. Resident Care Plan updated to reflect pressure ulcer and interventions. Communicated in 24 hour Resident Report Sheet. Update documented in Nurses Notes. 4. Two (2) hour Turn and Reposition documentation flowsheet placed in Treatment Administration Record. Notification documented on 24 hour Resident Report Sheet. 5. Medical Director informed of incident and immediate corrective measures. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted 07/12/18 at 1:45 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review the facility failed to update the Care Plans for 1 (R #17) of 1 (R #17) sampled for pressure ulcers, when they failed to 1) update R #17's care plan that the CNAs use on the floor, to reflect her current status of having a stage 4 pressure ulcer, 2) have care plan interventions for R #17's pressure ulcers, and 3) have care plan interventions for R #17's occasional refusal to be laid down in bed to off load her pressure from being up in her wheelchair. This deficient practice resulted in R #17's development of a Stage 4 pressure ulcer. The findings are: A. Record review of the fax sent to R #17's MD dated 03/24/18 revealed the presence of 2 Stage 2 ulcers on R #17 Coccyx area each about 1 in (inch) diameter . Start wound care for decubitus ulcers . The DON confirmed that the resident only had these two pressure ulcers and that one developed into a stage 4 and the other healed. The location did not change it was a documentation error (coccyx sacral pressure ulcer). B. Record review of R #17's Care Plan dated 03/22/18 found in R #17's paper chart and in the resident Care Plan book located by CNA documentation desk for their use revealed: (Name of R #17) is at risk for skin break down d/t (due to) impaired mobility and being chairfast. Approach start date: 03/21/2018 - Consider PT (physical therapy) consult for conditioning and prevention of contractures w/c (wheelchair) assessment. Has high w/c with w/c cushion. Approach start date: 03/21/2018 - Do skin assessment and inspection weekly with close attention to heels and bony areas. Approach start date: 03/21/2018 - Encourage resident to set in her special chair in room after lunch, with her feet elevated. C. Record review of R #17's Care Plan dated 06/22/18 found in the electronic medical records revealed the following: (Name of R #17) is at risk for skin break down d/t (due to) impaired mobility and being chairfast. She has a pressure ulcer on sacrum. Approach start date: 05/30/2018 - Pressure relief mattress to bed and chair. Approach start date: 05/30/2018 - Tx. (treatment) as ordered to sacrum; monitor for healing. Approach start date: 03/21/2018 - Consider PT consult for conditioning and prevention of contractures w/c (wheelchair) assessment. Has high w/c with w/c cushion. Approach start date: 03/21/2018 - Do skin assessment and inspection weekly with close attention to heels and bony areas. Approach start date: 03/21/2018 - Encourage resident to sit in her special chair in room after lunch, with her feet elevated. D. Record review of the Skin Assessment Flow Sheet -Pressure Ulcer for Wound #1- revealed the following: 1. 04/13/18 - Stage II Length (L) 1.5 cm, Width (W) 0.5 cm, Depth (D) < 0.1 cm 2. 04/20/18 - Unstageable L 1.5 cm, W 0.6 cm, D slough (A layer or mass of dead tissue separated from surrounding living tissue) present 3. 04/21/18 - comment Faxed (Name of R 7's MD) wound update and asked for santyl for wound . 04/2318 response from (Name of R #17's MD) to use Santyl in wound bed waiting on Santyl to come in. 4. 04/24/18 - Unstageable no measurements 5. 04/29/18 - unstageable no measurements resident refused 6. 04/30/18 - Unstageable no measurements resident refused 7. 05/06/18 - Unstageable L 1.0 cm, W 0.5 cm, D slough; comment . refaxed (Name of pharmacy) for santyl. If med does not come in wound maybe healed on its own. 3rd attempt and called. 8. 05/13/18 - Unstageable L 1.0 cm, W 1.0 cm, D < 0.2 cm 9. 05/22/18 - Unstageable L 2.8 cm, W 2.0 cm, D slough present; comment Wound worsening, refaxed (name of pharmacy) spoke with (name of employee) to get a hold of (name of R #17's MD) for Santyl . Spoke with (name of employee) about Santyl. Who stated would take fax to (name of R #17 MD) on the floor . 10. 05/25/18 - Unstageable L 2.0 cm, W 2.5 cm, D slough present 11. 05/28/18 - Unstageable L 2.0 cm, W 2.5 cm, D slough present 12. 06/03/18 - Unstageable L 2.4 cm, W 2.9 cm, D 0.8 cm 13. 06/11/18 - Stage IV L 2.4 cm, W 2.4 cm, D 0.7 cm 14. 06/18/18 - Stage IV L 2.7 cm, W 2.0 cm, D 0.5 cm 15. 06/24/18 - Stage IV L 2.5 cm, W 1.3 cm, D 0.5 cm 16. 07/01/18 - Stage IV L 2.5 cm, W 1.5 cm, D 0.5 cm 17. 07/09/18 - Stage IV L 2.2 cm, W 1.2 cm, D 0.5 cm E. Record review of the Skin Assessment Flow Sheet -Pressure Ulcer for Wound #2- revealed the following: 1. 04/24/18 - Stage II L 1.0 cm, W 1.0 D < (less than) 0.1 cm; comments .stg (Stage) II . 2. 05/06/18 - resolved; comments excoriation resolved lighter pigmentation to skin 100% pink healthy tissue. F. Record review of R #17's Nurse's Notes revealed the following: 1. 04/21/18 - Faxed (Name of R #17's MD) about slough in wound bed waiting for response and possible new order of Santyl . 2. 04/23/18- Received response from (Name of R #17's MD) . use Santyl to wound bed . 3. 04/30/18 - .Santyl was refaxed still waiting for med from (Name of pharmacy) . 4. 05/06/18 - .Refaxed (Name of R #17's MD) response to add Santyl to above order to pharmacy . Healing well, area may be healed in the interim of waiting for Santyl 5. 05/22/18 - This nurse called the pharmacy to check on status of Santyl; 4th attempt. Talked w/ (with) (name of employee) who stated there is no prescription in (sic) notes for that ointment. (Name of employee) said fax to pharmacy she would walk to the floor doctor (name of doctor) since (Name of R #17's MD) (sic) not available till Thursday . G. On 07/10/18 at 9:49 am, during an interview, the DON confirmed that R #17 had a Stage 4 pressure ulcer that was facility acquired. H. Record review of the fax to pharmacy dated 05/25/18 revealed 5 attempts 04/23/18, 04/27/18, 05/06/18, 05/22/18, and 05/25/18 to contact pharmacy for Santyl. I. On 07/11/18 at 8:46 am, during an interview, CNA #5 stated that, We will put her (R #17) down after meals, but sometimes she will not lay down. She will stay out in common area. She does refuse to lay down sometimes. J. On 07/11/18 at 9:00 am, during an interview, the DON stated, We had Santyl here that we were using (for R #17). There was a house stock (of Santyl) . There was Santyl in the wound cart . She (the nurse) should have call (Name of R #17's MD) for outside source. We do not have anything in place (a protocol) to prevent this from happening again with (name of pharmacy). K. Record review of a fax to R #17's MD dated 05/30/18 requesting an air mattress for R #17's Stage 4 pressure ulcer. No response from MD was documented. L. Record review of the Treatment Administration Record date (MONTH) (YEAR) revealed Treatment order: (sacral, coccyx) . Apply Santyl to wound bed . Documentation recorded as being performed only on the following dates 05/26/18, 05/27/18, 05/28/18, 05/29/18, 05/30/18, and 05/31/18. M. On 07/11/18 at 10:03 am, during an interview, the DON confirmed the only documentation of R #17 having an order for [REDACTED].#17 Stage 4 pressure ulcer and no real interventions for her pressure ulcer or refusal to be laid to bed to offload pressure. After review R #17's TAR (Treatment Administration Record) and conferring with RN #1, the DON confirmed that the first time R #17 receive the Santyl treatment was on 05/26/18. The DON was asked what would be the outcome to the resident if the there was a delay in Santyl treatment, she stated You cannot heal the wound until you remove the barrier (with the santyl). During this interview, RN #1 was asked about wound treatment. She stated that she did not like to perform wound care, but confirmed that she did do wound care when the wound nurse was not available. N. On 07/11/18 at 10:30 am, during an interview, RN #1 stated that R #17 does refuse to be laid down. RN #1 also confirmed that R #17 refusals should be on her care plan. O. On 07/11/18 at 1:35 pm, during an interview, the DON stated that R #17 developed her pressure ulcer because at that time (March (YEAR)) Staff was critically low, and they were not turning her. P. Record review of R #17's Medical Chart revealed no documentation for repositioning. Q. On 07/11/18 at 11:44 am, during an interview, the Minimum Data Set (MDS) Coordinator confirmed that the facility does not document repositioning of residents. R. On 07/12/18 at 10:15 am, during observation of RN #1 performing wound care for R #17 pressur ulcer on the lower sacrum (at the bottom of the spine above the tail bone), the following was observed: RN #1 had performed hand hygiene, gloved, and opened supplies. When RN #1 removed the R #17's brief there were feces in the brief on the resident's buttocks. The residents open, soiled brief was pressed down into the bed and RN #1 used disposable wipes to clean the majority of the feces from the resident and placed the soiled wipes on top of the soiled brief occasionally pressing them down into a pile directly below the wound. RN#1 then removed her gloves, performed hand hygiene and regloved. RN #1 used a skin preparation pad to apply the solution to the periwound (around the wound) area. The wound cleanser bottle was placed on the mattress and tipped onto the soiled brief. The wound cleanser was then used to spray in and around the wound, and gauze sponges were used to dab away the wound cleanser only on the area around the wound but the wound bed itself was not cleansed. RN #1 opened the foil pouch that contained the collagen (a protein powder used for wound healing) and tossed the powder toward the wound, some of the powder fell into the wound, but approximately 1/3 of the wound bed remained pink and untouched by the powder. RN #1 took a pen from her pocket and wrote the date on the outside of the dressing then putting the pen directly back in her pocket. RN #1 put the bottle of wound cleanser back into the resident's box of clean supplies. S. On 07/12/18 at 10:28 am, during an interview with RN #1, when asked about the wound care; she stated, I should have removed the brief and the wipes before I started. When asked about not cleaning the wound bed and the possible outcome to the resident, RN #1 stated, I guess that could cause infection. RN #1 said she usually brings cotton tipped swabs to clean the wound bed, but had forgotten them today. RN #1 said she had not noticed the wound cleanser bottle being contaminated before touching it again with her gloves or placing it back in the supply box. T. On 07/12/18 at 10:44 am, during an interview, the DON was asked about reviewing wound care observations regarding the proximity of the soiled brief and wipes to the wound, no wound bed cleansing, wound cleanser bottle touching soiled items before it was used, and use of pen from the pocket and replaced in the pocket while the nurse wearing gloves she had performed wound care with. The DON confirmed the nurse's actions could cause contamination of wound and cause infection and delay or prevent healing. The DON stated she had no documentation of wound care competency for anyone at that time.

During an annual survey the following deficient practice was found to be Immediate Jeopardy: 1) R #17 had developed 2 facility acquired (developed in the facility) one that healed and one that progressed to a stage 4 pressure ulcer on her sacral (bony structure that is located at the base of the lumbar vertebrae) both discovered on 03/24/18. 2) Record review of R #17's care plan dated 03/22/18 revealed no interventions for her pressure ulcers, or her refusal to be laid in bed to relieve pressure on her wound. 3) Record review of a fax to R #17's Medical Doctor (MD) dated 04/21/18 requesting a Treatment Order for Santyl (Wound Care drug used to remove dead, damaged, or infected tissue to improve the healing potential) to treat R #17's stage 4 pressure ulcer. MD responded back on 04/23/17. There were 5 attempts to get Santyl from the Pharmacy 04/23/18, 04/27/18, 05/06/18, 05/22/18, and 05/25/18. 4) On 07/11/18 at 9:00 am, during an interview the DON confirmed that the facility had Santyl in the treatment cart but that it did not get used for R #17 until 05/26/18. 5) Record review of a fax to R #17's MD dated 05/30/18 requesting an air mattress for R #17's stage 4 pressure ulcer. No response from MD was documented. 6) Observation of R #17's wound care showed several deficiencies in wound care and infection control practices. 7) No documentation of residents repositioning could be found. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 1:35 pm. A Plan of Removal were submitted on 07/12/18 at 1:01 pm and approved. Plan of Removal 1. Wound care by staff nurses is immediately suspended. Staff informed verbally. 2. certified Wound Care Nurse (DON) will complete and document all aspects of resident wound care. Resident wound cares, by nurses, may resume only after wound care protocols, education, wound care competencies, and ongoing training are complete/established. 3. Resident Care Plan updated to reflect pressure ulcer and interventions. Communicated in 24 hour Resident Report Sheet. Update documented in Nurses Notes. 4. Two (2) hour Turn and Reposition documentation flowsheet placed in Treatment Administration Record. Notification documented on 24 hour Resident Report Sheet. 5. Medical Director informed of incident and immediate corrective measures. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 07/12/18 at 1:45 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review the facility failed to provide services to residents to prevent the development and promote healing of pressure ulcers for 1 (R #17) of 1 (R #17) sampled for pressure ulcers, when they failed to 1) prevent R #17 from developing 2 pressure ulcers on her sacral area one that healed and one that progressed to a Stage 4, 2) update R #17's care plan to reflect her current status of having a Stage 4 pressure ulcer and have interventions, 3) obtain Santyl medication from the Pharmacy to treat R #17's eventual Stage 4 pressure ulcer for over a month even when the facility had Santyl in the treatment cart, 4) document repositioning for residents, and 5) provide wound care appropriately and incongruently with infection control practices. This deficient practice resulted in R #17's Stage 4 pressure ulcer developing. The findings are: A. Record review of the fax sent to R #17's MD dated 03/24/18 revealed the presence of 2 Stage 2 ulcers on R #17 Coccyx area each about 1 in (inch) diameter . Start wound care for decubitus ulcers . The DON confirmed that the resident only had these two pressure ulcers and that one developed into a stage 4 and the other healed. The location did not change it was a documentation error (coccyx sacral pressure ulcer). B. Record review of R #17's Care Plan dated 03/22/18 found in R #17's paper chart and in the resident Care Plan book located by CNA documentation desk for their use revealed: (Name of R #17) is at risk for skin break down d/t (due to) impaired mobility and being chairfast. Approach start date: 03/21/2018 - Consider PT (physical therapy) consult for conditioning and prevention of contractures w/c (wheelchair) assessment. Has high w/c with w/c cushion. Approach start date: 03/21/2018 - Do skin assessment and inspection weekly with close attention to heels and bony areas. Approach start date: 03/21/2018 - Encourage resident to set in her special chair in room after lunch, with her feet elevated. C. Record review of R #17's Care Plan dated 06/22/18 found in the electronic medical records revealed the following: (Name of R #17) is at risk for skin break down d/t (due to) impaired mobility and being chairfast. She has a pressure ulcer on sacrum. Approach start date: 05/30/2018 - Pressure relief mattress to bed and chair. Approach start date: 05/30/2018 - Tx. (treatment) as ordered to sacrum; monitor for healing. Approach start date: 03/21/2018 - Consider PT consult for conditioning and prevention of contractures w/c (wheelchair) assessment. Has high w/c with w/c cushion. Approach start date: 03/21/2018 - Do skin assessment and inspection weekly with close attention to heels and bony areas. Approach start date: 03/21/2018 - Encourage resident to sit in her special chair in room after lunch, with her feet elevated. D. Record review of the Skin Assessment Flow Sheet -Pressure Ulcer for Wound #1- revealed the following: 1. 04/13/18 - Stage II Length (L) 1.5 cm, Width (W) 0.5 cm, Depth (D) < 0.1 cm 2. 04/20/18 - Unstageable L 1.5 cm, W 0.6 cm, D slough (A layer or mass of dead tissue separated from surrounding living tissue) present 3. 04/21/18 - comment Faxed (Name of R 7's MD) wound update and asked for santyl for wound . 04/2318 response from (Name of R #17's MD) to use Santyl in wound bed waiting on Santyl to come in. 4. 04/24/18 - Unstageable no measurements 5. 04/29/18 - unstageable no measurements resident refused 6. 04/30/18 - Unstageable no measurements resident refused 7. 05/06/18 - Unstageable L 1.0 cm, W 0.5 cm, D slough; comment . refaxed (Name of pharmacy) for santyl. If med does not come in wound maybe healed on its own. 3rd attempt and called. 8. 05/13/18 - Unstageable L 1.0 cm, W 1.0 cm, D < 0.2 cm 9. 05/22/18 - Unstageable L 2.8 cm, W 2.0 cm, D slough present; comment Wound worsening, refaxed (name of pharmacy) spoke with (name of employee) to get a hold of (name of R #17's MD) for Santyl . Spoke with (name of employee) about Santyl. Who stated would take fax to (name of R #17 MD) on the floor . 10. 05/25/18 - Unstageable L 2.0 cm, W 2.5 cm, D slough present 11. 05/28/18 - Unstageable L 2.0 cm, W 2.5 cm, D slough present 12. 06/03/18 - Unstageable L 2.4 cm, W 2.9 cm, D 0.8 cm 13. 06/11/18 - Stage IV L 2.4 cm, W 2.4 cm, D 0.7 cm 14. 06/18/18 - Stage IV L 2.7 cm, W 2.0 cm, D 0.5 cm 15. 06/24/18 - Stage IV L 2.5 cm, W 1.3 cm, D 0.5 cm 16. 07/01/18 - Stage IV L 2.5 cm, W 1.5 cm, D 0.5 cm 17. 07/09/18 - Stage IV L 2.2 cm, W 1.2 cm, D 0.5 cm E. Record review of the Skin Assessment Flow Sheet -Pressure Ulcer for Wound #2- revealed the following: 1. 04/24/18 - Stage II L 1.0 cm, W 1.0 D < (less than) 0.1 cm; comments .stg (Stage) II . 2. 05/06/18 - resolved; comments excoriation resolved lighter pigmentation to skin 100% pink healthy tissue. F. Record review of R #17's Nurse's Notes revealed the following: 1. 04/21/18 - Faxed (Name of R #17's MD) about slough in wound bed waiting for response and possible new order of Santyl . 2. 04/23/18- Received response from (Name of R #17's MD) . use Santyl to wound bed . 3. 04/30/18 - .Santyl was refaxed still waiting for med from (Name of pharmacy) . 4. 05/06/18 - .Refaxed (Name of R #17's MD) response to add Santyl to above order to pharmacy . Healing well, area may be healed in the interim of waiting for Santyl 5. 05/22/18 - This nurse called the pharmacy to check on status of Santyl; 4th attempt. Talked w/ (with) (name of employee) who stated there is no prescription in (sic) notes for that ointment. (Name of employee) said fax to pharmacy she would walk to the floor doctor (name of doctor) since (Name of R #17's MD) (sic) not available till Thursday . G. On 07/10/18 at 9:49 am, during an interview, the DON confirmed that R #17 had a Stage 4 pressure ulcer that was facility acquired. H. Record review of the fax to pharmacy dated 05/25/18 revealed 5 attempts 04/23/18, 04/27/18, 05/06/18, 05/22/18, and 05/25/18 to contact pharmacy for Santyl. I. On 07/11/18 at 8:46 am, during an interview, CNA #5 stated that, We will put her (R #17) down after meals, but sometimes she will not lay down. She will stay out in common area. She does refuse to lay down sometimes. J. On 07/11/18 at 9:00 am, during an interview, the DON stated, We had Santyl here that we were using (for R #17). There was a house stock (of Santyl) . There was Santyl in the wound cart . She (the nurse) should have call (Name of R #17's MD) for outside source. We do not have anything in place (a protocol) to prevent this from happening again with (name of pharmacy). K. Record review of a fax to R #17's MD dated 05/30/18 requesting an air mattress for R #17's Stage 4 pressure ulcer. No response from MD was documented. L. Record review of the Treatment Administration Record date (MONTH) (YEAR) revealed Treatment order: (sacral, coccyx) . Apply Santyl to wound bed . Documentation recorded as being performed only on the following dates 05/26/18, 05/27/18, 05/28/18, 05/29/18, 05/30/18, and 05/31/18. M. On 07/11/18 at 10:03 am, during an interview, the DON confirmed the only documentation of R #17 having an order for [REDACTED].#17 Stage 4 pressure ulcer and no real interventions for her pressure ulcer or refusal to be laid to bed to offload pressure. After review R #17's TAR (Treatment Administration Record) and conferring with RN #1, the DON confirmed that the first time R #17 receive the Santyl treatment was on 05/26/18. The DON was asked what would be the outcome to the resident if the there was a delay in Santyl treatment, she stated You cannot heal the wound until you remove the barrier (with the santyl). During this interview, RN #1 was asked about wound treatment. She stated that she did not like to perform wound care, but confirmed that she did do wound care when the wound nurse was not available. N. On 07/11/18 at 10:30 am, during an interview, RN #1 stated that R #17 does refuse to be laid down. RN #1 also confirmed that R #17 refusals should be on her care plan. O. On 07/11/18 at 1:35 pm, during an interview, the DON stated that R #17 developed her pressure ulcer because at that time (March (YEAR)) Staff was critically low, and they were not turning her. P. Record review of R #17's Medical Chart revealed no documentation for repositioning. Q. On 07/11/18 at 11:44 am, during an interview, the Minimum Data Set (MDS) Coordinator confirmed that the facility does not document repositioning of residents. R. On 07/12/18 at 10:15 am, during observation of RN #1 performing wound care for R #17 pressur ulcer on the lower sacrum (at the bottom of the spine above the tail bone), the following was observed: RN #1 had performed hand hygiene, gloved, and opened supplies. When RN #1 removed the R #17's brief there were feces in the brief on the resident's buttocks. The residents open, soiled brief was pressed down into the bed and RN #1 used disposable wipes to clean the majority of the feces from the resident and placed the soiled wipes on top of the soiled brief occasionally pressing them down into a pile directly below the wound. RN#1 then removed her gloves, performed hand hygiene and regloved. RN #1 used a skin preparation pad to apply the solution to the periwound (around the wound) area. The wound cleanser bottle was placed on the mattress and tipped onto the soiled brief. The wound cleanser was then used to spray in and around the wound, and gauze sponges were used to dab away the wound cleanser only on the area around the wound but the wound bed itself was not cleansed. RN #1 opened the foil pouch that contained the collagen (a protein powder used for wound healing) and tossed the powder toward the wound, some of the powder fell into the wound, but approximately 1/3 of the wound bed remained pink and untouched by the powder. RN #1 took a pen from her pocket and wrote the date on the outside of the dressing then putting the pen directly back in her pocket. RN #1 put the bottle of wound cleanser back into the resident's box of clean supplies. S. On 07/12/18 at 10:28 am, during an interview with RN #1, when asked about the wound care; she stated, I should have removed the brief and the wipes before I started. When asked about not cleaning the wound bed and the possible outcome to the resident, RN #1 stated, I guess that could cause infection. RN #1 said she usually brings cotton tipped swabs to clean the wound bed, but had forgotten them today. RN #1 said she had not noticed the wound cleanser bottle being contaminated before touching it again with her gloves or placing it back in the supply box. T. On 07/12/18 at 10:44 am, during an interview, the DON was asked about reviewing wound care observations regarding the proximity of the soiled brief and wipes to the wound, no wound bed cleansing, wound cleanser bottle touching soiled items before it was used, and use of pen from the pocket and replaced in the pocket while the nurse wearing gloves she had performed wound care with. The DON confirmed the nurse's actions could cause contamination of wound and cause infection and delay or prevent healing. The DON stated she had no documentation of wound care competency for anyone at that time.

The following deficient practices were found during an annual/complaint survey that were immediate jeopardy. 1) A nurse had administered humalog insulin to R #185 on 07/02/18 when his blood sugar was 418. The sliding scale revealed: 350-399 mg/dl give 4 units and call MD. The nurse gave 5 units of insulin. 2) R #20 had 4 episodes of blood sugar over 400 in June. The orders were to call the physician if the blood sugar was over 400. Nurse chose to report the over 400 sugars because the resident had snacks. When nurses asked to provide copy of order for the sliding scale, they were unable to produce the order. The order was discovered by staff 2 days later. 3) Nurses were giving long-acting insulin to R #185 form orders that were not clear, the MAR entry showed both 30 units and 40 units in direction and there was no clarification before the insulin was given. 4)Nurses were also administering [MEDICATION NAME] to R #24 and R #25 without obtaining a clarification whether the doctor wanted [MEDICATION NAME] (short acting) or [MEDICATION NAME] (long-acting). 5) On 07/09/18 a nurse gave R #185 [MEDICATION NAME] 5/325 when his order was for [MEDICATION NAME] 10/325. The resident is no fearful and anxious of medications he is presented with and feels like he must examine each one. The nurse further failed to assess the resident after this, failed to document the medication error, and further failed to notify the MD and DON about the error. The error was discovered because the family member complained about 2 errors in 2 weeks. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 6:49 pm. A acceptable Plan of Removal was submitted on 07/27/18 at 11:00 am and approved. The plan was: 1. Nurses giving insulin without having orders for 2 different residents. Nurses not notifying the MD for elevated blood sugars. * Interventions: A. Nurse will be in-serviced prior to working on the floor regarding diabetes management. (i.e., disease process, medication management; assessment and monitoring; and hypo and [MEDICAL CONDITION], and implications to residents' health and intervention.) B. Nurses will be education prior to working on the floor regarding following physician orders [REDACTED]. * Date of Completion: 07/30/18 2. Nurses were giving medications (insulin and [MEDICATION NAME] vs [MEDICATION NAME]) from incomplete or ambiguous orders and/or MARs without clarification. * Interventions: Nurses will be in-serviced on the necessary components of a medication order; taking an order; and the process of transcribing; placing the order on the MAR; verifying, clarifying PRN; and administering the medication. (Verifying the resident and clarifying the MAR PRN.) * Date of Completion: 07/27/18 3. Nurses were giving wrong opioid medication, not assessing the resident after this incident, not documenting the wrong medication, and not notifying the DON or the MD. * Interventions: A. Nurses will be in-serviced on medication administration (Right resident, etc.). B. Nurses will be in-serviced regarding assessing the resident for the effectiveness and side-effects of the medications. C. Nurses will be in-serviced on the procedure for medication errors (notifying the physician, the DON, and documentation). * Date of Completion: 07/30/18 The IJ was lifted after the Plan of Removal implemented and verified on 07/31/18 at 12:58 pm. This resulted in a lowering of the scope and severity from a K to a H. Based on record review and interview, the facility failed to provide correct administration medication for 1 (R #185) out of 17 ( R #2, R #4, R #5, R #6, R #7, R #8, R #11, R #19, R #20, R #21, R#23, R #24, R#25, R #27, R #30, R #36, and R #185) residents reviewed for medication administration and/or medication orders when they 1) gave the wrong medication for R #185 then failed to assess the resident and notify the doctor and the Director of Nurses, and 2) gave an insulin (a medication used treat diabetes-a disease of metabolism) outside of the sliding scale (an order that directs the dose of insulin to be given based on the results of the blood sugar) order. This deficient practice resulted in worry and anxiety for a resident who received the wrong medication, and a resident receiving a medication in a doseage not prescribed by the physician that could result in over or under treatment, unnecessary side effects, risk of adverse reactions and death. The findings are: R #185 Wrong Medication A. On 07/09/18 at 4:13 pm, during an interview, the family member of R #185 stated, (Name of R #185) has received the wrong medication for the second time in two weeks. The medication dispensing worries me. They gave him a sleeping pill and it was wrong and (Name of DON) said they were looking into it. He got the wrong pain medication too. You can talk to him about it. There is no specific person to talk to here. B. On 07/10/18 at 8:46 am, during an interview, R #185 stated, Yesterday, they gave me a sleeping pill instead of a pain pill. Yesterday, I couldn't wake up and when they took me for breakfast and I could not hold my head up. The nursing staff needs the beejesus scared out of them because they are not real careful with the pills. In the evening, I had asked for pain pill; they gave me two pills and one was sleeping pill. One of the nurses told me yesterday after they woke me up and told me that a mistake had been made. Now, I have to watch pills carefully. I am worried. Another time, I asked for pain pill. I noticed the pill was not the same shape--it was round, not oblong. The nurse said it was same thing, different shape when I asked her why it looked different. It made me incoherent into the next day. The nurse then fessed (confessed) up she gave me the wrong pill. C. On 07/10/18 at 1:10 pm, during an interview, the DON was asked about the two medication errors that R #185 had indicated he had received. She stated, I know of one error--a nurse gave him (R #185) [MEDICATION NAME] (an opioid pain medication with an Oxygen molecule in the chemical make-up) instead of [MEDICATION NAME] (an opioid pain medication with a Hydrogen molecule in the chemical make-up). I believe it was on 4th or 5th of July, I am not sure of the date. He got (Name of R #184's) medication. There was no incident report, or drug error report. The DON confirmed she heard about the medication from R #185's family member, then confronted RN #3 sometime after (MONTH) 4 and asked the nurse to write it up but had not received the documentation yet. D. Record review of the admission orders [REDACTED]. E. Record review of R #184's controlled drug record revealed: [MEDICATION NAME] (an opioid pain medication) /APAP (generic for Tylenol) (A.K.A.) [MEDICATION NAME] 5/325 mg take one table by mouth q 6 hrs as needed. F. On 07/10/18 at 3:28 pm, during an interview, RN #3 was asked about a medication error with R #185. She stated, I would say it would have been on 07/04/18. I would have to look at the narcotic sign out sheet. (Name of R #185)'s family member said he needed something for pain. I got R #184's pain medication -from a bottle of 5 mg (a metric unit of measure)/325 mg [MEDICATION NAME] (an opioid pain medication). I took it in him (R #185) at same time I was helping to pass trays, feeding another resident in dining room, and passing meds (medications). R #185 said, It's white (a different color than he was used to). He didn't have to swallow it if he had questions. He started getting woozy and he complained. I wondered if I gave him right thing. He (R #185) said it really knocked me out. I went and talked to him. The family member said he was slurring his speech--but I saw he was alert and joking around. When I looked at pills, I thought I made an error. Remember, all these guys (new admissions) were called the same nickname. When I looked at the pills, I knew I made a mistake. I went an apologize to (Name of R #185). I just kept an eye on him. No special vital signs or anything else. I did not notify doctor or my supervisor. He (R #185) went to bed he was fine. The DON came to me or the wife went to her, I don't remember. The DON asked me about the error. There is a medication error form, but I did not do one because I was not asked to do one. I did not document (the error) on his (R #185's) drug log or document it in his chart. I think I signed it out on the control drug sheet for R #184. After reviewing the control drug logs, RN #3 said she was unsure of the date it happened, or if she had signed it out. I can't really read it (the documentation). G. On 07/10/18 at 05:29 pm, during interview with the DON regarding the opioid administration error that involved RN #3 and the lack of an assessment by RN #3 after the error was discovered, the DON stated, I talked to(NAME)about the error, I did not notify the physician either. I have a concern that she did not report or document the error. I was going to make a plan of action with her about the error but had not done it yet because you guys (surveyors) walked thought the door. She apologized to the resident. She (RN #3) did not know she made an error until I told her. She (RN #3) didn't make an assessment because she didn't know at the time. The DON was advised that her (DON's) recall of what she knew of the incident did not match what RN #3 stated in the interview. The DON said she did not know what to say about the differences. R #185 Humalog Insulin H. Record review of the (Name of facility) admission orders [REDACTED]. I. Record review of a faxed order for R #185, fax confirmation date 06/26/18 revealed: Humalog (a type of insulin) sliding scale (amount of insulin to be given based on the results of blood glucose (sugar)). AC (before meals) & HS (at bedtime). Call if less than 100. Less than 150 mg (milligram)/dl (deciliter) - 0 units (give no insulin) 150-199 mg/dl - 1 unit 200-249 mg/dl - 2 units 250-299 mg/dl - 3 units 300-349 mg/dl - 4 units 350-399 mg/dl - 4 units and call MD (medical doctor) Call if greater than 400 06/26/2018 - Open ended (no end date for the order) J. Record of of the MAR (medication administration record) for R #185 dated as generated 06/26/18 revealed: Humalog 100 units/ml Injection Amount to administer: sliding scale; subcutaneous (to be given as injection under the skin and into the fatty tissue) Before Meals and at Bedtime Call MD if less than 100 or greater than 400 (blood sugar) Dx (diagnosis): Diabetes mellitus due to underling condition with diabetic [MEDICAL CONDITION] (nerve damage from elevated blood sugar) 150-199 - 1 unit 200-249 - 2 units 350-299 - 3 units 300-349 - 4 units 350-399 - 5 units Further review of the same MAR revealed: 1. On 06/29/18, R #185 blood sugar was 400 and 5 units of Humalog insulin was given (actual order was for 4 units and there was no higher coverage indicated) 2. On 06/30/18, resident had a blood sugar of 419 and there is no notation of insulin given K. On 07/11/18 at 2:46 pm, during an interview, the DON, when asked about the discrepancy between the MAR and sliding scale orders on 06/26/18, the DON stated, The nurse should have clarified the order. And after talking with the doctor, the MAR should have been yellowed out (with a yellow marker to indicate it is not a current order) and the order should have been rewritten. The nurse shouldn't try to guess the doctor probably wanted (for a dose) and write a 5 when that is not what the order says. L. On 07/12/18 at 10:52 am, during an interview, RN #1 affirmed the order for the sliding scale insulin dated 6/26/18 and the MAR written on 06/26/18 does not agree. RN #1 stated she does not know why they do not agree, and does not know who wrote the MAR. M. On 07/19/18 at 01:27 pm, during an interview, the DON was asked about possible outcomes for the residents from the unclear insulin orders, and nurses guessing at sliding scale insulin coverage. She stated, Possible outcome to patient is [DIAGNOSES REDACTED] (low blood sugar) or even death by Diabetic Ketoacidosis (a life-threatening complication diabetes that occurs when the body produces high levels of [MEDICATION NAME] due to lack of insulin).

During an annual survey, the following deficient practice was an Immediate Jeopardy was found: On 07/09/18, a nurse gave R #185 [MEDICATION NAME] (an anti-psychotic) PRN order for sleep. The resident and his wife report that on the next day, he was over sedated. The resident further reported that he an anxious about getting his medication. This resulted in an Immediate Jeopardy that was called on 07/11/18 at 6:49 pm. A acceptable Plan of Removal was submitted on 07/27/18 at 11:00 am and approved. The plan was: MD was writing orders for anti-psychotic for PRN for sleep. The Nurse did not seek clarification from the MD prior to giving the medication. * Interventions: A. Nurses will be in-serviced on the use of anti-psychotic medications including indications for use, the new PRN regulations and time frames, and contacting the physician with questions and concerns. B. Facility will review the orders for other residents that might be similarly impacted. * Date of Completion: 07/30/18 The IJ was lifted after the Plan of Removal was implemented and verified on 07/31/18 at 12:58 pm. This resulted in a lowering of the scope and severity from a J to a G. Based on record review, interview, and observation, the facility failed to ensure [MEDICATION NAME] (anti-psychotic medication) was given for an appropriate indication (diagnosis) for 1 (R #185) of 1 (R #185) resident reviewed for complaint of wrong medication. This deficient practice resulted in unnecessary fear, worry and anxiety for R #185, and adverse consequences to include over sedation. The findings are: A. Record review of the (Name of facility) admission orders [REDACTED] B. On 07/09/18 at 4:13 pm, during an interview, the family member of R #185 stated, (Name of R #185) has received the wrong medication for the second time in two weeks. The medication dispensing worries me. They gave him a sleeping pill and it was wrong and (Name of R #185) said they were looking into it. He got the wrong pain medication, too. You can talk to him about it. There is no specific person to talk to here. C. On 07/10/18 at 8:46 am, during an interview, R #185 stated, Yesterday, they gave me a sleeping pill instead of a pain pill. Yesterday, I couldn't wake up and when they took me for breakfast, I could not hold my head up. The nursing staff needs the beejesus scared out of them because they are not real careful with the pills. In the evening, I had asked for pain pill. They gave me two pills and one was sleeping pill. One of the nurses told me yesterday after they woke me up, told me a mistake had been made. Now, I have to watch pills carefully. I am worried. Another time I asked for pain pill, I noticed the pill was not the same shape--it was round not oblong. The nurse said it was same thing different shape when I asked her why it looked different. It made me incoherent into the next day. The nurse then fessed (confessed) up she gave me the wrong pill. D. On 07/10/18 at 1:10 pm, during an interview, the DON was asked about the two medication errors that R #185 had indicated he had received. The DON stated she heard about the medication errors from R #185's family member, then confronted RN #3 sometime after (MONTH) 4 and asked the nurse to write it up but had not received the documentation yet. When the DON was shown the order for [MEDICATION NAME] 50 mg prn (as needed) for sleep, the DON stated, I would have hoped the nurses would clarify the order. It is a anti-psychotic and not given for sleep. Electronic orders and hand written orders don't always coincide. Nobody is verifying anything against (confirming with) the chart. E. Record review of the physician order [REDACTED]. F. On 07/10/18 at 12:47 pm, during an interview, RN #1 was asked about the resident complaint about receiving a medicine for sleep. She stated, Yesterday, he (R #185) was very sleepy, but the night before he had [MEDICATION NAME] for sleep. I checked blood sugar and it was normal and he was given [MEDICATION NAME]. When we get new admission, we put in orders with diagnosis. That (the [MEDICATION NAME]) was carried over from the hospital. If I had input the information in with that order for [MEDICATION NAME] for sleep, I would have contacted the doctor for clarification since [MEDICATION NAME] is not a sleeping medication. G. On 07/11/18 at 2:46 pm, during an interview with the DON regarding the administration of [MEDICATION NAME] on 07/09/18 to R #185 for sleep, she stated, I know [MEDICATION NAME] cannot be given on as as needed basis and it is not appropriate for sleep or for his anxiety and depression. The risk to the resident is oversedation. H. Record review of Drugs.com revealed [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION], bi-polar, and severe depression. Further review of the website revealed that this medication was not designed to help with sleep.

Based on interview and record review, the Medical Director (MD) failed to coordinate care for 1 (R #71) of 2 (R #52, and R #71) residents sampled for accidents when the MD delayed orders for R #71 to receive diagnostics services after a fall which resulted in a [MEDICAL CONDITION] requiring surgical intervention. This deficient practice could likely result in residents remaining in prolong pain and unable to function to best of their ability from having an a fracture undiagnosed . The findings are: A. On 05/04/16 at 7:27 am, during an interview, the DON stated, He (R #71) has had 6 [MEDICAL CONDITION]. He can not understand that he can not get up an walk. We tell him, but he can not understand. It took us a little while to figure out he could not understand. He seems to answer appropriately to questions and comments but if you go deeper you understand that he may not understand. We put fall mats and a bed alarm. His (R #71's) room mate had visitor. He (R #71) asked the visitor to give him a walker to help him get to the restroom and he fell . We assessed him all was fine. The second day he was saying it was hurting but only on standing. So, we were trying to obtain physician's orders [REDACTED]. We had the family calling as well. We tried to get physicians orders, we tried calling and faxing. We got the order on the 21'st (04/21/16). The x-rays revealed [MEDICAL CONDITION]. He went to (name of local hospital) for surgery. B. Record review of the incident/accident report dated 04/17/16 revealed, (R #71) got out of chair to ambulate to bathroom with assist - lost balance and fell to his left side - hit his head on roommates feet (he was in recliner) as he went to floor, 3 corner skin tear to left elbow (1cm) (centimeter) c/o (complain of) some pain to left upper leg/hip. C. Record review of the fax to Medical Director dated 04/19/16 revealed resident has had 3 falls since admit of 04/15/16 transfers. Have been difficult + (and) resident c/o pain to L (left) leg + (and) hip can we get an order for [REDACTED]. Faxed twice 04/19/16 (&) 04/20/16. D. Record review of the (name of the local hospital) Discharge Instructions date of discharge 04/25/16 revealed Reason for hospitalization L (left) Hip fx (fracture). R #71 also had staples from surgery. E. On 05/04/16 at 8:35 am, during an interview, LPN #1 stated, I faxed and called (name of MD's Secretary #1) and (name of MD's Secretary #2) they said they would relay the message for the x-rays. He (R #71) only showing the pain only when he would ambulate. The orders came in on the 21st (04/21/16). He went to (name of local town) and they sent him to (name of local hospital). His pain perception might be off. F. Record review skilled daily nurses note dated 04/17/16 revealed, @ (at)1545 (3:45 pm) res (resident) found on floor of room - tried to ambulate to restroom - visitor from across the hall gave him his roommates walker - he lost his balance and fell - hit his head on roommates feet (he was in is recliner with feet up) res stated that he didn't hit hand - received 1 cm 3 corner skin tear to left elbow- ROM (range of motion) good - no extending ligature rotation or shortening to either leg however; he had some c/o slight pain to upper left leg/ hip area-he was crossing his legs and bending/straightening legs with any pain. Neuro started - MD notified via fax - wife called (name of R #71's wife) 2030 (8:30 pm) ROM still good with s/sx (sign/symptoms) pain - he states 'doesn't hurt now.' G. Record review of the skilled daily nurses notes dated 04/19/16 revealed Complaint with care denies any pain or discomfort @ this time one person assist resident having difficulty at transfer. PT (physical therapy) has pt orders will orders will continue to monitor. 1330 (1:30 pm) resident c/o pain to left leg and hip during transfers and to pt faxed (name of MD) of changes of condition and requesting x-rays. H. Record review of the skilled daily nurses notes dated 04/19/16 revealed Placed call to physician to get an order for [REDACTED]. Will continue to try and reach physician. I. Record review of the skilled daily nurses notes dated 04/20/16 revealed Compliant with care denies any discomfort, continues to have pain to left leg. 0 (no) response to fax @ this time. J. Record review of the skilled daily nurses notes dated 04/21/16 revealed Resident received N.O. (new order) for x-ray of left hip and thigh. Sisters @ facility, took resident to (name of local hospital) radiology department called radiology department for assistance with transfers. K. Record review of the skilled daily nurses notes dated 04/21/16 revealed Resident assessed at (name of local hospital) and found to have a [MEDICAL CONDITION]. Wife states that resident would be sent to (name of local town) for surgery. Late entry wife stated she attempted to call (name of MD) x4 with 0 results. L. On 05/04/16 at 9:40 am, during an interview, the MD stated We always send them (residents) out to get x-rays with a fall or any pain. It is an automatic thing. I do not know why they (the facility) couldn't get a hold of me it was the middle of the week, everyone else got a hold of me. I contest those statement (interviews with the DON and LPN #1) and nurses notes. M. On 05/04/16 at 10:08 am, during an interview LPN #1 stated, Yes, I did do follow up calls to (name of MD) but got a hold (name of Secretary #2). She said they would have to get back with me he (MD) was with patients. N. On 05/04/16 at 2:34 pm, during an interview, the DON stated, I called only once. It must have been a miss communication between (name of MD) staff and (name of MD). It never takes 3 days to get a resident out of here, but we couldn't do anything without an order. O. Record review of the Contract For Medical Director Services December 2015 revealed Section III Duties and Obligations Of (Name of MD) Generally, (name of MD) shall be responsible for: 1) Overall medical direction and coordination of medical care in the (name of the facility).

The facility failed to ensure that fluids were thickened to the prescribed consistency for residents prescribed thickened fluids due to aspiration risk. During meal observations, Residents #7, 24 and 34 were each prescribed thickened fluids. They were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. Resident #7 was also served soda without thickener. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 03/12/13 at 3:05 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 03/13/13 at 1:00 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to provide fluids thickened to the consistency prescribed by the residents' physicians to prevent aspiration for 3 (#7, 24, and 34) of 3 (#7, 24, and 34) sampled residents with physician's orders [REDACTED]. Residents #7, 24, and 34 were each prescribed thickened fluids, and were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. Resident #7 was also served soda without thickener. This deficient practice had the potential to expose residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs, which could lead to pneumonia or other complications. The findings are: Resident #7 A. Review of the records of resident #7 revealed a Resident Admission Record dated 02/25/13, documenting that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED]." A telephone order dated 02/20/13 ordered, "Mechanical soft diet, nectar thick liquids." B. On 03/12/13 at 11:30 am, resident #7 was seated at a dining table in the facility dining room. The resident was served beverages including an 8 ounce glass of thickened water with a 1 inch layer of clear thin water on top of the thickened water. Resident #24 C. Review of the record of resident #24 revealed a face sheet dated 08/14/2012 documenting admission to the facility with [DIAGNOSES REDACTED].(red blood cell deficiency), hallucinations, dysphagia (swallowing problems), hypercoagulable state (abnormal increased tendency toward clotting), diarrhea, signs/symptoms emotional state. D. At 11:30 on 03/12/13, resident #24 was observed sitting at a table in the dining room. The resident is on thickened liquids. A glass of water was sitting by the resident's lunch plate with the liquids separated, clear liquid on the top 1/3 of the glass and the bottom 2/3 of the glass filled with cloudy liquid. The liquids had not been stirred. The resident had just finished drinking a Pepsi and requested another Pepsi. Diet Aide #1 placed ice in a plastic drinking glass and filled it with Pepsi from the dispenser in the kitchen. No thickener was placed in the glass with the Pepsi. The resident requested a third Pepsi and the Dietary Manager filled the plastic drinking glass with ice and Pepsi and returned and gave it to the resident; no thickener was placed in the glass. During lunch, the resident was observed drinking all three Pepsi's. The resident's glass of water, with thicken liquid separated, remained unstirred throughout lunch. E. At 12:50 on 03/12/13, during an interview with the Dietary Manager regarding no thickener mixed with Pepsi, he stated, "Every time thickener is placed in the cup with Pepsi, it would foam out of the glass." F. Review of the Physician order [REDACTED]." Resident #34 G. Review of the records of resident #34 revealed a Resident Admission Record dated 03/07/13, documenting that the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Speech Clinical Swallow Eval (evaluation) dated 09/25/12 documented, "Throat clearing impaired ... cough impaired ... Gag reflex is absent." A Physician order [REDACTED]. A 02/06/12 Patient Discharge Instruction from a local hospital ordered the resident discharged , "Back to care center," with a pureed diet but made no changes to fluid texture. H. On 03/12/13 at 11:30 am, resident #34 was seated at a dining table in the facility dining room. The resident was served beverages including an 8 ounce glass of thickened water with a 1 inch layer of clear thin water on top of the thickened water. I. On 03/12/13 at 3:00 pm, review of the resident's dietary meal card revealed instructions to dietary staff to serve a mechanical soft diet with nectar-thickened fluids, dated 02/13/12. During an interview at that time, the facility Dietary Manager stated that the date on the card was the last date on which the diet had been changed. No records corresponding to an 02/13/12 diet change were found in the resident's record. J. On 03/12/13 at 11:45 am, Dietary Aide #1 was asked about provision of thickened fluids to residents. She stated, "Right now we have three people that have thickened (thickened liquids)," and she identified residents #7, 24 and 34 as the residents receiving thickened fluids. When asked how she handled provision of thickened water, she stated that she prepared it immediately before putting it on the tables and stated, "We put it (on the table) before the resident gets here. We put water at all the tables, maybe 2 - 3 minutes before they get here." K. On 03/13/13 at 10:45 am, during an interview, the Director of Nursing was asked to provide facility policies and procedures on provision of thickened fluids. On 03/14/13 at 3:30 pm, the facility provided a policy dated 03/13/13; during an interview at that time, the DON was asked if the facility had a policy for thickened fluids prior to that date. She stated, "No. We have four books on policies and procedures in there, but it wasn't there."

The facility failed to ensure that fluids were thickened to the prescribed consistency for residents prescribed thickened fluids due to aspiration risk. During meal observations, Residents #7, 24 and 34 were each prescribed thickened fluids. They were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. Resident #7 was also served soda without thickener. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 03/12/13 at 3:05 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 03/13/13 at 1:00 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to provide fluids thickened to the consistency prescribed by the residents' physicians to prevent aspiration for 3 (#7, 24, and 34) of 3 (#7, 24, and 34) sampled residents with physician's orders [REDACTED]. Residents #7, 24, and 34 were each prescribed thickened fluids, and were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. Resident #7 was also served soda without thickener. This deficient practice had the potential to expose residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs, which could lead to pneumonia or other complications. The findings are: Resident #7 A. Review of the records of resident #7 revealed a Resident Admission Record dated 02/25/13, documenting that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED]." A telephone order dated 02/20/13 ordered, "Mechanical soft diet, nectar thick liquids." B. On 03/12/13 at 11:30 am, resident #7 was seated at a dining table in the facility dining room. The resident was served beverages including an 8 ounce glass of thickened water with a 1 inch layer of clear thin water on top of the thickened water. Resident #24 C. Review of the record of resident #24 revealed a face sheet dated 08/14/2012 documenting admission to the facility with [DIAGNOSES REDACTED].(red blood cell deficiency), hallucinations, dysphagia (swallowing problems), hypercoagulable state (abnormal increased tendency toward clotting), diarrhea, signs/symptoms emotional state. D. At 11:30 on 03/12/13, resident #24 was observed sitting at a table in the dining room. The resident is on thickened liquids. A glass of water was sitting by the resident's lunch plate with the liquids separated, clear liquid on the top 1/3 of the glass and the bottom 2/3 of the glass filled with cloudy liquid. The liquids had not been stirred. The resident had just finished drinking a Pepsi and requested another Pepsi. Diet Aide #1 placed ice in a plastic drinking glass and filled it with Pepsi from the dispenser in the kitchen. No thickener was placed in the glass with the Pepsi. The resident requested a third Pepsi and the Dietary Manager filled the plastic drinking glass with ice and Pepsi and returned and gave it to the resident; no thickener was placed in the glass. During lunch, the resident was observed drinking all three Pepsi's. The resident's glass of water, with thicken liquid separated, remained unstirred throughout lunch. E. At 12:50 on 03/12/13, during an interview with the Dietary Manager regarding no thickener mixed with Pepsi, he stated, "Every time thickener is placed in the cup with Pepsi, it would foam out of the glass." F. Review of the Physician order [REDACTED]." Resident #34 G. Review of the records of resident #34 revealed a Resident Admission Record dated 03/07/13, documenting that the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Speech Clinical Swallow Eval (evaluation) dated 09/25/12 documented, "Throat clearing impaired ... cough impaired ... Gag reflex is absent." A Physician order [REDACTED]. A 02/06/12 Patient Discharge Instruction from a local hospital ordered the resident discharged , "Back to care center," with a pureed diet but made no changes to fluid texture. H. On 03/12/13 at 11:30 am, resident #34 was seated at a dining table in the facility dining room. The resident was served beverages including an 8 ounce glass of thickened water with a 1 inch layer of clear thin water on top of the thickened water. I. On 03/12/13 at 3:00 pm, review of the resident's dietary meal card revealed instructions to dietary staff to serve a mechanical soft diet with nectar-thickened fluids, dated 02/13/12. During an interview at that time, the facility Dietary Manager stated that the date on the card was the last date on which the diet had been changed. No records corresponding to an 02/13/12 diet change were found in the resident's record. J. On 03/12/13 at 11:45 am, Dietary Aide #1 was asked about provision of thickened fluids to residents. She stated, "Right now we have three people that have thickened (thickened liquids)," and she identified residents #7, 24 and 34 as the residents receiving thickened fluids. When asked how she handled provision of thickened water, she stated that she prepared it immediately before putting it on the tables and stated, "We put it (on the table) before the resident gets here. We put water at all the tables, maybe 2 - 3 minutes before they get here." K. On 03/13/13 at 10:45 am, during an interview, the Director of Nursing was asked to provide facility policies and procedures on provision of thickened fluids. On 03/14/13 at 3:30 pm, the facility provided a policy dated 03/13/13; during an interview at that time, the DON was asked if the facility had a policy for thickened fluids prior to that date. She stated, "No. We have four books on policies and procedures in there, but it wasn't there."