Every finding on record at Mt. Tabor Health & Rehabilitation

Based on interview and record review, it was determined the facility failed to report an allegation of verbal abuse within two hours to the State Agency for 1 of 4 sampled residents (#14) reviewed for abuse. This placed residents at risk for ongoing verbal abuse. Findings include:Resident 14 admitted to the facility in 12/2025 with diagnoses including hemiplegia and hemiparesis following a stroke affecting her/his left non-dominant side. Resident 14 no longer resided in the facility and was unable to be observed or interviewed.A 3/22/26 Alleged Abuse Investigation initiated by Staff 15 (LPN) documented Resident 14 reported an allegation of verbal abuse to Staff 9 (CNA) on 3/22/26. Staff 9 reported the abuse to Staff 15 on 3/22/26. The investigation documented the alleged verbal abuse was perpetrated by Staff 16 (LPN) on 3/20/26 and was witnessed by Staff 26 (CNA).On 7/8/26 at 11:41 AM, Staff 16 (LPN) stated she did not verbally abuse Resident 14 on 3/20/26 or any other time.On 7/8/26 at 1:20 PM, Staff 15 (LPN) stated he initiated the Alleged Abuse Investigation documentation on 3/22/26 when he was made aware of the incident, even though the alleged abuse had occurred several days earlier.On 7/8/26 at 2:16 PM, Staff 9 (CNA) stated on 3/22/26 Staff 26 told her that she witnessed Staff 16 verbally abuse Resident 14 on 3/20/26.On 7/9/26 at 12:28 PM, Staff 26 stated she witnessed Staff 16 verbally abuse Resident 14 on 3/20/26 but did not immediately report it because she was an agency staff and did not know who to notify.On 7/10/26 at 11:27 AM, Staff 1 (Administrator) stated a CNA was aware of the alleged abuse on 3/20/26 but did not notify other facility staff until 3/22/26 which caused a delay in reporting to the state agency.

Based on interview and record review it was determined the facility failed to fully develop a baseline care plan related to falls within 48 hours for 1 of 3 sampled residents (#13) reviewed for care plans. This placed residents at risk for falls. Findings include:Resident 13 admitted to the facility on [DATE] with diagnoses including sacrum fracture and left pubis fracture. Resident 13 discharged on 6/22/26. Resident 13's 6/19/26 Baseline Care Plan indicated the resident was at risk for falls and injury related to impaired mobility, muscle weakness, and decreased balance; however, no fall interventions were developed and implemented. The 6/20/26 Fall Risk Assessment indicated Resident 13 was at risk for falling. Resident 13's 6/20/26 and 9/22/26 Progress Notes indicated she/he sustained a non-injury fall on 6/20/26 and a fall with injury on 6/22/26. On 7/9/26 at 11:04 AM, Staff 2 (DNS) and Staff 4 (RNCM) acknowledged Resident 13's baseline care plan was not fully completed within the required 48 hours to include fall interventions and acknowledged Resident 13 had a second fall on 6/22/26.

Based on interview and record review it was determined the facility failed to implement care plan interventions for 1 of 3 sampled residents (#6) reviewed for ADLs. This placed residents at risk for not receiving showers. Findings include:Resident 6 admitted to the facility in 5/2023 with diagnoses including traumatic brain injury.Resident 6's 1/28/19 Behavior Monitoring Care Plan instructed staff to call Resident 6's parents if Resident 6 refused a shower so they could speak to resident regarding the refusal.Resident 6's 5/15/26 Care Conference Note indicated if Resident 6 refused a shower staff should call the resident's family.Resident 6's Point of Care Shower documentation for 12/13/25 through 1/12/26 and 6/7/26 through 7/7/26 revealed Resident 6 refused a shower on 12/25/25, 1/1/26, 1/4/26, 6/14/26, and 6/25/26.Resident 6's clinical record found no evidence Resident 6's family was called on 12/25/25, 1/1/26, 1/4/26, 6/14/26, and 6/25/26 to inform the family of the resident's shower refusals. On 7/9/26 at 10:14 AM, Staff 11 (RN) stated when Resident 6 refused a shower staff were supposed to call the resident's mother, but staff did not always notify the nurses until the end of the shift. On 7/9/26 at 10:46 AM, Staff 9 (CNA) stated when Resident 6 refused a shower staff were supposed to call the resident's mother. Staff 9 stated she was unable to remember if she called Resident 6's mother when she/he refused a shower with her.On 7/9/26 at 10:47 AM, Staff 2 (DNS) and Staff 4 (RNCM) acknowledged staff were to notify Resident 6's family if the resident refused a shower and to document that the call was made in the clinical record. Staff 4 stated she was unable to find any evidence Resident 6's family was notified of the refused showers on 12/25/25, 1/1/26, 1/4/26, 6/14/26, and 6/25/26.

Based on interview and record review it was determined the facility failed to provide showers or bed baths for 1 of 3 sampled residents (# 11) reviewed for ADLs. This placed residents at risk for not receiving adequate assistance with ADLs. Findings include:Resident 11 admitted to the facility in 2/2026 with diagnoses including orthopedic aftercare and an infection of the skin and subcutaneous tissue. Resident 11 no longer resided in the facility and was unable to be observed or interviewed. Resident 11's current care plan indicated Resident 11 was to receive a bed bath twice a week. Resident 11's CNA task charting documented Resident 11 received a bed bath on one occasion between 4/1/26 and 4/20/26, with no refusals documented. Resident 11 should have received five bed baths during this time frame. On 7/10/26 at 9:24 AM, Staff 21 (CNA) stated residents typically receive two showers or bed bath per week and as needed. Staff stated Resident 11 had wanted showers but had not received them. Staff 21 stated Resident 11 and the resident's family were upset that Resident 11 was receiving assistance for bathing. On 7/10/26 at 10:10 AM, Staff 3 (LPN Unit Manager) stated Resident 11 was care planned to receive bed baths on Tuesday and Friday but did not receive them. On 7/10/26 at 10:11 AM, Staff 2 (DNS) stated all residents were to receive a bed bath or shower at least twice per week and acknowledged that Resident 11 had not received her/his showers or bed bath.

Based on interview and record review it was determined the facility failed to follow physician orders for 3 of 4 sampled residents (#s 2, 4, and 13) reviewed for medications. This placed residents at risk for medication errors. Findings include: 1. Resident 2 admitted to the facility in 2/2026 with diagnoses including metabolic encephalopathy, pneumonia, alcoholic cirrhosis of liver without ascites, acute and chronic respiratory failure with hypoxia. Resident 2 discharged from the facility on 2/11/26. Resident 2's 2/10/26 SNF admission Orders revealed the following medication orders: -Seroquel (an antipsychotic medication) 50 mg two tablets at bedtime. -Xanax (an anti-anxiety medication) 0.5 mg one tablet BID. Resident 2's 2/2026 MAR documented both medications were not administered on 2/10/26. On 7/7/26 at 11:26 AM, Resident 2 stated she requested her/his Seroquel and Xanax on 2/10/26 but was told the facility could not administer them. On 7/10/26 at 10:38 AM, Staff 4 (RNCM) stated the orders were entered incorrectly on the MAR and were not given per physician orders on 2/10/26. On 7/10/26 at 11:18 AM, Staff 2 (DNS) stated physician orders were to be inputted accurately, confirmed by a second nurse and medications were to be given per physician orders. Staff 2 acknowledged Resident 2 did not receive her/his medications per orders. 2. Resident 4 admitted to the facility in 2/2026 with diagnoses including thyroid disorder, stroke, malnutrition and dysphagia. Resident 4's clinical record revealed the following physician orders: -Megestrol (a medication to treat severe weight loss) 20 mg one tablet daily, ordered on 2/16/26.-Creon (a medication for the pancreas) one tablet TID with meals. Resident 4's 2/2026 MAR documented the following: -Megestrol was started on 2/19/26, three days after it was ordered by the physician.-Creon was scheduled by the facility and given at 8:00 AM, 2:00 PM and 8:00 PM from 2/4/26 to 2/18/26, which was not during a meal. On 7/10/26 at 11:18 AM, Staff 6 (LPN/Former Unit Manager) and Staff 2 (DNS) acknowledged Resident 4's medications were not given consistent with the resident's physician orders. 3. Resident 13 admitted to the facility in 6/2026 with diagnoses including sacrum and left pubis fracture. Resident 13's admission Orders included Haldol (an antipsychotic medication) every 6 hours as needed for agitation or delirium. Resident 13's Progress Notes from 6/19/26 through 6/22/26 indicated Resident 13 was confused and agitated on 6/19/26, 6/20/26, and 6/21/26. Resident 13's 6/2026 MAR indicated Resident 13 had not received Haldol at any time during her/his stay in the facility. Resident 13's clinical record found the resident's Haldol order was not transcribed onto her/his 6/2026 MAR and no discontinue order was received. On 7/9/26 at 11:04 PM, Staff 4 (RNCM) acknowledged Resident 13's order for Haldol was not discontinued, was not transcribed onto Resident 13's MAR, and was not administered as ordered.

Based on observation, interview and record review, it was determined the facility failed to provide meals according to preferences and according to recommendations made by a clinician for 1 of 3 sampled residents (#12) reviewed for food preferences. This placed residents at risk for weight loss. Findings include:Resident 12 admitted to the facility in 1/2026 with diagnoses including chronic kidney disease stage 5, congestive heart failure and end stage renal disease. On 7/7/26 at 12:48 PM, Resident 12 stated she/he had requested to receive extra-large portions of food based on a recommendation from Resident 12's dietician at her/his dialysis clinic and stated she/he never received extra-large portions. On 7/7/26 at 12:59 PM, Resident 12's lunch tray was observed and included one portion of quiche, four pieces of asparagus and a slice of cake. The resident's lunch ticket noted extra-large portions.On 7/8/26 at 9:01 AM, Resident 12's breakfast tray delivery was observed and included two pancakes and one piece of bacon. The resident's breakfast ticket noted extra-large portions.On 7/8/26 at 9:01 AM, Staff 22 (CNA) stated two pancakes, and one piece of bacon was a regular portion and not an extra-large portionOn 7/9/26 at 12:11 PM, Witness 14 (Dietician, Fresenius Dialysis Clinic) stated she had faxed an order to the facility on 1/21/26 which included a recommendation for double protein portions as Resident 12 had frequently complained of not getting enough to eat in the facility. This documentation was unable to be located in Resident 12's clinical record.On 7/9/26 at 1:22 PM, Staff 23 (Cook) stated Resident 12 was to receive extra-large portions at each meal as follows:- 7/7/26 lunch tray: two portions of quiche and 8 pieces of asparagus.-7/8/26 breakfast tray: four pancakes and four pieces of bacon.On 7/9/26 at 1:33 PM, Staff 24 (Dietary Manager) confirmed Resident 12 was to receive extra-large portions at every meal and acknowledged the resident had not received extra-large portions.

Based on observation, interview and record review it was determined the facility failed to provide transportation for dialysis treatments for 1 of 3 sampled residents (#1) reviewed for dialysis care. This placed residents at risk for not receiving their dialysis services according to their schedules. Findings include: Resident 1 was admitted to the facility in 12/2025, with diagnosis including acute kidney failure, dependence on renal dialysis and metabolic encephalopathy. Resident 1's Care Plan dated 11/22/25 documented the resident received dialysis, was to be transported to dialysis center three days a week (Tuesday, Thursday and Saturday) and would be free from complications secondary to requiring dialysis. Resident 1's Progress Note dated 12/24/25 noted Resident 1 received a dialysis treatment at the hospital on [DATE] and did not receive treatment on 12/25/25. There was no documentation of her/his treatment on 12/27/25. In an interview on 2/19/26 at 12:22 PM, Staff 11 (Receptionist) stated she or nursing staff will assist with dialysis transportation planning. Staff 11 stated she was unable to set up Resident 1's dialysis transportation over the holiday in December. In an interview on 2/20/26 at 3:11 PM, Witness 1 (Family Member) stated she received a call from the dialysis center on 12/29/25 which inquired why Resident 1 was not at dialysis. Witness 1 stated she went to the facility and requested staff send Resident 1 to the ER for dialysis. Witness 1 stated dialysis was completed on 12/29/25. Witness 1 stated Resident 1 was very sick and had not admitted to the facility in that state. In an interview on 2/24/26 at 11:25 AM, Staff 29 (LPN) stated evening shift staff informed her Resident 1's transportation to dialysis needed to be scheduled. Staff 29 stated Resident 1 missed her/his dialysis treatment. Staff 29 stated Resident 1 was supposed to receive dialysis on 12/27/25 but she/he never received it. In an interview on 2/24/26 at 2:54 PM, Staff 2 (DNS) acknowledged Resident 1 missed dialysis due to no transportation being scheduled.

Based on observation, interview and record review it was determined the facility failed to ensure licensed nursing staff had the necessary competencies to care for residents with feeding tubes for 1 of 1 licensed staff (#25) reviewed for tube feedings. This placed residents at risk for incorrect tube feed and water flush administration. Findings include:Resident 1 was admitted to the facility in 10/2025 with diagnoses including Gastroesophageal Reflux Disease (GERD) and choledochoduodenal fistula (a rare complication often caused by a perforated duodenal ulcer).Resident 1's Physician Orders dated 10/31/25 indicated Resident 1's tube feeding was scheduled for 2:00 PM.On 11/17/25 at 2:40 PM, Staff 25 (LPN) was observed to wash his hands, don gown and gloves and enter Resident 1's room. Staff 25 identified Resident 1's tube feeding port and discovered the connector was missing. Staff 25 removed his gown and gloves and left the room.On 11/17/25 at 3:12 PM, Staff 20 (Interim DNS) and Staff 25 entered Resident 1's room wearing only gloves and handled Resident 1's feeding tube. Both staff verbalized confusion over the connector. Staff 25 stated he was unsure whether the tube should directly connect directly to the port or if an adapter was needed. Staff 20 agreed she did not know. At 3:18 PM, Staff 25 left Resident 1's room to get assistance from Staff 26 (MDS Coordinator, LPN).On 11/17/25 at 3:45 PM, Staff 25 returned to Resident 1's room with Staff 26. Staff 26 assessed the situation, left the room to obtain a connector and returned with connectors that were not compatible with the Resident 1's feeding tube.On 11/17/25 at 4:30 PM, Staff 25 checked for residuals per physician orders and initiated Resident 1's tube feedings, which occurred two and a half hours later than scheduled.On 11/17/25 at 4:35 PM, Staff 26 stated nurses receive a skills checklist for administering tube feedings during orientation. On 11/20/25 at 12:10 PM, Staff 25 stated he had requested additional training on 11/17/25 after working with Resident 1's feeding tube. Staff 25's Skill Checklist, initiated on 11/17//25, indicated he required additional training in tube feeding administration after working with Resident 1's feeding tube. On 11/20/25 at 12:41 PM, Staff 20 and Staff 24 (Regional RN) acknowledged Staff 25 needed further orientation and training regarding feeding tubes.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for physician orders. This placed residents at risk for adverse health consequences. Findings include: Resident 1 admitted to the facility in 10/2025 with diagnoses including fistula of gallbladder.Resident 1's admission MDS dated [DATE] revealed a BIMS score of 10, indicating moderate impairment. Resident 1's care plan dated 11/10/25 revealed she/he was at risk for weight loss and/or malnutrition. Interventions were to encourage Resident 1 to eat, consult with the Registered Dietitian (RD) and follow a therapeutic diet.Resident 1's Physician Orders dated 10/31/25 were to administer one Phos-Nak (a dietary supplement used for people who cannot get enough phosphorus, needed for strong bones and controlling calcium in the body and urine) packet three times per day, to be taken with meals and at bedtime.Resident 1's 11/2025 MAR revealed the medication was not administered three times per day from 11/1/25 through 11/13/25.Progress notes from 11/1/25 through 11/13/25 indicated the medication was not available and/or was on order from the pharmacy.On 11/14/25 at 3:27 PM, Staff 17 (LPN) stated nursing staff called the pharmacy to request the supplement, but the pharmacy did not send it. Staff 17 stated she left a note for the previous RCM but did not know if the RCM followed up with the pharmacy.On 11/20/25 at 12:30 PM, Staff 24 (Regional Nurse Consultant) confirmed the supplement was not administered to Resident 1 as ordered and should have been followed up by staff.

Based on observation, interview and record review it was determined the facility failed to provide necessary care and services for tube feeding nutrition for 1 of 2 sampled residents (#1) reviewed for tube feedings. This placed residents at risk for dehydration and declining nutritional status. Findings include:Resident 1 was admitted to the facility in 10/2025 with diagnoses including GERD (gastroesophageal reflux disease) and choledochoduodenal fistula (a rare complication often caused by a perforated duodenal ulcer) requiring Resident 1 to have nutrition delivered via tube feedings (the delivery of nutrients through a feeding tube directly into the stomach, duodenum or jejunum).Resident 1's 10/31/25 Physician Orders included the following orders:-Administer free water BID via feeding tube at a rate of 35 ml/hr for 18 hours per day and feeding tube off for six hours per day, and-Enteral feeding BID, administer Peptamen AF (a nutritional formula for individuals with impaired gastrointestinal function) via feeding tube for 18 hours per day to provide 2160 calories over a 24-hour period, and feeding tube off six hours per day.Resident 1's 11/5/25 Progress Note stated the resident's water flush was administered at 100 ml/hr instead of 35 ml/hr as ordered. Resident 1 had a large emesis, and her/his provider was notified. Resident 1's tube feeding was held for 1.75 hours to rest the abdomen, and STAT labs were ordered on 11/6/25.On 11/6/25 at 8:00 AM, Resident 1 was transported to the emergency department due to the concern Resident 1 continued to vomit and the additional water she/he received could alter Resident 1's electrolytes. Resident 1 returned from the hospital in the evening.Resident 1's 11/10/25 Progress Note stated staff ran out of Peptamen AF. Peptamen 1.5 was obtained. The on-call provider was notified and stated not to give this alternative product until it was reviewed by the registered dietician and by the team who initiated the Peptamen AF. Peptamen 1.5 was administered on 11/9/25 without orders. Resident 1 indicated she/he had increased digestive symptoms since receiving the Peptamen 1.5.On 11/17/25 at 11:25 AM, Resident 1 was observed in her/his room, visiting with her/his spouse, and ambulating in the halls after lunch.On 11/17/25 at 4:05 PM, Witness 4 (Former RN) stated Resident 1's water flush ran at 100 ml/hour instead of the ordered 35 ml/hour.On 11/20/25 at 12:10 PM, Staff 25 (LPN) stated he had administered the wrong tube feeding formula to Resident 1. Staff 25 stated the resident was administered Peptamen 1.5, instead of Peptamen AF. Staff 25 stated he should have double checked orders prior to administration. On 11/20/25 at 2:28 PM, Staff 1 (Administrator) and Staff 26 (Regional Director of Operations) confirmed there was a medication error with Resident 1's water flush order, and that Staff 25 had administered the wrong tube feeding formula for Resident 1.

Based on observation, interview and record review it was determined the facility failed to adhere to Enhance Barrier Precautions related to feeding tubes for 1 of 2 sampled residents (#1) reviewed for infection control. This placed residents at risk for infection. Findings include:Resident 1 was admitted to the facility in 10/2025 with diagnoses including GERD (gastroesophageal reflux disease) and the presence of a gastric tube.According to the Centers for Disease Control and Prevention, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. On 11/17/25 at 10:00 AM, signage was observed outside Resident 1's room indicating Resident 1 required Enhanced Barrier Precautions. On 11/17/25 at 3:12 PM, Staff 20 (Interim DNS) and Staff 25 (LPN) were observed handling Resident 1's feeding tube and assess the pump and the gastric tube on the resident's abdomen while wearing only gloves and no gown. On 11/20/25 2:48 PM, Staff 20 acknowledged that neither she nor Staff 25 wore a gown when they accessed Resident 1's gastric tube.

Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances. Findings include: Record review of the facility's 2025 Grievances binder revealed written grievances were completed by residents or family members on the following dates: - 1/20/25; - 3/27/25; - 4/14/25; - 5/24/25; - 5/30/25. Record review of the facility's 2024 Grievances binder revealed written grievances were completed by residents or family members only four times in 10/2025. No other grievance were completed in 2024. During the 6/4/25 at 1:30 PM Resident Council meeting, multiple residents stated they did not know there was a grievance process in the facility, they did not know how to file a grievance and several stated it did not matter because when you reported a concern to staff nothing was ever done. On 6/4/25 the lobby reception area, facility common areas on the third, fourth and fifth floors were observed. No information was clearly visible regarding how to file a grievance in writing or orally, how to submit a grievance anonymously or readily available grievance forms. On 6/5/25 at 1:22 PM Staff 16 (CMA) stated if a resident expressed a concern, they would tell the charge nurse, Resident Care Manager or DNS. Staff 16 stated they had not provided grievance forms to residents. On 6/5/25 at 1:29 PM Staff 5 (LPN/Charge Nurse) stated if a resident expressed concerns, they would tell the Resident Care Manager and they thought there might be a grievance form. On 6/5/25 at 3:31 PM Staff 15 (CNA) stated if a resident or family expressed a concern, they would tell the Charge Nurse. Staff 15 could not recall assisting a resident or family member with a grievance form. On 6/5/25 at 3:42 PM Staff 14 (Social Services) acknowledged for the past week she had been the facility's Grievance Officer. Staff 14 confirmed the 2024 and 2025 grievance binders were correct and no other grievances were on file. Staff 14 acknowledged the grievance forms were not available to residents or family unless a staff member provided and collected the grievance form. On 5/31/24 at 11:01 AM Staff 1 (Administrator) stated the grievance forms were available at nursing stations and residents needed to ask for them. Staff 1 confirmed the residents did not have a means to complete grievance form anonymously. Staff 1 confirmed the lack of grievances filed by residents or resident representatives in 2024 and 2025.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment for 4 of 8 sampled resident (#s 3, 254, 355 and 404) who were reviewed for accidents, ADLs, pain and food. This placed residents at risk for unidentified care needs. Findings include: 1. Resident 3 admitted to the facility in 5/2018 with diagnoses including dementia. Resident 3's Annual MDS completion deadline date was 4/22/25 and was incomplete as of 6/4/25 at 12:49 PM. On 6/5/25 at 4:27 PM, Staff 2 (DNS) confirmed Resident 3's Annual MDS was not completed in the required time frame. Staff 2 stated she expected the MDS assessments to be completed within the required timeframes. 2. Resident 254 was readmitted to the facility in 5/2025 with diagnoses including chronic kidney disease and transient ischemic attack (interruption of bloodflow to the brain). Resident 254's admission MDS completion deadline date was 5/9/25 and was incomplete as of 6/5/25 at 1:32 PM. On 6/5/25 at 1:52 PM Staff 2 (DNS) stated she was responsible for completion of Resident 254's admission MDS. Staff 2 confirmed Resident 254 admission MDS had not been completed within the required 14 days of her/his admission. 3. Resident 355 admitted to the facility in 5/2025 with diagnoses including aftercare following cardiovascular surgery. Resident 355's admission MDS completion deadline date was 6/2/25 and was incomplete as of 6/5/25. On 6/5/25 at 11:59 AM, Staff 10 (RNCM) stated she was the person who was responsible for completing MDS assessments and acknowledged Resident 355's MDS assessment was late. Staff 10 stated the facility struggled with completing MDS assessments timely. 4. Resident 404 admitted to the facility in 5/2025 with diagnoses including acute chronic diastolic (congestive) heart failure. Resident 404's admission MDS completion deadline date was 6/1/25. The admission MDS was signed as complete on 6/2/25 (one day late). On 6/5/25 at 11:59 AM, Staff 10(RNCM)stated she was the person responsible for completing MDS assessments and acknowledged the Resident 404's MDS assessment was late. Staff 10 stated the facility struggled with completing MDS assessments timely.

Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to medication administration and treatment management for 7 of 7 sampled residents (#s 5, 17, 21, 27, 31, 36, and 155) reviewed for failure to follow physician orders. This placed residents at risk for adverse side effects and unmet medical needs. Findings include: 1. Resident 5 admitted to the facility in 2004 with diagnoses including esophageal reflux (stomach contents leak backwards from the stomach into the food pipe) and Cerebral Palsy (affect ability to move, balance and posture). Review of Resident 5's 3/2024 MAR revealed a physician order which directed staff to administer 20 mg of Omeprazole Suspension 2 MG/ML via G-tube (tube to stomach), and eternal feeding (tube delivers nutrients directly to stomach) water flushes on 3/1/24 at 3:00 AM. Resident 5's 3/1/24 MAR revealed she/he was not administered the medication or treatment on 3/1/24 at 3:00 AM. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medications for Residents 5 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 2. Resident 17 admitted to the facility in 2022 with diagnoses including chronic gastritis (inflammation and damage to stomach lining) and Gastro-Esophageal reflux (stomach contents flow back up). Review of Resident 17's 3/2024 MAR revealed a physician order which directed staff to administer 40 mg of Pantoprazole Sodium before breakfast for digestion at 6:00 AM. Resident 17's MAR revealed she/he was not administered Pantoprazole Sodium on 3/1/24. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medication for Resident 17 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 3. Resident 21 admitted to the facility in 2020 with diagnoses including hypothyroidism. Resident 21's 3/2024 MAR revealed a physician order for Levothyroxine (treats an underactive thyroid) 100 mg to be administered on 3/1/24 at 6:00 AM. Resident 21's 3/1/24 MAR revealed she/he was not administered the Levothyroxine. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medication for Residents 21 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed and medication passed as ordered. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 4. Resident 27 admitted to the facility in 2020 with diagnoses including hypothyroidism. Record review of Resident 27 3/3024 MAR revealed a physician order for Levothyroxine (treats an underactive thyroid) 100 mg to be administered on 3/1/24 at 6:00 AM. Resident 27's 3/1/24 MAR revealed she/he was not administered the Levothyroxine. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medication for Resident 27 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed and medication passed as ordered. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 5. Resident 31 admitted to the facility in 2023 with diagnoses including hypothyroidism. Record review of Resident 31's 3/3024 MAR revealed a physician order for Levothyroxine (treats an underactive thyroid) 100 mg to be administered on 3/1/24 at 6:00 AM. Resident 31's 3/1/24 MAR revealed she/he was not administered the Levothyroxine. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medication for Residents 31 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed and medication passed as ordered. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 6. Resident 36 admitted to the facility in 2023 with diagnoses including Parkinson's Disease (disorder of central nervous system). Review of Resident 36's 3/3024 MAR revealed a physician order which directed staff to administer Carbidopa-Levodopa (medication for Parkinson's Disease) 0.5 - 1 tablet per resident preference on 3/1/24 at 3:00 AM, Carbidopa-Levodopa one tablet extended release on 3/1/24 at 4:00 AM and she/he was not administered the medication. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medications for Resident 36 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed and medications passed as ordered. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. 7. Resident 155 admitted to the facility in 2019 with diagnoses including hypothyroidism and pain. Review of Resident 155's 3/3024 MAR revealed a physician order which directed staff to administer Levothyroxine (treats an underactive thyroid) 100 mg at 6:00 AM and Oxycodone 5 MG for pain on 3/1/24 at 6:00 AM. Resident 155's 3/2024 MAR revealed she/he did not receive Levothyroxine or Oxycodone medications as ordered. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medications for Resident 155 on her scheduled shift on 3/1/24. Staff 2 stated she expected all physician orders to be followed and medications passed as ordered. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17.

Based on observation, interview and record review it was determined the facility failed to properly store food and failed to maintain sanitary conditions in 1 of 1 kitchen and 1 of 3 unit refrigerators. This placed residents at risk for food borne illness and contaminated food. Findings include: 1. On 6/2/25 at 8:12 AM during the initial tour of kitchen, the following items were observed in refrigerator walk-in #1: *Tofu salad dated 5/26/25 (stored eight days) *Chicken salad dated 5/26/25 (stored eight days) *Two separate containers of lunch meat which were undated. On 6/2/25 at 10:36 AM Staff 11 (Dietary Manager) confirmed salad was made on 5/26/25 and she discarded the items after four days. The salad should have been removed from the refrigerator. 2. A review of the undated Employee Cleanliness Policy for the kitchen revealed facial hair must be completely covered with a beard net. On 6/2/25 at 8:23 AM Staff 12 (Dietary Aid) was observed with a beard which was uncovered while moving throughout the kitchen prepping items for breakfast. On 06/2/25 at 10:39 AM Staff 8 (Maintenance Director) was observed with a beard and entered the kitchen area without obtaining a beard net. On 6/2/25 at 10:39 AM Staff 11 (Dietary Manager)confirmed staff were required to wear facial beard restraints and hairnets whenever in the kitchen area. 3. An undated Refrigerator Maintenance and Food Storage Policy stated all refrigerators located in unit kitchenettes were to be maintained in a clean, sanitary and operational condition. Cleaning and Maintenance, Housekeeping was responsible to clean and sanitize the refrigerator interior and exterior weekly. It was expected that staff would immediately clean any spills or removed spoiled foods in between cleanings. On 6/3/25 at 1:49 PM a review of the fourth floor unit refrigerator revealed a spilled substance and crumbs on the bottom of the fridge. The following items were undated and unlabeled: *Foiled item in a plastic bag stuck to the bottom of the refrigerator. *Glass container with food unlabeled without a date. On 6/3/25 3:03 PM Staff 4 (CMA)and Staff 13(CNA)were present for an interview. Staff 4 stated staff were responsible for monitoring and discarding food items after three days however she was unsure who was responsible for cleaning the refrigerator. Staff 13 acknowledged food items in the refrigerator were unlabeled. On 6/4/25 at 8:40 AM Staff 8 (Maintenance Director) stated they believed Staff 11 (Dietary Manager) was in charge of the unit refrigerators. On 6/3/25 at 11:19 AM and 6/4/25 at 9:08 AM Staff 11 stated staff were expected to discard any items in the unit refrigerators which were undated or if the date on the food item exceeded three days. Staff 11 stated housekeeping was responsible for cleaning the unit refrigerators. 4. On 6/3/25 at 12:17 PM, 6/4/25 at 9:04 AM, and 6/5/25 at 10:13 AM a fan was observed blowing on a shelving unit with cleaned utensils and dishware. The fan was covered with dark brown debris over the intake vent. On 6/5/25 at 1:43 PM Staff 11 (Dietary Manager) acknowledged the dirty fan in the dishwashing area and confirmed it was not to be placed in the dishwashing area.

Based on record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#45) reviewed for medications. This placed residents at risk for inaccurate assessment and care. Findings include: Resident 45 was admitted in 2/2025 with diagnoses including major depressive disorder (mood disorder) and schizophrenia (chronic brain disorder characterized by disconnection from reality). On the 2/7/25 Admissions MDS and the 5/13/25 Quarterly MDS, schizophrenia was coded in Section I. On 6/6/25 at 9:05 AM and at 11: 22 AM, Staff 2 (DNS) stated there was no supporting evidence in the medical record regarding Resident 45's diagnosis of schizophrenia and the MDS should not have been coded without supporting evidence of the diagnosis.

Based on interview and record review it was determined the facility failed to respect resident rights for 1 of 1 sampled resident (#8) reviewed for personal property. This placed residents at risk for diminished quality of life. Findings include: Resident 8 was admitted to the facility in 4/2016 with diagnoses including depression. An 8/31/24 Progress Note revealed the facility called the police related to reports of Resident 8 watching illegal pornography on her/his phone. The police spoke with Resident 8 and directed facility staff to take Resident 8's phone away and not give the phone back. The nurse took Resident 8's phone and locked it in the Resident Care Manager's office. A 5/1/25 Significant Change MDS indicated Resident 8 was cognitively intact. On 6/2/25 at 9:13 AM Resident 8 stated the facility took her/his phone in 9/2024 due to an accusation of watching pornographic videos on her/his phone. Resident 8 stated she/he wanted her/his phone back. On 6/3/25 at 2:10 PM Staff 20 (LPN) stated on 8/31/24 Resident 8 was observed watching illegal pornography and Staff 20 called the police. Staff 20 stated the police came to the facility and told her to take Resident 8's phone away and not to give it back to Resident 8. On 6/4/25 at 9:51 AM Staff 1 (Administrator) stated there was no formal investigation completed after Resident 8's phone was taken on 8/31/24. Staff 1 stated the police instructed Staff 20 to take Resident 8's phone on 8/31/24. Staff 1 stated facility staff assisted Resident 8 with the internet as requested and Resident 8 had access to a cordless phone to make phone call. On 6/5/25 at 11:39 AM Staff 3 (LPN Care Manager) stated Resident 8 had a history of viewing illegal pornography, so her/his phone was locked in the medication room. Staff 3 stated Resident 8 had access to the cordless phone, she assisted Resident 8 with looking up things on the internet, and Resident 8's friend assisted Resident 8 obtain a flip phone without internet access. On 6/5/25 at 12:06 PM Staff 14 (Social Service Director) stated Resident 8's phone was taken in the past, but was given back to Resident 8 because it was her/his right to have her/his phone. Staff 14 was unaware Resident 8 did not have her/his phone. On 6/5/25 at 12:13 PM Staff 2 (DNS) stated Resident 8's phone was lock up in the medication room on 8/31/25 due to Resident 8 watching illegal pornographic videos on her/his phone. On 6/6/25 at 8:36 AM Staff 1 acknowledged it was Resident 8's right to have her/his phone.

Based on observation and interview it was determined the facility failed to provide maintenance to maintain a safe, comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for an unsafe and unkempt interior building. Findings include: 1. An observation on 6/2/25 at 9:39 AM, revealed the wall to the right of room [ROOM NUMBER]'s bed was in disrepair with scratches of paint missing from the wall. On 6/5/25 at 2:02 PM, Staff 8 (Maintenance Director) observed the wall to the right of room [ROOM NUMBER]'s bed which was in disrepair with scratches of paint missing from the wall. Staff 8 stated he was unaware of the scratches of paint missing from the wall and he would expect the wall to be painted. On 6/6/25 at 11:25 AM Staff 1 (Administrator) stated she expected all resident rooms to be in good condition and walls maintained. 2. On 6/2/25 at 10:35 AM four sections of approximately 5 feet long areas of carpet were observed buckled 4 inches high in a high traffic area of the third floor. On 6/5/25 at 2:04 PM Staff 8 (Maintenance Director) stated the areas of buckled carpet had been present for a significant amount of time and confirmed they were tripping hazards particularly for those with a shuffling gait. 3. Resident 355 admitted to the facility on [DATE] with diagnoses including aftercare following cardiovascular surgery. On 6/2/25 at 10:03 AM, Resident 355's window was observed to have a bath towel draped over the opening. Resident 355's room was located on the fifth floor of the facility, and she/he stated the towel was to prevent the draft from coming into the room. Resident 355 stated there was nothing holding the window closed and demonstrated by detaching the window. Resident 355 stated the window was this way since her/his admission to the facility. The window was observed to have no screen. On 6/3/25 at 10:18 AM, Resident 355 stated a gust of wind had blown the window and towel down to the floor and Staff 8 (Maintenance Director) screwed the window shut. On 6/5/25 at 3:40 PM, Staff 8 (Maintenance Director) acknowledged the arms of Resident 355's window had broken off the rivets on 6/3/25. Staff 8 stated the detachable window was a safety issue for residents and anybody who came into the room. Staff 8 stated he did not have a system to check facility windows for safety and repair before residents moved into the facility and there was no system to audit current resident windows for repair and maintenance.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#44) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include: The facility's Self-Administration of Drugs policy, dated 5/2010, revealed the following: - Residents who wished to self-administer medications may do so if it was determined they were capable of doing so. -Medications must be stored in a safe and secure place, not accessible by other residents. Resident 44 was admitted to the facility in 1/2025 with diagnoses including a stroke with hemiparesis and hemiplegia (weakness or complete paralysis or loss of function on one side of the body) affecting the left dominant side. During observations on 6/2/25 at 12:13 PM, four round pills and one capsule was observed, unsecured, on top of the resident's nightstand and on 6/3/25 at 8:24 AM, one round pill was observed, unsecured, on top of the same nightstand. Resident 44's 4/22/25 Quarterly MDS indicated the resident had no significant cognitive impairment. Resident 44's 4/2025, 5/2025 and 6/2025 MAR indicated on 4/26/25, the resident was approved by her/his PCP to have Tylenol and Melatonin at the bedside to self administer, every shift, for pain and sleep. A review of Resident 44's health record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer Tylenol or Melatonin. On 6/2/25 at 12:13 PM and 6/3/25 at 8:24 AM and 11:22 AM, Resident 44 stated, since 4/2025, it was ok for her/him to have medications at the bedside and she/he did not have a lockbox to secure and store the medications. Resident 44 stated every evening shift she/he asked for two Tylenol and two Melatonin pills which were administered to her/him, and if she/he did not need them she/he saved them to take later. On 6/2/25 at 12:13 PM, Resident 44 confirmed there were four round pills and one capsule on top of her/his bedside nightstand and on 6/3/25 at 8:24 AM, the resident confirmed one round pill remained on her/his bedside nightstand because she/he had taken the other pills. On 6/3/25 at 11:09 AM, Staff 4 (CMA) stated Resident 44 was able to have Tylenol and Melatonin at her/his bedside since 4/2025. On 6/3/25 at 12:05 PM and 6/5/25 at 9:17 AM, Staff 3 (LPN Care Manager) stated in the morning on 6/3/25, Resident 44 came to me and reported she/he kept medications at her/his bedside. Staff 3 stated she was unaware the resident kept medications at the bedside. Staff 3 stated in 4/2025, Staff 5 (LPN) obtained a physician order which allowed Resident 44 to have Tylenol and Melatonin at her/his bedside but the nurse did not follow the facility process thus Resident 44 did not have a self-administration of medication assessment completed and no lockbox was given to the resident. Staff 3 stated Resident 44 should not have had medications at her/his bedside. On 6/4/25 at 9:49 AM, Staff 5 stated on 4/26/25, she obtained a physician order which allowed Resident 44 to have her/his Tylenol and Melatonin at her/his bedside. Staff 5 stated she was unsure why Resident 44 did not receive a self-administration of medication assessment until 6/3/25. On 6/5/25 at 1:02 PM, Staff 2 (DNS) confirmed, in 4/2025, nursing staff obtained a physician order which allowed Resident 44 to have Tylenol and Melatonin at her/his bedside. Staff 2 stated the resident care manager missed the order thus Resident 44 did not receive a self-administration of medication assessment. Staff 2 stated she expected all residents, who desired to self-administer medications, have an assessment completed and be provided with a lockbox prior to having medications at the bedside.

Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to professional standards for medication management and licensed nurse oversight of assigned residents. This placed residents at risk for adverse side effects of medication and unmet medical needs. Findings include: The facility initiated an investigation on 3/1/24 regarding Staff 17 for her night shift which started on 2/29/24. Staff 2 (DNS) completed interviews and record reviews for residents which were assigned under Staff 17's supervision. Staff 2 concluded on the evening of 2/29/24 until 3/1/24 at about 6:30 AM, Staff 17 slept in her car in the facility parking lot most of the shift and was not available. Staff 2 concluded seven residents missed ordered medications, opportunities for PRN medications or treatments. On 6/4/25 at 6:39 AM Staff 18 (CNA) confirmed Staff 17 was the charge nurse when she worked in the facility on 3/1/24. Staff 18 stated Staff 17 went missing from the facility and at around 6:00 AM she found Staff 17 asleep in her car and Staff 17 told her she did not think she could finish the shift. Staff 18 stated Staff 17 was a mess. On 6/4/25 at 7:39 AM Staff 19 (LPN) confirmed she worked the night shift when Staff 17 was scheduled to work on 3/1/24. Staff 19 reported Staff 17 was late to her shift on 2/29/24, left the facility sometime during the shift and by the time Staff 17 was found on 3/1/24 at 6:00 AM the morning medications were scheduled to be passed. Staff 19 stated she instructed Staff 18 to inform Staff 17 she needed to return to the facility to count medications before the end of the shift. However, Staff 17 told Staff 18 she was not going to return to the shift. On 6/5/25 at 10:38 AM the Agency Staffing company provided three phone numbers to contact Staff 17. Attempts were made to call Staff 17 on 6/5/25 at 10:47 AM. Two of the phone numbers were disconnected, one phone number had a generic voicemail message and a voicemail was left for Staff 17 to return the phone call. No return phone call was received by Staff 17. On 6/6/25 at 9:50 AM Staff 2 confirmed the investigation for Staff 17 leaving the facility during the night shift of 2/29/24 to 3/1/24 and seven residents were found to have missed medications, opportunities for medications or treatments. Staff 2 stated she expected all licensed nurses to attend to the residents they were assigned and to complete provider orders for the medications and treatments. Refer to F684

Based on interview and record review, it was determined the facility failed to assess and monitor a facility acquired pressure ulcer for 1 of 4 sampled residents (#203) reviewed for pressure ulcers. As a result, Resident 203's pressure ulcer worsened from a Stage 2 (partial-thickness loss of skin; shallow open ulcer) to Stage 3 (full-thickness loss of skin; subcutaneous fat may be visible in the ulcer) to Unstageable (full thickness skin and tissue loss and wound bed is obscured by slough or eschar), and became septic (infected with microorganisms, especially harmful bacteria). Resident 203 was admitted to the hospital and died . Findings include: Resident 203 admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 203's care plan initiated [DATE] identified a focus for skin impairment/pressure ulcer with the following interventions: - Notify charge nurse of skin impairment. - Pressure/Other Ulcer/Wound/Skin impairment documentation due on LPN skin mobile app. The [DATE] Significant Change of Condition MDS revealed Resident 203's BIMS score was 4 (severe cognitive impairment) and the resident did not have a pressure ulcer. Resident 203's Weekly Skin at Risk Assessment completed by Staff 19 (LPN) on [DATE] indicated No new skin issue. A progress note for [DATE], created as a late entry on [DATE], revealed a CNA changed Resident 203's brief and told Staff 18 (RN) a nurse needed to assess the resident's skin. Staff 18 assessed a pressure ulcer on the sacrum area. The Skin & Wound Evaluation completed by Staff 18 on [DATE] revealed Resident 203 acquired a new in-house pressure ulcer, Stage 2, to the sacrum which measured 7.1 cm in length and 2.3 cm in width. The surrounding area was dark reddish brown. A new physican order was issued on [DATE] and directed staff to cleanse the Stage 3 pressure ulcer on the sacrum with saline solution, apply no sting skin prep to wound, apply [MEDICATION(S)] dressing every day shift Monday/Thursday, on shower days and PRN, three days after the wound was identified. Resident 203's ,d+[DATE] TAR revealed Staff 19 provided the Stage 3 pressure ulcer treatment on [DATE], [DATE], [DATE] and [DATE] (Monday/Thursdays). No PRN or other dressing changes were provided. No other assessments were completed of the wound until [DATE], 16 days after the wound was identified. The [DATE] Skin Event, Licensed Nurse Skin Event Assessment completed by Staff 19 for Resident 203 indicated the pressure wound was 7.8 cm in length, 7.19 cm in width, dark purple, slough (separating dead from living tissue) covering 90% of wound bed, bright red wound which was blanching (whitening of external tissue) with a foul odor. Resident 203's [DATE] Skin & Wound Evaluation, completed by Staff 19 indicated the sacral pressure ulcer was a Stage 2 with slough at 90%, blanching, [CONDITION(S)] (redness of skin) and the wound was deteriorating. Although the facility continued to identify the pressure ulcer as stage 2, notes revealed the wound was obscured by 90% slough which would indicate an unstageable pressure ulcer. A [DATE] at 11:02 AM progress note revealed an infection evaluation for Resident 203 with suspected/confirmed skin/wound infection. A [DATE] at 11:02 AM Skin/Wound progress note revealed Staff 19 called Resident 203's daughter to speak about the wound and attempts to manage her/his pain. On [DATE] at 11:05 AM a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 203's [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:58 PM a progress note by Staff 19 revealed Resident 203 was unresponsive and the daughter wanted the resident sent to the hospital. A progress note revealed Resident 203 was transferred to the hospital on [DATE] at 2:39 PM. A [DATE] progress note indicated Staff 19 spoke with a hospital nurse who reported Resident 203 was septic, most likely from the wound and her/his health rapidly declined. During a [DATE] at 11:28 AM Witness 3 (Family Representive) stated Resident 203 went to the hospital, was septic from the wound infection and died . On [DATE] at 9:35 AM Staff 2 (DNS) acknowledged the lack of pressure ulcer monitoring and assessment. Staff 2 stated she expected CNA staff to report any skin impairments during incontinence care immediately to the charge nurse or management. Staff 2 stated she identified the lack of documentation for Resident 203's wound care and educated the staff. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a program of systematic identification, analysis and action was in place related to medication administration and nursing competencies for 1 of 1 QAA (quality assurance and assessment) reviewed for QAA. This failure resulted in Staff 5 (Former Staff/RN) administering an incorrect medication on [DATE] to Resident 1 which she/he was allergic to and resulted in Resident 1's [DATE] respiratory distress, hospitalization and [DATE] death. This was determined to be an Immediate Jeopardy (IJ) situation. Findings include: The ,d+[DATE] QAPI policy statement revealed the committee would ensure and maintain ongoing monitoring, assessment and improvement processes to meet the highest level of quality for the residents. The committee would meet at minimum, quarterly. Review of facility QAA documentation revealed ,d+[DATE] through ,d+[DATE] the QAA committee met on [DATE], [DATE] and [DATE]. Review of the Medication Error Policy indicated the Medical Director, DNS and Consultant Pharmacist would review medication errors and adverse medication consequences as part of the facility's QA process. Review of Medication Error Reports revealed 22 medication administration and/or medication transcription errors from [DATE] through [DATE]. An [DATE] medication error investigation revealed on [DATE] at 11:30 PM Staff 5 went to administer medications to Resident 1. Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 5 pulled a medication from the narcotic drawer labeled #19 to correspond to a page number in the narcotic book. Staff 5 did not realize there were two medications labeled with #19 that corresponded with two different narcotic books, one was for [MEDICATION(S)] and one was for [MEDICATION(S)], for two different residents. By Staff 5's own admission she reported she opened a new bottle and measured 12.5 ml and administered the medication. Staff 5 did not check the label to verify that she had the correct medication. Resident 1 was sent to the hospital on ,d+[DATE] [[DATE]] at approximately 5:10 AM in respiratory distress. Hospital records on [DATE] and [DATE] revealed the following: -Resident 1 presented to the emergency department on [DATE] at 5:29 AM for evaluation of respiratory arrest. -Resident 1 was given three doses of [MEDICATION(S)] (a medication used to reverse the side effects of narcotics) in the emergency department. -Resident 1 had respiratory depression and apnea between doses of [MEDICATION(S)]. -Resident 1's improvement with [MEDICATION(S)] indicated the resident was likely overmedicated and could have been from a medication error. -On [DATE] Resident 1 was on comfort care and medicated for air hunger. -Resident 1 died on [DATE] at 6:46 PM. The immediate cause of death was respiratory failure due to suspected unintentional narcotic overdose. A request was made to the facility for Staff 5's nursing skill competency records. The facility did not have one. A review of five additional nursing staff revealed nursing skill competency reviews were not completed for five nurses. On [DATE] at 11:34 AM and [DATE] at 10:36 AM Witness 5 (Consultant Pharmacist) stated he was not invited and did not attend any QAA meetings from [DATE] through [DATE]. Witness 5 further stated he did not have a role in reviewing medication errors. On [DATE] at 12:36 PM and [DATE] at 12:17 PM Witness 7 (Manager for Medical Directors) stated Witness 4 (Former Medical Director) was the facility's Medical Director from [DATE] through ,d+[DATE], was not involved in the QAA process and was not notified of or involved in reviewing Resident 1's medication error which resulted in Resident 1's death. Additionally, Witness 7 further stated Witness 9 (Current Medical Director) was not involved in the [DATE] QAA meeting. On [DATE] at 11:23 AM Staff 2 (DNS) stated the QAA committee did not identify the medication error trend until [DATE]. Staff 2 verified Staff 5's medication error and Resident 1's respiratory distress which sent the resident to the hospital. Staff 2 stated she was unaware of Resident 1's cause of death. Staff 2 further stated the facility did not have a working system in place to address nurse competency and the QAA committee did not identify this concern. On [DATE] at 1:02 PM the facility was informed of the identified Immediate Jeopardy for the failure to ensure the facility had a QAA program of systematic identification, analysis and action in place related to medication administration and nursing competencies after Resident 1's death. The QAA committee did not identify the multiple medication errors prior to [DATE] and the facility did not have a working system in place to address nurse competency. All residents were identified at risk for significant medication errors. A medication pass completed on [DATE] revealed an error rate of 16%. Six of six nursing staff reviewed for medication administration competencies revealed competency was not completed prior to being deemed independent to administer medications. On [DATE] at 6:53 PM the IJ Abatement Plan was received and approved. The Plan included: 1. The facility scheduled a high priority QAPI (Quality Assurance and Process Improvement - another term for QAA) meeting for [DATE] to review medication errors, tracking process and policies, medication competencies evaluation and tracking action plan to ensure competencies were met for all Licensed Nurses and Certified Medication Aides upon hire. This meeting would include, but not limited to, the Pharmacist, Medical Director, DNS, Vice President of Clinical Services and the RNCMs. 2. The QAA committee would complete a root cause analysis to analyze the causes and to implement preventative action that could contribute to the identified citation related to safe and effective medication administration. 3. The Process Improvement Team(s) would be established by the QAA committee on [DATE], would continue to evaluate the systems impacted and identify opportunities for best practice with the goal of establishing ongoing compliance. 4. Attendance with facility QAPI/QAA meetings would include the Pharmacist and Physician (Medical Director). 5. The facility QAPI committee would review reports monthly of all audits related to medication administration competencies and medication errors and would ensure ongoing compliance and any potential opportunity for improvement. On [DATE] at 1:51 PM observation, interview and record review verified the IJ Abatement Plan for the [DATE] QAPI meeting were implemented. Review of the IJ Abatement Plan revealed the Plan was fully implemented.

Based on interview and record review it was determined the facility failed to ensure Staff 5 (Former Staff/RN) had the appropriate skills and competencies necessary to care for resident needs related to medication administration. This failure resulted in Resident 1 receiving Resident 2's [MEDICATION(S)] (narcotic pain medication). Resident 1 had an allergy to [MEDICATION(S)]. Resident 1 experienced respiratory distress, hospitalization and death. This constituted an immediate jeopardy situation. Findings include: a. Resident 1 admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's medical record indicated she/he had an allergy to [MEDICATION(S)]. The [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] medication error investigation completed by Staff 2 (DNS) indicated the following: -Staff 5 (Former Staff/RN) was a recent nurse graduate and had worked at the facility since [DATE]. -Staff 5 worked on a different unit for the first time on [DATE] and was responsible for injectable medications and medications that were to be administered via tube. -Staff 5 was interviewed on [DATE] by Staff 2 and indicated she felt overwhelmed on the evening of [DATE] and fell behind in her tasks. -At 11:30 PM Staff 5 went to administer medications to Resident 1. Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 5 pulled a medication from the narcotic drawer labeled #19 which corresponded to a page number in the narcotic book. Staff 5 did not realize there were two medications labeled with #19 that corresponded with two different narcotic books, one was for [MEDICATION(S)], one was for [MEDICATION(S)] for two different residents. By Staff 5's own admission she reported she opened a new bottle and measured 12.5 ml and administered the medication. Staff 5 did not check the label to verify that she had the correct medication. It is believed that she administered [MEDICATION(S)] instead of [MEDICATION(S)]. Resident 1 was sent to the hospital on [DATE] [[DATE]] at approximately 5:10 AM in respiratory distress. -The investigation indicated staff did not identify the discrepancy in the amounts of the liquid medications during the narcotic count over multiple shifts. On [DATE] at 8:22 PM Staff 4 (RN) stated she worked on [DATE] night shift. She stated she went in to administer Resident 1's 4:00 AM medications early at around 3:00 AM, since the medication can be given an hour early. She stated the resident was snoring really loud and it was not a consistent snore. Staff 4 stated she was preparing her/his medications and Resident 1's pauses were getting longer in between snoring and it was noticeable that the resident was having apneic (intermittent cessation of breathing) periods. Staff 4 stated she went and got Staff 3 (LPN) to assist her. Staff 4 stated they attempted to wake the resident up, she/he was pale and perspiring, she stated they got the ambubag (breathing resuscitation device) and called 911. She stated she returned to work two days later and that is when facility staff alerted her that there was missing [MEDICATION(S)]. On [DATE] at 8:48 AM Staff 3 (LPN) stated she worked on [DATE] night shift and arrived at 10:45 PM. She stated she counted narcotics when she arrived on [DATE] with a CMA due to the CMA wanting to leave early, and did not note any discrepancies with narcotics. She stated Staff 5 was still working after the narcotics were counted. She stated when she arrived to work Staff 5 appeared to be frustrated and was stressed out due to having too many residents, not knowing the residents and did not know how to administer g-tube medications. Staff 3 stated she looked at the medications in the computer and they were all in pink meaning they were late medications. She stated Staff 5 was looking at Resident 1's medications and Staff 3 told Staff 5 to administer medications to Resident 1 since she had already given the resident medications earlier that shift. Staff 3 stated Staff 5 was looking for [MEDICATION(S)] and Staff 3 told her it was #19. Staff 3 stated she went to do a treatment and came back and the medications were on a tray. Staff 3 stated she looked at the color of the medication and it was bright pink and she thought the formula had been changed. Staff 3 stated she later told Staff 4 about the [MEDICATION(S)] being bright pink. She stated later during the shift Resident 1 started making loud noises like she/he was trying to breathe and this was not normal for her/him. She stated they realized something was definitely wrong and the resident had low oxygen, could not get air and was sent out to the hospital. Staff 3 stated on [DATE] Staff 11 (RN) stated there was a bottle of [MEDICATION(S)] that was open and 13 mls was missing. Staff 3 stated she worked with Staff 4 and investigated what happened to the [MEDICATION(S)]. Staff 3 stated she recalled telling Staff 5 Resident 1's [MEDICATION(S)] was #19. Staff 3 and Staff 4 reviewed the narcotic logs and did the narcotic count for [MEDICATION(S)] and it was over what it should have been and Resident 2 had 12.5 mls of [MEDICATION(S)] missing. She further stated Resident 2 did not normally receive [MEDICATION(S)] Staff 3 stated she discovered the discrepancy on [DATE] during night shift and notified Staff 14 (RNCM) on the morning of [DATE]. Staff 14 told Staff 3 to notify Staff 2. Staff 2 was notified and provided a written statement. The investigation indicated Resident 1 received 12.5 ml of [MEDICATION(S)] which was equivalent to 250 mg. According to Mayoclinic.org the standard dose of [MEDICATION(S)] for moderate to severe pain is ,d+[DATE] mg every four hours. On [DATE] at 12:41 PM Staff 2 (DNS) stated there was a discrepancy noted on [DATE] regarding Resident 2's missing [MEDICATION(S)]. Staff 2 stated narcotic medication should be counted three times per day, and approximately five shifts went by before the [MEDICATION(S)] was discovered missing due to narcotic counts not being completed correctly. Staff 2 stated Staff 4 (RN) and Staff 3 (LPN) brought the medication error to her attention and received statements from both nurses. Staff 2 stated Staff 5 received 1:1 orientation after the medication error and staff received an in-service regarding medication pass safety but not all staff were in-serviced. On [DATE] at 3:00 PM Staff 5 stated she administered medication to Resident 1 on [DATE]. Staff 5 stated page 19 of the narcotic book was labeled [MEDICATION(S)]. Staff 5 further stated the medication administration directions corresponded with #19 in the narcotic drawer. Staff 5 stated she pulled what she thought was [MEDICATION(S)] and looked at the label on the Ziploc bag and it matched the book, but did not look at the label on the bottle. Staff 5 stated It was my mistake, it had a seal on it, I opened it and gave it to the patient [Resident 1]. Staff 5 stated she did not see signs of distress and this was the last time she observed Resident 1 before she left. She further stated an LPN came on the floor and noticed Staff 5 pull the medication. Staff 5 stated on [DATE], five days later, she found out she administered [MEDICATION(S)] instead of [MEDICATION(S)] to Resident 1. An [DATE] progress note indicated the nurse was giving Resident 1 her/his 4:00 AM medications and the resident was snoring loudly with 30+ seconds of periods of apnea. The nurse turned on the light which normally jolted the resident awake and her/his eyes flickered open after the nurse shook her/his shoulder and yelled the resident's name. The resident was unarousable and her/his oxygen saturation was 54% and temperature was 96.6. 911 was called and staff provided eight liters of oxygen and put an ambubag (manual resuscitator) on the resident. Resident 1's oxygen saturation went up to 93% and the resident was completely reliant on this intervention. EMS took the resident to the hospital at 5:10 AM. A review of the narcotic books indicated there were two books on Resident 1's floor. Book 97, page 19 was Resident 2's [MEDICATION(S)]. Book 98, page 19 was Resident 1's [MEDICATION(S)]. Resident 1's [MEDICATION(S)] 12.5 ml was signed by Staff 5 on [DATE] at 11:36 PM. Resident 2's [MEDICATION(S)] was 30 ml and the count was corrected to 18 ml on [DATE] at 7:15 AM. The [DATE] through [DATE] hospital records indicated the following: -Resident 1 presented to the emergency department on [DATE] at 5:29 AM for evaluation of respiratory arrest. -Resident 1 was given three doses of [MEDICATION(S)] (a medication used to reverse the side effects of narcotics) in the emergency department. -Resident 1 had respiratory depression and apnea between doses of [MEDICATION(S)]. -Resident 1's improvement with [MEDICATION(S)] indicated the resident was likely overmedicated and could have been from a medication error. -On [DATE] Resident 1 was on comfort care and medicated for air hunger and resident appeared more comfortable. -Resident 1 died on [DATE] at 6:46 PM. The immediate cause of death was respiratory failure due to suspected unintentional narcotic overdose. On [DATE] at 11:51 AM Staff 2 (DNS) stated narcotic book 97, page 19 indicated Resident 2's [MEDICATION(S)] was discovered missing on [DATE]. On [DATE] at 1:30 PM Staff 2 stated Staff 5 worked on [DATE], [DATE] and [DATE] and was not aware Staff 5 made a medication error and administered Resident 2's [MEDICATION(S)] to Resident 1 until [DATE] when Staff 3 and Staff 4 brought it to Staff 2's attention. On [DATE] at 10:11 AM and 12:41 PM Staff 2 (DNS) stated there was a discrepancy noted on [DATE] regarding Resident 2's missing [MEDICATION(S)]. Staff 2 stated narcotic medication should be counted three times per day, and approximately five shifts went by before the [MEDICATION(S)] was discovered missing due to narcotic counts not being completed correctly. Staff 2 stated Staff 4 (RN) and Staff 3 (LPN) brought the medication error to her attention and received statements from both nurses. Staff 2 stated after the medication error was discovered, all staff did not receive an in-service training regarding medication pass safety. b. The [DATE] statement by Staff 5 indicated the following: -Staff 5 (Former staff/RN) reported to the 5th floor for her shift on [DATE] and was told to float the the 4th floor to work. -Staff 5 normally worked on the 5th floor and cared for ,d+[DATE] residents with another nurse on the floor to consult with or ask for help if needed. -Staff 5 was told that she would be the only nurse for 23 patients and she was stressed and overwhelmed. -Staff 5 was concerned because it was her first time floating and knew very little about tube feeds and was unsure of the chain of command, wanted to call for help but did not know who to call. The [DATE] medication error investigation completed by Staff 2 (DNS) indicated the following: -Staff 5 was a recent nurse graduate and had worked at the facility since [DATE]. -Staff 5's primary floor was the 5th floor where she was responsible for a smaller number of residents. -Staff 5 worked on the 4th floor for the first time on [DATE], there was a larger number of residents and she was responsible for injectable medications and medications that were to be administered via tube. -Staff 5 (Former staff/RN) was interviewed on [DATE] by Staff 2 and indicated she felt overwhelmed on the evening of [DATE] and fell behind in her tasks. -At 11:30 PM Staff 5 went to administer medications to Resident 1. Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 5 pulled a medication from the narcotic drawer labeled #19 to correspond to a page number in the narcotic book. Staff 5 did not realize there were two medications labeled with #19 that corresponded with two different narcotic books, one was for [MEDICATION(S)], one was for [MEDICATION(S)] for two different residents. By Staff 5's own admission she reported she opened a new bottle and measured 12.5 ml and administered the medication. Staff 5 did not check the label to verify that she had the correct medication. It is believed that she administered [MEDICATION(S)] instead of [MEDICATION(S)]. Resident 1 was sent to the hospital on ,d+[DATE] [[DATE]] at approximately 5:10 AM in respiratory distress. -During the investigation it was noted that the staff did not identify the discrepancy in the amounts of the liquid medications during the narcotic count over multiple shifts. c. A [DATE] medication error report indicated Staff 5 pulled one oxycodone (narcotic pain medication) pill from Resident 12's medication card and administered the medication to Resident 11. The report noted there was no ill effects because the dose of oxycodone was the same. The reason for the error was I was not paying attention to the resident's name on the card. This was signed by Staff 5. There was no signature by the RNCM or the DNS and there was no indication there was follow up by the RNCM or the DNS regarding the error. d. A [DATE] medication error report indicated Staff 5 administered [MEDICATION(S)] (blood pressure medication) and the medication was on hold due to the resident having low blood pressure. The reason for the error was misunderstood medication administration directions. There was no signature by the RNCM or the DNS and there was no indication there was follow up by the RNCM or the DNS regarding the error. On [DATE] at 3:00 PM Staff 5 indicated she made a medication error during orientation. She stated there was no outcome to the resident and she filled out a medication error form. She stated no one ever followed up on the medication error. On [DATE] at 1:05 PM Staff 2 stated there was no documented follow up to the medication errors that occurred on [DATE] and [DATE]. Staff 2 further stated the orientation process for nurses is that they work with another nurse 30 days and a form is filled out regarding competencies. She stated there are no documented competencies for Staff 5. e. There was no evidence staff competencies were completed for Staff 5 (Former Staff/RN), Staff 19 (RN), Staff 4 (RN), Staff 3 (LPN), Staff 18 (RN), and Staff 20 (RN). On [DATE] at 1:05 PM Staff 2 (DNS) stated there are no documented competencies for Staff 5. On [DATE] at 11:15 AM Staff 2 indicated staff competencies were not completed for Staff 19 (RN), Staff 4 (RN), Staff 3 (LPN), Staff 18 (RN), and Staff 20 (RN). f. On [DATE] at 1:29 PM Staff 15 (Former Staff/ RN) stated she was Staff 5's (Former Staff/RN) preceptor for four weeks and recommended more orientation because Staff 5 was not ready to work independently. Staff 15 further stated she was concerned because Staff 5 struggled with nursing responsibilities including medication pass and did not do well under stress. Staff 15 stated she did not fill out any skills or competency checklist for Staff 5. Staff 15 stated Staff 5 had difficulty receiving feedback during training. Staff 15 stated she had a few conversations with Staff 2 (DNS) regarding her struggle with training and Staff 2 stated she would provide additional training for Staff 5. On [DATE] at 9:48 AM Staff 16 (Former Staff/RN) stated he precepted Staff 5 for one day. Staff 16 stated he had concerns with Staff 5 because she appeared to be overwhelmed, stressed, and struggled with organizational skills even though she did not have a large workload at that time. Staff 16 stated he voiced his concerns to Staff 2 in person the same day he precepted Staff 5 and recommended Staff 5 receive additional training. On [DATE] at 11:15 AM and at 2:33 PM Staff 2 indicated Staff 15 and Staff 19 had voiced concerns to her about Staff 5's organizational skills and difficulty adjusting to change, especially when moving from the A side of the hall versus the B side of the hall about two weeks into orientation. Staff 2 stated Staff 15 reported Staff 5 was improving and a couple of days later it was reported to her that Staff 5 had difficulties once again with changing sections. As a result of the conversation, Staff 5's orientation was extended another week. On [DATE] at 11:53 AM Staff 19 (RN) stated she was Staff 5's preceptor for one day and struggled significantly, could not complete medications and treatments timely, had poor time management skills. Staff 19 stated she brought up to her concerns to Staff 14 (RNCM) and Staff 2 separately and Staff 14 indicated she would bring the concerns to Staff 2. On [DATE] at 9:23 AM Staff 35 (RN) stated she was Staff 5's preceptor for one day and Staff 5 was overwhelmed and frazzled even though she had extended training, general nursing duties were hard for Staff 5 to grasp, had difficulty with time management, difficulty completing tasks and felt like Staff 5 was always a little behind and it wasn't clicking. g. On [DATE] at 1:02 PM Staff 2, Staff 22 (Corporate Nurse Consultant) and Staff 24 (Director of Operations were notified of the Immediate Jeopardy (IJ) situation. A copy of the IJ template related to the facility's failure to ensure Staff 5 (Former staff/RN) had the appropriate skills and competencies necessary to care for resident needs related to medication administration. An immediate plan of correction (POC) was requested. On [DATE] at 6:53 PM the facility submitted a plan of correction for the IJ and it was accepted. The IJ removal plan included: -Nurse Consultant, VP of Clinical Services, DNS and/or Nurse Pharmacy Consultants will complete 1:1 medication administration competencies for all licensed nurses and CMAs beginning at HS medication pass. All licensed nurses and CMAs whose competency has not been validated will verify the correct high-risk medication (insulin, opiates, pain, and anticoagulant medication) is being administered by validating accuracy through a peer licensed nurse and documented in the MAR. -Medication administration competency will be completed across all shifts 1:1 during medication pass, coordinated with staffing scheduled to ensure all staff are completed by [DATE] at 5:00 PM. -On [DATE] a prescheduled in-service at 7:00 AM, 2:00 PM and 6:00 PM on the five rights of medications/narcotic reconciliation is being conducted by the DNS for all licensed nurses and CMA staff. -Ongoing licensed nurse and CMA orientation will include evidence of medication administration competency observation, prior to completion of scheduled orientation. On [DATE] a review was completed to verify staff in-service training and competencies related to the IJ abatement plan. All staff who pass medications had completed the in-service training. On [DATE] the morning medication pass was observed and there were no significant medication errors. It was determined the IJ removal plan was implemented. On [DATE] at 1:51 PM Staff 1 was informed of the immediacy removal.

Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 1 sampled resident (#1) reviewed for significant medication error. This failure resulted in Resident 1 receiving Resident 2's [MEDICATION(S)] (narcotic pain medication). Resident 1 had an allergy to [MEDICATION(S)] which resulted in Resident 1 experiencing respiratory distress, hospitalization and death. This constituted an immediate jeopardy situation. Findings include: Resident 1 admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's medical record indicated she/he had an allergy to [MEDICATION(S)]. The [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] medication error investigation completed by Staff 2 (DNS) indicated the following: -Staff 5 (Former Staff/RN) was a recent nurse graduate and had worked at the facility since [DATE]. -Staff 5 worked on a different unit for the first time on [DATE] and was responsible for injectable medications and medications that were to be administered via tube. -Staff 5 was interviewed on [DATE] by Staff 2 and indicated she felt overwhelmed on the evening of [DATE] and fell behind in her tasks. -At 11:30 PM Staff 5 went to administer medications to Resident 1. Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 5 pulled a medication from the narcotic drawer labeled #19 which corresponded to a page number in the narcotic book. Staff 5 did not realize there were two medications labeled with #19 that corresponded with two different narcotic books, one was for [MEDICATION(S)], one was for [MEDICATION(S)] for two different residents. By Staff 5's own admission she reported she opened a new bottle and measured 12.5 ml and administered the medication. Staff 5 did not check the label to verify that she had the correct medication. It is believed that she administered [MEDICATION(S)] instead of [MEDICATION(S)]. Resident 1 was sent to the hospital on [DATE] [[DATE]] at approximately 5:10 AM in respiratory distress. -The investigation indicated staff did not identify the discrepancy in the amounts of the liquid medications during the narcotic count over multiple shifts. On [DATE] at 8:22 PM Staff 4 (RN) stated she worked on the [DATE] night shift. She stated she went in to administer Resident 1's 4:00 AM medications early at around 3:00 AM, since the medication can be given an hour early. She stated the resident was snoring really loud and it was not a consistent snore. Staff 4 stated she was preparing her/his medications and Resident 1's pauses were getting longer in between snoring and it was noticeable that the resident was having apneic (intermittent cessation of breathing) periods. Staff 4 stated she went and got Staff 3 (LPN) to assist her. Staff 4 stated they attempted to wake the resident up, she/he was pale and perspiring, she stated they got the ambubag (breathing resuscitation device) and called 911. She stated she returned to work two days later and that is when facility staff alerted her that there was missing [MEDICATION(S)]. On [DATE] at 8:48 AM Staff 3 (LPN) stated she worked on [DATE] night shift and arrived at 10:45 PM. She stated she counted narcotics when she arrived on [DATE] with a CMA due to the CMA wanting to leave early, and did not note any discrepancies with narcotics. She stated Staff 5 was still working after the narcotics were counted. She stated when she arrived to work Staff 5 appeared to be frustrated and was stressed out due to having too many residents, not knowing the residents and did not know how to administer g-tube medications. Staff 3 stated she looked at the medications in the computer and they were all in pink meaning they were late medications. She stated Staff 5 was looking at Resident 1's medications and Staff 3 told Staff 5 to administer medications to Resident 1 since she had already given the resident medications earlier that shift. Staff 3 stated Staff 5 was looking for [MEDICATION(S)] and Staff 3 told her it was #19. Staff 3 stated she went to do a treatment and came back and the medications were on a tray. Staff 3 stated she looked at the color of the medication and it was bright pink and she thought the formula had been changed. Staff 3 stated she later told Staff 4 about the [MEDICATION(S)] being bright pink. She stated later during the shift Resident 1 started making loud noises like she/he was trying to breathe and this was not normal for her/him. She stated they realized something was definitely wrong and the resident had low oxygen, could not get air and was sent out to the hospital. Staff 3 stated on [DATE] Staff 11 (RN) stated there was a bottle of [MEDICATION(S)] that was open and 13 mls was missing. Staff 3 stated she worked with Staff 4 and investigated what happened to the [MEDICATION(S)]. Staff 3 stated she recalled telling Staff 5 Resident 1's [MEDICATION(S)] was #19. Staff 3 and Staff 4 reviewed the narcotic logs and did the narcotic count for [MEDICATION(S)] and it was over what it should have been and Resident 2 had 12.5 mls of [MEDICATION(S)] missing. She further stated Resident 2 did not normally receive [MEDICATION(S)] Staff 3 stated she discovered the discrepancy on [DATE] during night shift and notified Staff 14 (RNCM) on the morning of [DATE]. Staff 14 told Staff 3 to notify Staff 2. Staff 2 was notified and provided a written statement. The investigation indicated Resident 1 received 12.5 ml of [MEDICATION(S)] which was equivalent to 250 mg. According to Mayoclinic.org the standard dose of [MEDICATION(S)] for moderate to severe pain is ,d+[DATE] mg every four hours. On [DATE] at 12:41 PM Staff 2 (DNS) stated there was a discrepancy noted on [DATE] regarding Resident 2's missing [MEDICATION(S)]. Staff 2 stated narcotic medication should be counted three times per day, and approximately five shifts went by before the [MEDICATION(S)] was discovered missing due to narcotic counts not being completed correctly. Staff 2 stated Staff 4 (RN) and Staff 3 (LPN) brought the medication error to her attention and received statements from both nurses. Staff 2 stated Staff 5 received 1:1 orientation after the medication error and staff received an in-service regarding medication pass safety but not all staff were in-serviced. On [DATE] at 3:00 PM Staff 5 stated she administered medication to Resident 1 on [DATE]. Staff 5 stated page 19 of the narcotic book was labeled [MEDICATION(S)]. Staff 5 further stated the medication administration directions corresponded with #19 in the narcotic drawer. Staff 5 stated she pulled what she thought was [MEDICATION(S)] and looked at the label on the Ziploc bag and it matched the book, but did not look at the label on the bottle. Staff 5 stated It was my mistake, it had a seal on it, I opened it and gave it to the patient [Resident 1]. Staff 5 stated she did not see signs of distress and this was the last time she observed Resident 1 before she left. She further stated an LPN came on the floor and noticed Staff 5 pull the medication. Staff 5 stated on [DATE], five days later, she found out she administered [MEDICATION(S)] instead of [MEDICATION(S)] to Resident 1. A [DATE] progress note indicated the nurse was giving Resident 1 her/his 4:00 AM medications and the resident was snoring loudly with 30+ seconds of periods of apnea. The nurse turned on the light which normally jolted the resident awake and her/his eyes flickered open after the nurse shook her/his shoulder and yelled the resident's name. The resident was unarousable and her/his oxygen saturation was 54% and temperature was 96.6. 911 was called and staff provided eight liters of oxygen and put an ambubag (manual resuscitator) on the resident. Resident 1's oxygen saturation went up to 93% and the resident was completely reliant on this intervention. EMS took the resident to the hospital at 5:10 AM. A review of the narcotic books indicated there were two books on Resident 1's floor. Book 97, page 19 was Resident 2's [MEDICATION(S)]. Book 98, page 19 was Resident 1's [MEDICATION(S)]. Resident 1's [MEDICATION(S)] 12.5 ml was signed by Staff 5 on [DATE] at 11:36 PM. Resident 2's [MEDICATION(S)] was 30 ml and the count was corrected to 18 ml on [DATE] at 7:15 AM. The [DATE] through [DATE] hospital records indicated the following: -Resident 1 presented to the emergency department on [DATE] at 5:29 AM for evaluation of respiratory arrest. -Resident 1 was given three doses of [MEDICATION(S)] (a medication used to reverse the side effects of narcotics) in the emergency department. -Resident 1 had respiratory depression and apnea between doses of [MEDICATION(S)]. -Resident 1's improvement with [MEDICATION(S)] indicated the resident was likely overmedicated and could have been from a medication error. -On [DATE] Resident 1 was on comfort care and medicated for air hunger and resident appeared more comfortable. -Resident 1 died on [DATE] at 6:46 PM. The immediate cause of death was respiratory failure due to suspected unintentional narcotic overdose. On [DATE] at 11:51 AM Staff 2 (DNS) stated narcotic book 97, page 19 indicated Resident 2's [MEDICATION(S)] was discovered missing on [DATE]. On [DATE] at 1:30 PM Staff 2 stated Staff 5 worked on [DATE], [DATE] and [DATE] and was not aware Staff 5 made a medication error and administered Resident 2's [MEDICATION(S)] to Resident 1 until [DATE] when Staff 3 and Staff 4 brought it to Staff 2's attention. On [DATE] at 11:27 AM Staff 14 (RNCM) stated she was unaware of the date of the medication error and was fuzzy on the dates. On [DATE] at 12:41 PM Staff 2 stated an in-service regarding medication errors was provided by the pharmacy and staff were required to watch a video. On [DATE] and [DATE] Staff 2 provided a Medication Safety and Controlled Substance Accountability in-service document. The document indicated the in-services were completed on [DATE], [DATE] and [DATE]. There was no indication all staff who pass medications were in-serviced regarding medication errors. Staff 5 was not given the in-service until [DATE]. On [DATE] at 10:11 AM Staff 2 stated after the medication error was made, the facility initiated an in-service regarding medication errors. Staff 2 stated not all staff who provide medications were given the in-service. On [DATE] at 1:02 PM Staff 2, Staff 22 (Corporate Nurse Consultant) and Staff 24 (Director of Operations) were notified of the Immediate Jeopardy (IJ) situation. A copy of the IJ template related to the facility's failure to ensure residents were free from significant medication errors was provided. An immediate plan of correction (POC) was requested. On [DATE] at 6:53 PM the facility submitted a plan of correction for the IJ and it was accepted. The IJ removal plan included: -Nurse Consultant, Vice President of Clinical Services, DNS and/or Nurse Pharmacy Consultants will complete 1:1 medication administration competencies for all licensed nurses and CMAs beginning at HS medication pass. All licensed nurses and CMAs whose competency has not been validated will verify the correct high-risk medication (insulin, opiates, pain, and anticoagulant medication) was being administered by validating accuracy through a peer licensed nurse and documented in the MAR. -Medication administration competency would be completed across all shifts 1:1 during medication pass, coordinated with staffing scheduled to ensure all staff completed the in-service by [DATE] at 5:00 PM. -On [DATE] a prescheduled in-service at 7:00 AM, 2:00 PM and 6:00 PM on the five rights of medications/narcotic reconciliation would be conducted by Staff 2 for all licensed nurses and CMA staff. -Ongoing investigation of medication errors will include identification of the error, physician and family notification and staff education as applicable. Medication errors will be reviewed by the DNS as part of facility standup meetings. The facility will implement any identified required action based on error and/or trends. On [DATE] a review was completed for staff in-service training and competencies related to the IJ abatement plan. All staff who pass medications completed the in-service training. On [DATE] the morning medication pass was observed and there were no significant medication errors. It was verified the IJ removal plan was implemented. On [DATE] at 1:51 PM Staff 1 (Administrator) was informed of the immediacy removal. 2. Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 4 sampled residents (#7) reviewed for medication errors. This placed residents at risk for hemorrhage and death. Findings include: Resident 7 was admitted to the facility ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Medication Error Report revealed Resident 7 was administered [MEDICATION(S)] 1 ml/150 mg instead of the ordered 0.9 ml/135 mg on [DATE]. The report indicated this could have endangered the life/welfare of the resident. On [DATE] at 12:38 PM Staff 2 (DNS) verified Resident 7 was administered [MEDICATION(S)] 1 ml/150 mg instead of the ordered 0.9 ml/135 mg on [DATE]. Staff 2 further stated this medication error could have endangered the life and welfare of Resident 7 and acknowledged Resident 7 was not monitored and placed on alert charting.

Based on interview and record review it was determined the facility failed to ensure Staff 5 (RN) administered medications per the current standard of practice and Staff 2 (DNS) failed to ensure nursing staff assigned to residents had the skills, experience and knowledge to provide care and services to meet resident needs. These failures resulted in Resident 1's hospitalization and death. This constituted an immediate jeopardy situation. Findings include: -Staff 2 failed to ensure nurse competency training was completed, reported and documented during Staff 5 as well as additional nursing staff orientations. -Staff 2 failed to investigate report and document medication errors and identify and investigate missing narcotic medication. -Staff 2 did not originally initiate the investigation for Resident 2's missing [MEDICATION(S)] which occurred on [DATE]. Two nursing staff identified the medication error four days after the [MEDICATION(S)] was missing and informed Staff 2. -An in-service was provided for the five rights of medication. The first in-services were completed on [DATE], [DATE] and [DATE]. As of [DATE] all staff had yet to be in-serviced regarding medication errors. -Staff 2 failed to ensure all staff who administer medications were competent in medication administration. -Staff 2's lack of investigation and follow up of medication errors placed all residents at risk for medication errors. Resident 1 admitted to the facility in 2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's medical record indicated she/he had an allergy to [MEDICATION(S)]. The [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] medication error investigation completed by Staff 2 (DNS) indicated the following: -Staff 5 (Former Staff/RN) was a recent nurse graduate and had worked at the facility since [DATE]. -Staff 5 worked on a different unit for the first time on [DATE] and was responsible for injectable medications and medications that were to be administered via tube. -Staff 5 was interviewed on [DATE] by Staff 2 and indicated she felt overwhelmed on the evening of [DATE] and fell behind in her tasks. -At 11:30 PM Staff 5 went to administer medications to Resident 1. Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 5 pulled a medication from the narcotic drawer labeled #19 which corresponded to a page number in the narcotic book. Staff 5 did not realize there were two medications labeled with #19 that corresponded with two different narcotic books, one was for [MEDICATION(S)], one was for [MEDICATION(S)] for two different residents. By Staff 5's own admission she reported she opened a new bottle and measured 12.5 ml and administered the medication. Staff 5 did not check the label to verify that she had the correct medication. It is believed that she administered [MEDICATION(S)] instead of [MEDICATION(S)]. Resident 1 was sent to the hospital on [DATE] [[DATE]] at approximately 5:10 AM in respiratory distress. -The investigation indicated several staff did not identify the discrepancy in the amounts of the liquid medications during the narcotic count over multiple shifts. On [DATE] at 8:22 PM Staff 4 (RN) stated she worked on [DATE] night shift. She stated she went in to administer Resident 1's 4:00 AM medications early at around 3:00 AM, since the medication can be given an hour early. She stated the resident was snoring really loud and it was not a consistent snore. Staff 4 stated while she was preparing her/his medications Resident 1's pauses were getting longer in between snoring and it was noticeable the resident was having apneic (intermittent cessation of breathing) periods. Staff 4 stated she went and got Staff 3 (LPN) to assist her. Staff 4 stated they attempted to wake the resident up, she/he was pale and perspiring, she stated they got the ambubag (breathing resuscitation device) and called 911. She stated she returned to work two days later and that is when facility staff alerted her that there was missing [MEDICATION(S)]. On [DATE] at 8:48 AM Staff 3 (LPN) stated she worked on [DATE] night shift and arrived at 10:45 PM. She stated she counted narcotics when she arrived on [DATE] with a CMA due to the CMA wanting to leave early, and did not note any discrepancies with narcotics. She stated Staff 5 was still working after the narcotics were counted. She stated when she arrived to work Staff 5 appeared to be frustrated and was stressed out due to having too many residents, not knowing the residents and did not know how to administer g-tube medications. Staff 3 stated she looked at the medications in the computer and they were all in pink meaning they were late medications. She stated Staff 5 was looking at Resident 1's medications and Staff 3 told Staff 5 to administer medications to Resident 1 since she had already given the resident medications earlier that shift. Staff 3 stated Staff 5 was looking for [MEDICATION(S)] and Staff 3 told her it was #19. Staff 3 stated she went to do a treatment and came back and the medications were on a tray. Staff 3 stated she looked at the color of the medication and it was bright pink and she thought the formula had been changed. Staff 3 stated she later told Staff 4 about the [MEDICATION(S)] being bright pink. She stated later during the shift Resident 1 started making loud noises like she/he was trying to breathe and this was not normal for her/him. She stated they realized something was definitely wrong and the resident had low oxygen, could not get air and was sent out to the hospital. Staff 3 stated on [DATE] Staff 11 (RN) stated there was a bottle of [MEDICATION(S)] was open and 13 mls were missing. Staff 3 stated she worked with Staff 4 and investigated what happened to the [MEDICATION(S)]. Staff 3 stated she recalled telling Staff 5 Resident 1's [MEDICATION(S)] was #19. Staff 3 and Staff 4 reviewed the narcotic logs and did the narcotic count for [MEDICATION(S)] and it was over what it should have been and Resident 2 had 12.5 mls of [MEDICATION(S)] missing. She further stated Resident 2 did not normally receive [MEDICATION(S)]. Staff 3 stated she discovered the discrepancy on [DATE] during night shift and notified Staff 14 (RNCM) on the morning of [DATE]. Staff 14 told Staff 3 to notify Staff 2. Staff 2 was notified and provided a written statement. The investigation indicated Resident 1 received 12.5 ml of [MEDICATION(S)] which was equivalent to 250 mg. According to Mayoclinic.org the standard dose of [MEDICATION(S)] for moderate to severe pain is ,d+[DATE] mg every four hours. On [DATE] at 12:41 PM Staff 2 (DNS) stated there was a discrepancy noted on [DATE] regarding Resident 2's missing [MEDICATION(S)]. Staff 2 stated narcotic medications should be counted three times per day, and approximately five shifts went by before the [MEDICATION(S)] was discovered missing due to narcotic counts not being completed correctly. Staff 2 stated Staff 4 (RN) and Staff 3 (LPN) brought the medication error to her attention and received statements from both nurses. Staff 2 stated Staff 5 received 1:1 orientation after the medication error and staff received an in-service regarding medication pass safety but not all staff were in-serviced. On [DATE] at 3:00 PM Staff 5 stated she administered medication to Resident 1 on [DATE]. Staff 5 stated page 19 of the narcotic book was labeled [MEDICATION(S)]. Staff 5 further stated the medication administration directions corresponded with #19 in the narcotic drawer. Staff 5 stated she pulled what she thought was [MEDICATION(S)] and looked at the label on the Ziploc bag and it matched the book, but did not look at the label on the bottle. Staff 5 stated It was my mistake, it had a seal on it, I opened it and gave it to the patient [Resident 1]. Staff 5 stated she did not see signs of distress and this was the last time she observed Resident 1 before she left. She further stated an LPN came on the floor and noticed Staff 5 pull the medication. Staff 5 stated on [DATE], five days later, she found out she administered [MEDICATION(S)] instead of [MEDICATION(S)] to Resident 1. An [DATE] progress note indicated Staff 4 (RN) was giving Resident 1 her/his 4:00 AM medications and the resident was snoring loudly with 30+ seconds of periods of apnea (temporary cessation of breathing). The nurse turned on the light which normally jolted the resident awake and her/his eyes flickered open after the nurse shook her/his shoulder and yelled the resident's name. The resident was unarousable, her/his oxygen saturation was 54% and temperature was 96.6. 911 was called and staff provided 8 liters of oxygen and put an ambubag (manual resuscitator) on the resident. Resident 1's oxygen saturation went up to 93% and the resident was completely reliant on this intervention. EMS took the resident to the hospital at 5:10 AM. A review of the narcotic books indicated there were two books on Resident 1's floor. Book 97, page 19 was Resident 2's [MEDICATION(S)]. Book 98, page 19 was Resident 1's [MEDICATION(S)]. Resident 1's [MEDICATION(S)] 12.5 ml was signed by Staff 5 on [DATE] at 11:36 PM. Resident 2's [MEDICATION(S)] was 30 ml and the count was corrected to 18 ml on [DATE] at 7:15 AM. The [DATE] through [DATE] hospital records indicated the following: -Resident 1 presented to the emergency department on [DATE] at 5:29 AM for evaluation of respiratory arrest. -Resident 1 was given 3 doses of [MEDICATION(S)] (a medication used to reverse the side effects of narcotics) in the emergency department. -Resident 1 had respiratory depression and apnea between doses of [MEDICATION(S)]. -Resident 1's improvement with [MEDICATION(S)] indicated the resident was likely overmedicated and could have been from a medication error. -On [DATE] Resident 1 was on comfort care and medicated for air hunger and resident appeared more comfortable. -Resident 1 died on [DATE] at 6:46 PM. The immediate cause of death was respiratory failure due to suspected unintentional narcotic overdose. On [DATE] at 11:51 AM Staff 2 (DNS) stated narcotic book 97, page 19 indicated Resident 2's [MEDICATION(S)] was discovered missing on [DATE]. On [DATE] at 1:30 PM Staff 2 stated Staff 5 worked on [DATE], [DATE] and [DATE] and was not aware Staff 5 made a medication error and administered Resident 2's [MEDICATION(S)] to Resident 1 until [DATE] when Staff 3 and Staff 4 brought it to Staff 2's attention. On [DATE] at 11:27 AM Staff 14 (RNCM) stated she was unaware of the date of the medication error and was fuzzy on the dates. On [DATE] at 12:41 PM Staff 2 stated an in-service regarding medication errors was provided by the pharmacy and staff were required to watch a video. On [DATE] and [DATE] Staff 2 provided a Medication Safety and Controlled Substance Accountability in-service document. The document indicated the in-services were completed on [DATE], [DATE] and [DATE]. There was no indication all staff who pass medications were in-serviced regarding medication errors. Staff 5 was not given the in-service until [DATE]. On [DATE] at 10:11 AM Staff 2 stated after the medication error was made the facility initiated an in-service regarding medication errors. Staff 2 stated not all staff who provide medications were given the in-service. On [DATE] at 1:02 PM Staff 2, Staff 22 (Corporate Nurse Consultant) and Staff 24 (Director of Operations) were notified of the Immediate Jeopardy (IJ) situation. A copy of the IJ template related to the facility's failure to ensure residents were free from significant medication errors. An immediate plan of correction (POC) was requested. On [DATE] at 6:53 PM the facility submitted a plan of correction for the IJ and it was accepted. The IJ removal plan included: -Vice President of Clinical Services and Director of Operations will review medication administration competencies and medication error management and tracking with facility, regarding policy and expected standards including investigation of medication error on [DATE]. -Effective immediately Nurse Consultant, Vice President of Clinical Services, DNS and/or nurse pharmacy consultants beginning HS pass on [DATE] will complete 1:1 medication administration competencies for all licensed nurses and CMAs. -Medication administration competency will be completed across all shifts 1:1 during medication pass, coordinated with staffing, scheduled to ensure all staff are completed by [DATE] at 5:00 PM. -DNS to be trained on the DNS role related to medication error investigations and nurse competency requirements by [DATE] at 5:00 PM. -On [DATE] a prescheduled in-service at 7:00 AM, 2:00 PM and 6:00 PM on the five rights of medications/narcotic reconciliation is being conducted by the DNS for all licensed nurses and CMA staff. -Ongoing medication errors will be reviewed by the DNS as part of facility standup meetings. The facility will implement any identified required action based on error and/or trends. On [DATE] a review was completed to verify staff in-service training and competencies related to the IJ abatement plan. All staff who pass medications had completed the in-service training. Interviews with staff completed on [DATE] through [DATE] and [DATE]. It was determined the IJ removal plan was implemented. On [DATE] at 1:51 PM Staff 1 was informed of the immediacy removal. Refer to F760 and F726.

Based on interview and record review it was determined the facility failed to prevent accident hazards for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 sustained a wrist fracture after a fall. Findings include: Resident 1 admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. The 11/22/17 Fall Care Plan indicated Resident 1 was at risk for falls related to weakness, diabetes and [MEDICAL CONDITION]. Fall interventions included bed to knee height, reinforcement to call for assistance and non-skid socks while in bed. A Progress Note dated 12/19/17 indicated Resident 1 was found in her/his room sitting on the floor leaning against the bed with her/his feet out in front of her/him. Resident 1 stated she/he needed to use the bathroom. The fall investigation dated 12/19/17 indicated Resident 1 was found on the floor in her/his room leaning against the bed with both legs straight out in front of her/him. Resident 1 told staff she/he was attempting to get out of bed to go to the bathroom. The investigation noted Resident 1 was barefoot and the fall was not witnessed. A Progress Note dated 12/20/17 indicated Resident 1 complained of pain in the left wrist, the wrist was swollen and red and an x-ray was ordered for latent injury from the fall on 12/19/17. The Radiology Report dated 12/21/17 indicated a left wrist fracture. On 3/9/18 at 11:56 am Staff 9 (RN) stated Resident 1 was found with her/his hands on the floor and could have easily smacked her/his hands on the floor to catch her/himself. On 3/13/18 at 9:07 am Staff 6 (CNA) stated she found Resident 1 on the floor with her/his left hand on the floor and her/his feet extended out in front of the resident. On 3/13/18 at 11:09 am Staff 1 (DNS) acknowledged the investigation indicated the fall was unwitnessed and Resident 1 was not wearing non-skid socks as care planned.

Based on observation, interview and record review it was determined the facility failed to provide an environment with a functioning call light system on the 4th floor in 13 of 19 resident rooms and/or bathrooms (#s 408, 410, 416, 418, 420, 422, 424, 426, 432, 424, 436, 440 and 442) and 2 common use rooms (the main shower room and hall bathroom) reviewed for accident hazards. Four sampled residents (#s 36, 81, 120 and 216) were observed or reported using a bathroom or shower room independently with a non-functioning call light and no staff supervision. This placed residents at risk for accidents and/or injuries and resulted in an immediate jeopardy situation. Findings include: The facility's policy and procedure for Answering the Call Light instructed staff to, "Be sure that the call light is plugged in at all times...Report all defective call lights to the Charge Nurse promptly...If assistance is needed when you enter the room, summon help by using the call signal." The facility's 4th floor included 19 occupied resident rooms, a shower room and a hall bathroom. A wireless call light system was used which alerted staff to residents' needs by way of a pager system. The pagers could be set to vibrate or sound and would activate if a call light was pushed or pulled. Each resident room had visible signals outside the door which were designed to light up if a call light was activated. 1. a. On 1/27/14 at 2:29 pm, room 424's bathroom call light was tested by Staff 4, CNA, and found not to function. Staff 4 then pulled the call light in room 434's bathroom and found it did not function. In interview on 1/27/14 at 2:35 pm, Staff 5, CNA, stated she had difficulties with room 424's call light the previous week, but it had been fixed. She stated she would write a maintenance request if a call light did not function. On 1/28/14 from 10:09 am to 2:45 pm, additional call lights in resident bathrooms were observed to not function for rooms 414, 420, 424, 432, 434 and 436. b. On 1/28/14 at 12:49 pm, Resident 36 was observed leaving the bathroom in room 434 independently. The resident stated she/he used that bathroom every day. Staff 5, CNA, confirmed the bathroom call light for room 434 did not function on 1/28/14 at 2:41 pm and when used, did not activate her pager. c. On 1/29/14 from 7:00 pm to 7:30 pm all call lights on the 4th floor were tested . The following call lights were observed to not function: -Resident rooms 408 and 442, -Resident bathrooms in rooms 410, 416, 418, 420, 422, 424, 426, 432, 434, 436, 440 and 442. -The main shower room, and -The hall bathroom. In a 1/29/14 interview at 8:05 pm, Staff 3, Maintenance Director, stated to his knowledge there were three non-functioning call lights on the 4th floor. The 4th floor shower room call light did not activate the visible signal outside the door, but would activate staffs' pagers. On 1/29/14 at 8:24 pm the 4th floor shower room call light was pulled and Staff 27, CNA, was asked if it activated her pager. Staff 27 was not carrying her pager. When retrieved, she verified the shower room call light did not activate the pager. 2. The following residents were found to be in immediate jeopardy situations: a. Resident 120 was admitted to the facility in 1/2012 with [DIAGNOSES REDACTED]. The current Care Plan revealed the resident was at risk for falls and staff were to reinforce her/his need to use the call light for assistance. On 1/29/14 at 6:04 pm Resident 120 stated the previous night she/he had been set up in the shower room and then requested staff to leave. When finished showering the resident had to yell for help and wait approximately ten minutes for staff assistance. The shower room call light, which was located on a wall across from the shower heads and out of reach for a dependent resident, was tested and did not function. In interview on 2/4/14 at 5:01 pm Staff 27, CNA, stated Resident 120 liked privacy in the shower room. Staff would set the resident up in the shower chair and leave the resident alone in the shower room. Staff remained close to the shower room so they could hear the resident call out when she/he was done. On 2/4/14 at 5:09 pm Staff 26, CNA, stated sometimes Resident 120 would indicate she/he wanted to be left alone in the shower. Staff 26 stated she knew the resident was in the shower and waited for the resident to call out when she/he was finished. On 2/4/14 at 5:27 pm Staff 19, RNCM, stated staff were always to be present during Resident 120's showers and the resident was not care planned to be left alone in the shower. Staff 19 stated most residents were unaware of their own limitations and put themselves in unsafe situations. b. Resident 81 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. The resident was Care Planned to use the hall bathroom and was not to be left alone since she/he needed assistance with clothing after toileting. Staff were to, "provide constant supervision with physical assist...washing/drying face, hands, and perineum (wiping after using the bathroom)." On 1/29/14 at 7:39 pm Resident 81 was observed as she/he exited the hall bathroom. The resident was alone, had her/his pants and incontinence briefs around her/his knees and used an electric wheelchair to travel down the hallway to her/his room. In interview on 1/29/14 at 7:56 pm Resident 81 stated the call light in the hall bathroom had not worked since she/he was admitted to the facility. On 1/30/14 at 3:03 pm Staff 25, CNA, stated Resident 81 used the hall bathroom without direct staff supervision. Staff 25 stated she would wait outside the hall bathroom and the resident would let her know when she/he was ready for help. Staff 25 stated the resident's legs were a little weak and the resident was unable to wipe her/himself. On 1/31/14 at 12:03 pm Resident 81 described how she/he communicated with staff when she/he used the hall bathroom. The resident would leave a little bag on the outside bathroom door handle to signal that she/he was in the bathroom because the call light had not worked for approximately two years. The resident stated if that didn't work she/he would have to go to her/his room to turn on the call light to summon staff to help pull up her/his pants. c. Resident 36 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. The current Care Plan indicated the resident was at risk for falls due to a history of falls, chose not to use her/his mobility aide at times and used psychotropic medications. The Care Plan also indicated the resident had five falls in the past year and staff were to encourage her/him to call for assistance with transfers. On 1/29/14 at 7:15 pm Resident 36 was observed exiting the bathroom in room 434. The resident did not use an assistive device to ambulate and no staff were present. The call light was tested and did not function. d. Resident 216 admitted to the facility within the prior three weeks for rehabilitation following surgery to repair a traumatic injury, and ankle sprain and strain. The current Care Plan indicated staff were to encourage the resident not to ambulate without assistance and to, "provide constant supervision with...washing/drying face, hands, and perineum. " On 1/29/14 at 7:23 pm Resident 216 was observed exiting the bathroom in room 426. The resident wore a heavy splint on her/his lower left leg and used a walker to ambulate from the bathroom to the bed. No staff were present. The bathroom call light was tested and did not function. 3. On 1/29/14 at 8:43 pm, following consultation with a Nursing Facility Survey Unit supervisor, surveyors informed Staff 1, Administrator, the lack of functioning call lights on the 4th floor constituted a situation of immediate jeopardy to residents. On 1/29/14 at 9:07 pm the facility's plan of correction was accepted and the immediate jeopardy was abated. On 1/31/14 at 1:34 pm Staff 1, Administrator, stated staff should never have used a maintenance slip to communicate a call light was not functioning. In interview on 2/5/14 at 10:22 am Staff 3, Maintenance Director, stated he checked call lights in all resident rooms weekly but had not checked the bathroom call lights. Many residents did not use their bathrooms and so it was lost in the shuffle. He confirmed the shower room and hall bathroom lights were not checked weekly. On 2/5/14 at 12:49 pm Staff 19, RNCM, indicated 23 out of 28 residents who resided on the 4th floor on 1/29/14 were physically and mentally capable of using a call light.

Based on observation, interview and record review it was determined the facility failed to provide an environment with a functioning call light system on the 4th floor in 13 of 19 resident rooms and/or bathrooms (#s 408, 410, 416, 418, 420, 422, 424, 426, 432, 424, 436, 440 and 442) and 2 common use rooms (the main shower room and hall bathroom) reviewed for physical environment. This placed residents and staff at risk for not being able to summon assistance and resulted in an immediate jeopardy situation. Findings include: The facility's policy and procedure for Answering the Call Light instructed staff to, "Be sure that the call light is plugged in at all times...Report all defective call lights to the Charge Nurse promptly...If assistance is needed when you enter the room, summon help by using the call signal." The facility's 4th floor rooms included 19 occupied resident rooms, a shower room and a hall bathroom. A wireless call light system was used which alerted staff to residents' needs by way of a pager system. The pagers could be set to vibrate or sound and would activate if a call light was pushed or pulled. Each resident room had visible signals outside each door which were designed to light up if a call light was activated. On 1/27/14 at 2:29 pm room 424's bathroom call light was observed with Staff 4, CNA, to not function. Staff 4 then tested the call light in room 434's bathroom and found it also did not function. On 1/27/14 at 2:35 pm Staff 5, CNA, stated room 424 had problems with the call light last week which were fixed. She stated she would write a maintenance request if a call light did not function. On 1/28/14 from 10:09 am to 2:45 pm call lights in resident bathrooms were observed to not function for rooms 414, 420, 424, 432, 434 and 436. On 1/28/14 at 2:41 pm Staff 5, CNA, confirmed the bathroom to room 434 had a non-functioning call light and stated it did not activate her pager. On 1/29/14 from 7:00 pm to 7:30 pm all call lights on the 4th floor were tested . The following call lights did not function: -Rooms 408 and 442 -Bathrooms in rooms 410, 416, 418, 420, 422, 424, 426, 432, 434, 436, 440 and 442 -The shower room and -The hall bathroom. On 1/29/14 at 8:24 pm Staff 27, CNA, verified the shower room call light did not activate her pager. On 1/29/14 at 8:43 pm, following consultation with a Nursing Facility Survey Unit supervisor, the surveyors informed Staff 1, Administrator, the lack of functioning call lights on the 4th floor constituted a situation of immediate jeopardy to residents. On 1/29/14 at 9:07 pm the facility's plan of correction was accepted and the immediate jeopardy was abated. On 1/31/14 at 1:34 pm Staff 1, Administrator, stated staff should never have used a maintenance slip to communicate a non-functioning call light. In interview on 2/5/14 at 10:22 am Staff 3, Maintenance Director, stated he checked call lights in all resident rooms weekly but had not checked the bathroom call lights. He stated since a lot of the residents weren't using the bathrooms it got lost in the shuffle. He confirmed the shower room and hall bathroom lights were not checked weekly. On 2/5/14 at 12:49 pm Staff 19, RNCM, indicated 23 out of 28 residents who resided on the 4th floor on 1/29/14 were physically and mentally capable of using a call light. Refer to F323