Every finding on record at Northern Neck Senior Care Community

Based on Staff interview, clinical record review, hospital record review, and facility document review, the facility staff failed to obtain and provide appropriate oxygen orders during a change in condition event for one Resident (Resident #100) in a survey sample of 13 residents.The findings included;Resident #100 was admitted to the facility on [DATE] with diagnoses including; encephalopathy, heart attack, hypertension, diabetes, chronic kidney disease stage 3, dysphagia, sick sinus cardiac syndrome, transient Ischemic attack [TIA], bradycardia, atherosclerotic cardiovascular disease, heart failure, and cerebral atherosclerosis.The Resident's most recent Minimum Data Set [MDS] assessment was a five day assessment and coded the Resident with severe cognitive impairment, memory problems, completely incontinent, and completely dependent on staff for all activities of daily living with the exception of eating which required only set up and clean up assistance from staff.Review of physician and nursing progress notes revealed an uncomplicated three day stay culminating in discharge on [DATE] at 2:17 PM. The chronological order of events as documented in the clinical record for that day follow below;On 6-29-26 at 8:30 AM the Registered Nurse Practitioner saw and evaluated the Resident with no signs of a worsening condition noted.At 1:45 PM nursing notes documented vital signs as Blood pressure 60/41, heart rate 46, respirations 14, temperature 97.5, pulse oximetry 78% on nasal cannula oxygen, blood sugar 201. At 2:04 PM an eInteract {SBAR} nursing change in condition evaluation was documented as Abnormal vital signs, altered mental status An order was received from the physician to send the Resident out to the emergency room for evaluation, and the nurse on duty called 911. The eInteract document revealed steps taken to improve the Resident's condition prior to Ems arrival, and Oxygen was listed as administered via nasal cannula at 4 liters per minute, however, this was insufficient.At 2:10 PM the Ems [emergency medical services] ambulance arrived, and at 2:17 PM the Resident was discharged to the hospital with EMS and a report to the emergency room was made via telephone by facility nursing staff. EMS records indicated that upon arrival they found the Resident hypoxemic with oxygen saturation remaining at 78%, and they immediately instituted a non-rebreather mask with high flow oxygen which improved the Resident's oxygen saturation status.Interviews were conducted with nursing staff and the Administrator on 7-9-26 who stated that non-rebreather masks and high flow oxygen were available in the facility to be used emergently for this Resident. facility Policies were requested and reviewed. They indicated that oxygen therapy would be ordered by a physician and provided as needed.Physician orders and the nursing care plan were reviewed and revealed that the Resident had no standing order for oxygen and did not require oxygen prior to this incident. Staff had no guidelines nor standing orders from the doctor to provide oxygen, nor high flow oxygen when the incident occurred.It is unknown why the physician did not request high flow oxygen for the hypoxemic Resident when the oxygen saturation was known at 78%, and high flow oxygen masks and supplies were available for use in the facility.Hospital records were requested and supplied. Review of those records indicated that the Resident improved only slightly in the hospital with intravenous [IV] blood pressure increasing medications [Levophed], body temperature increasing Bair Hugger apparatus, IV fluids, and high flow oxygen via nasal cannula, as the mask was removed. The hospital records further indicated that the family was at bedside and stated that the Resident had an altered level of consciousness on Friday when admitted to the nursing facility and had remained so during the 3 day stay there. Hospital records for 6-29-26 go on to diagnose the Resident with hypomagnesemia, altered mental status, hypotension, hypothermia, non ST elevated Myocardial infarction [NSTEMI Heart attack], and shock.Doctors notes described Pressor requirements have gone up significantly in the past 3 hours, Patient has demand [heart] [loss of blood flow to heart tissue] ischemia, acute hypoxic respiratory failure, mild pulmonary edema, oxygen saturation with high flow oxygen fell to a low of 64%, metabolic and lactic acidosis, and the physician told the family the Resident appears to be actively dying.On 6-29-26 after the Resident was stabilized in the community hospital, she was then transferred to a larger hospital for further treatment and care due to all beds being full in the community hospital which was on diversion. The Administrator and Director of Nursing [DON] stated education would be provided again to staff as a reminder of the oxygen order process and to improve skills for providing pulmonary resuscitation and oxygen support even when CPR compression is not warranted. At the end of day debrief on 7-10-26 the Administrator and DON were made aware of findings and stated they had nothing further to provide.

Based on observation, interview and clinical record review the facility staff failed to ensure receive treatment and care in accordance with physician orders for two residents (Resident #7-R7 and Resident #74-R74) in a survey sample of 37 residents. The failure to follow physician orders resulted in a delay in identification and treatment for a fracture, which resulted in harm for R7.The findings included:1. For Resident #7 (R7) the facility staff failed to ensure physician orders were followed/carried out for a post-fall x-ray of the pelvis and left hip, which resulted in a delay in treatment of a fractured left hip and caused the resident pain, which constituted harm. R7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, type II diabetes, anxiety disorder, history of cerebral infarction, osteoarthritis of knee, history of right hip fracture with ORIF (Open Reduction Internal Fixation), hypertension and depression. R7's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) coded R7 as having a BIMS (Brief Interview of Mental Status) score of 11 out of a possible 15 indicating moderate cognitive impairment. R7 requires physical assistance of 1 staff for all aspects of ADL care. On 5/18/25 at approximately 1:00 pm R7 was observed in bed dressed in a hospital gown watching television. An interview was conducted with R7 who stated that she did not remember much about the fall except that she was in a wheelchair and the CNA (Certified Nursing Assistant) attempted to assist her with transferring to the bed and fell to the floor. She stated that she remembered the fall and not much else until she woke up in the hospital. R7 stated she knows she sustained a broken left hip and had to have surgery. On 5/18/26 a review of the clinical record revealed that R7 had a fall at the facility on 4/14/26 while being transferred. The progress notes were not entered on the day of the fall. On 4/15/26 a progress note entry was made that read: 4/15/26 11:36 a.m. Resident stated that she had a fall on yesterday and now complains of left hip and back pain resident hit her head but denies and headache or dizziness at the time. Incident was reported to nursing manager. 4/15/26 6:51 p.m. - At approximately 8 pm on 4/14/26 the CNA assigned to [R7 name redacted] reported to this nurse that the resident lost her balance during a transfer from wheelchair to bed and landed against CNA. She reported that she tried to get the resident to stand upright but she was afraid and would not attempt to and she could not continue to hold [R7 name redacted] so she lowered her to a sitting position beside the bed . A review of the Fall Investigation revealed the same description of lowering to the floor by CNA. On the afternoon of 5/18/26 an interview was conducted with LPN2 (Licensed Practical Nurse) who stated that any unintentional change in position should be classified as a fall. LPN2 stated that when a fall occurs the resident is assessed by the nurse, a fall note is started with all the information surrounding the fall including vital signs and any injuries, the doctor and the RP (Responsible Party) are notified and follow up notes are done for three days. R7 was seen by the NP (Nurse Practitioner) on 4/16/26 excerpts from the NP notes are as follows: 4/16/26-12:30 p.m. - Acute Visit [NP and Facility names redacted] History of present illness: [R7 name redacted] seen today for complaint of left hip pain. Nursing staff reports that the patient fell while trying to transfer. The patient reports she fell to the floor and did not hit her head. She denies any loss of consciousness. Since the fall the patient has experienced left groin and hip pain and reports difficulty moving the leg due to pain . Assessment and Plan: Pain in left hip ordered X-ray of left hip and pelvis, Ordered Tylenol 650 mg three times per day for 7 days, Position for comfort . On 4/17/26 a nursing progress note entry read: 4/17/26 at 2:20 P.M. left hip and pelvis X-ray due to fall, one time only for fall 3 days not done. A review of the clinical record revealed there were no radiology results present for a left hip and pelvis and there was no indication that nursing staff had followed up with the x-ray company or notified the provider of the x-ray not being obtained. On 4/19/26 the following note was entered into R7's clinical record: 4/19/26 at 3:05 pm - resident family came to visit and was concerned with how resident was acting. Went to assess and resident was seeing things that were not there, being aggressive and agitated. Residents complain [sic] of left hip pain that was severe. family concerned and wanted resident sent out. Offer [sic] to see if STAT [Statum Latin term for immediately] urine could be sent out but family denied and wanted her to be evaluated. report called in, squad call. On call provider and nurse notified, sent bed hold form, med list and orders. According to hospital records titled, Inpatient Discharge to SNF [skilled nursing facility] Summary, page three noted, . presented from her nursing facility for acute change in mental status over ~ 24 hours. Facility reported biting staff and hallucinations . UA [urinalysis] showed cloudy urine with trace blood, leukocytes, and 'loaded with bacteria.' CT [computed tomography] head showed no acute process. X-rays obtained for reported fall revealed an acute nondisplaced left femoral neck fracture. She was admitted for management of suspected urinary tract infection and evaluation/treatment of the hip fracture . 05/20/2026 11:40 AM interview was conducted with the DON who stated that Resident #7 sustained a fall on 4/14/26 and got order for x-ray on 4-16-26. She stated that the x-ray was not obtained due to the mobile radiology service not coming when they were sent the order on 4/16/26. The DON (Director of Nursing) stated that the order was for three days, and it would have fallen off the MAR / TAR (Medication Administration Report / Treatment Administration Report) after 3 days. She stated that the nurses must have missed the fact that it was not done, until the resident was noted by family to have increased pain and altered mental status on 4/19/26 and was subsequently sent to the ER (Emergency Room) found to have a fractured left hip and a urinary tract infection. On 5/21/26 at approximately 2:30 pm an interview was conducted with the Administrator who stated that they realized the resident had a delay in treatment because of the X-ray order not being carried out, so they have changed mobile radiology services, to a more reliable company. On 5/21/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. Resident #74 (R74) was administered vitamin B12 1000 mcg (micrograms) when the physician ordered a 500-mcg dose. A medication pass observation was conducted on 5/19/26 at 7:31 a.m. with registered nurse (RN #2) administering medications to Resident #74. Among the medications prepared and administered to R74 was vitamin B12 1000 mcg. R74's clinical record documented a physician's order dated 3/31/25 for vitamin B12 with instructions to give 500 mcg each day as a supplement. There was no order for a 1000 mcg dose. On 5/19/26 at 9:27 a.m., RN #2 was interviewed about R74's vitamin B12. RN #2 searched the medication cart and the only bottle of vitamin B12 in the cart was the 1000 mcg dose. RN #2 reviewed the physician's order and stated the order required a 500-mcg dose. This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/26 at 4:45 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview and facility document review, the facility staff failed to properly store and label medications on two of three medications carts (Dogwood carts A and C).The findings include:A vial of Lispro insulin was stored in a medication cart with no pharmacy label indicating resident name, dosage or administration instructions. A handwritten last name of a current resident was written on the vial. A Lantus insulin pen was stored in a medication cart with no resident name and no pharmacy labelling indicating resident name, dosage or administration instructions. A vial of opened Lantus insulin was stored in a medication cart beyond the 28-day storage limit.On 5/19/26 at 7:46 a.m., accompanied by registered nurse (RN #2), the Dogwood medication cart A was inspected. Stored in the top drawer was an opened vial of Lispro insulin. The vial of insulin had no pharmacy label/packaging indicating a resident name or dose instructions. Handwritten on the vial was the last name of a current resident and the date opened. RN #2 was interviewed at this time about the insulin with no pharmacy label. RN #1 stated that all medications that came from pharmacy had printed labels with the resident name and dosage instructions. RN #1 was not sure why the vial had no pharmacy label.On 5/20/26 at 8:13 a.m., accompanied by license practical nurse (LPN #3), Dogwood medication cart C was inspected. Stored in this cart was a Lantus insulin pen with no pharmacy label, no resident name or date opened on the pen. An opened vial of Lantus insulin was stored on the cart with date opened recorded as 4/10/26 (40 days since opened). The pharmacy label on this vial documented to discard 28 days after opening. LPN #3 was interviewed at this time about the unlabeled insulin pen and insulin stored beyond 28 days. LPN #3 stated if the insulin pen came from the pharmacy, it should have a printed pharmacy label applied. LPN #3 stated the insulin pen was possibly retrieved from the backup supply. LPN #3 stated if she had obtained the pen from the backup supply, she would have written the resident's name on the pen. LPN #3 stated the vial of insulin opened on 4/10/26 was beyond the 28-day storage time and should have been discarded.On 5/20/26 at 8:17 a.m., the registered nurse unit manager (RN #1) was interviewed about the unlabeled and outdated insulin stored on carts A and C. RN #1 stated extra insulin pens and vials were stored in the medication refrigerator and signed out of the Omnicell storage unit if needed. RN #1 stated if used, nurses were expected to write the resident's name on the pen or vial for identification. RN #1 stated the Lantus insulin opened on 4/10/26 should have been discarded after 28 days.On 5/20/26 at 9:33 a.m., the director of nursing (DON) was interviewed about the unlabeled insulin pen observed on Dogwood cart C. The DON stated the pen was retrieved from the backup supply and there was only one resident on that cart that used the Lantus insulin pen. The DON stated the pen should have been labeled to identify the resident. The DON stated she would have to contact pharmacy about how to obtain pharmacy labeling for items pulled from the backup supply.The facility's policy titled Medication Storage (revised 10/1/23) documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy or destroyed .Manufacturer instructions regarding storage of Lantus insulin at room temperature documented, The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin left in it. (1)These findings were reviewed with the administrator and director of nursing during a meeting on 5/20/26 at 3:45 p.m. with no further information presented prior to the end of the survey.(1) How To Inject Lantus with a Vial and Syringe. November 2025. Sanofi US. 5/21/26. https://www.lantus.com/how-to-use/how-to-inject.

Based on staff interview, facility document review and clinical record review, the facility staff failed to develop a comprehensive care plan for two of thirty-seven residents in the survey sample (Residents #4 and #8).The findings include: For Resident #4 (R4) the facility staff failed to include hallucinations and delusions related to schizophrenia diagnosis in the comprehensive care plan. R4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to acute ischemic heart disease, hypertension, type 2 diabetes, peripheral vascular disease, vascular dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, auditory hallucinations, schizophrenia and visual hallucinations. R4's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/9/26 coded R4 as having a BIMS (Brief Interview of Mental Status Score) of 10 out of a possible 15 indicating moderate cognitive impairment. On 5/19/26 R4 declined to participate in interview. A review of the clinical record revealed that R4 had a diagnosis of Schizophrenia with auditory and visual hallucinations. R4 had orders that included the following psychotropics: Lexapro (an anti-depressant) 2.5 mg daily for depression Buspar (an anti-anxiety) 7.5 mg twice daily for anxiety Seroquel (an anti-psychotic) 12.5 mg daily for schizophrenia A review of R4's care plan revealed that the diagnosis of schizophrenia with hallucinations and the use of antipsychotic medication was not addressed in focus areas. On 5/19/26 at approximately 1:30 p.m. an interview was conducted with LPN 3 who stated, the purpose of a care plan is so that staff will know how to care for the residents. LPN 3 stated that the care plan should address all the diagnoses and the medications that are being used by the residents. A review of the care plan policy revealed the following excerpt: Page 3: Care Plan – Comprehensive Person-Centered – Specific Procedures / Guidance 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical nursing mental and psychosocial needs as identified through the comprehensive Resident Assessment Instrument (RAI) process. On 5/19/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. Resident #8 had no care plan developed regarding use of antidepressant medication. Resident #8 (R8) was admitted to the facility with diagnoses that included lower leg fracture, depression, obesity, history of pulmonary embolism, diabetes and hypertension. The minimum data set (MDS) dated [DATE] assessed R8 as cognitively intact. R8's clinical record documented a physician's order dated 4/25/26 for the antidepressant medication escitalopram 10 mg (milligrams) each day for treatment of depression. A psychiatry assessment dated [DATE] documented R8 had a history of depression and listed the escitalopram as current treatment for depression. R8's medication administration record documented the escitalopram was administered each day as ordered. R8's care plan (revised 4/27/26) documented no problems, goals and/or interventions regarding use of an antidepressant medication. On 5/19/26 at 3:49 p.m., the licensed practical nurse (LPN #4) responsible for MDS assessments and care plans was interviewed about R8. LPN #4 reviewed R8's clinical record and stated the antidepressant was listed on the resident's MDS assessment but had not been included in the care plan. LP #4 stated, I guess I missed it. LPN #4 stated the care plan was developed when the MDS was completed and that the antidepressant should have been included in the plan. The facility's policy titled Care Planning - Comprehensive Person-Centered (dated 10/1/23) documented, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/26 at 4:45 p.m. with no further information presented prior to the end of the survey.

Based on interview and clinical record review the facility staff failed to ensure that residents receive proper treatment to maintain vision, for one resident (Resident #38-R38) in a survey sample of 37 residents.The findings included: For R38 the facility staff failed to ensure follow up care by scheduling cataract surgery as ordered by physicians. R38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertension, venous insufficiency, atrial fibrillation, Chorioretinal scars left eye, and bilateral age-related nuclear cataracts. R38's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/27/26 coded R38 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15, indicating no cognitive impairment. On the afternoon of 5/18/26 an interview was conducted with R38 who stated that he would like to have an appointment with the eye doctor. R38 stated that he did not see well and did have glasses, but they were lost. R 38 stated it had been at least a year since his last eye exam. He stated that he did remember the doctor wanting to see him again about his cataracts as well. On 5/19/26 a review of the clinical record revealed that R38 had an appointment with the Optometrist that came to the facility. The progress notes revealed the following physician note/orders/ eyeglasses prescription: Glasses Prescription (Expires 2/24/27)OD [right eye] +0.75-1.00x108 ADD 2.50OS [left eye] +0.75-1.00x108 ADD 2.50 Physicians Orders: Please schedule cataract surgery OS [left eye] evaluation with Dr. [physician name and phone number redacted]. A review of the clinical record revealed that the appointment was not made. On 5/20/26 at 2:00 pm interview was conducted with the DON (Director of Nursing) who was asked about the procedure for follow-up appointments being scheduled. The DON stated that for the vision specialists come to the building and residents are seen annually or as needed. She stated that she could not find a follow up for R38 with the eye doctor for 2026 and could not find where R38 he had seen the Ophthalmologist for the cataract surgery. On 5/20/26 at approximately 2:15 pm an interview was conducted with the Administrator who stated that R38's follow-up with the surgeon for cataract surgery had Fallen through the cracks and gotten missed somehow. The Administrator agreed that this was a delay in treatment of the visual services needed and was going to take steps to ensure it did not happen in the future. On 5/20/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow protocols for enhanced barrier precautions for one of thirty-seven residents in the survey sample (Resident #10).The findings include:Facility staff failed to use a protective gown during the provision of catheter care for Resident #10 as required with enhanced barrier precautions.Resident #10 (R10) was admitted to the facility with diagnoses that included affective mood disorder, contractures, depression with psychotic features, insomnia, multiple sclerosis, diabetes, protein-calorie malnutrition and neurogenic bladder. The minimum data set (MDS) dated [DATE] assessed R10 as cognitively intact.R10's clinical record documented the resident had a physician's order for a Foley urinary catheter due to retention related to a neurogenic bladder. R10's door frame was posted with instructions for enhanced barrier precautions documenting that a gown and gloves were required for direct care activities.On 5/18/26 at 2:26 p.m., accompanied by licensed practical nurse (LPN #2) and with the resident' permission, catheter care was observed performed by LPN #2. LPN #2 put on gloves, had on a mask but used no protective gown during the provision of catheter care for R10. On 5/18/26 at 2:40 p.m., LPN #2 was interviewed about not wearing a gown during catheter care. LPN #2 stated that gowns and gloves were required during direct care for R10. LPN #2 stated she usually wore a gown during catheter care.On 5/19/26 at 2:32 p.m., the registered nurse unit manager (RN #1) was interviewed about LPN #2 not wearing a gown during catheter care for R10. RN #1 stated gown and gloves were required for those on enhanced barrier precautions. RN #1 stated LPN #2 was aware that a gown was required when performing catheter care.On 5/19/26 at 3:43 p.m., the director of nursing (DON) and acting infection preventionist was interviewed about R10's catheter care observation. The DON stated that gowns and gloves were required during direct care activities for those on enhanced barrier precautions.R10's plan of care (revised 5/7/26) documented the resident required enhanced barrier precautions due to use of a Foley urinary catheter. Interventions to minimize risk of spreading multidrug-resistant organisms included gown and gloves to be applied prior to and worn during high contact care activities.The facility's policy titled Enhanced Barrier Precautions (revised 3/1/24) documented, . EBP [enhanced barrier precautions] are used in conjunction with standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff's hands and clothing .For residents for who EBP are indicated, EBP is employed when performing the following high-contact resident care activities .Device care or use .urinary catheter .This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/26 at 4:45 p.m. with no further information presented prior to the end of the survey.

Based on resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of thirty-seven residents in the survey sample (Resident #84).The findings include:Resident #84's care plan inaccurately listed interventions regarding a fall when the fall and interventions were for another resident. Resident #84 (R84) was admitted to the facility with diagnoses that included end stage renal disease with hemodialysis, congestive heart failure, atrial fibrillation, anemia, epilepsy, cerebrovascular accident (stroke) with hemiplegia and depression. The minimum data set (MDS) dated [DATE] assessed R84 as cognitively intact.On 5/19/26 at 8:50 a.m., R84 was interviewed about quality of life/care in the facility. R84 stated during this interview that she had experienced no falls and/or accidents since her admission to the facility. R84's plan of care (revised 5/12/26) documented the resident had experienced a fall with no injury on 5/16/26 and that non-skid floor strips were implemented in response to the fall.R84's clinical record was reviewed and revealed no documented falls or accidents since the resident's admission. There was no fall listed on 5/16/26. On 5/19/26 at 11:41 a.m., R84's room was observed with no floor strips in place in the room or bathroom.On 5/19/26 at 2:39 p.m., the registered nurse unit manager (RN #1) was interviewed about R84's care plan indicating a fall and floor strip use. RN #1 stated R84 had experienced no falls since admission. RN #1 stated the fall, and interventions must have been documented on the wrong care plan. RN #1 reviewed the care plan history and stated the social worker was listed as the last to update the plan.On 5/19/26 at 2:53 p.m., the social worker was interviewed about R84's fall care plan. The social worker stated, I think I got the wrong person. The social worker stated she updated the wrong care plan. The social worker stated R84 had not had any falls and that the update was intended for another resident.This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/26 at 4:45 p.m. with no further information presented prior to the end of the survey.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure timely radiology diagnostic services for one resident (Resident #7-R7) in a survey sample of 37 residents.For Resident #7 (R7) the facility staff failed to ensure timely radiology services were obtained in accordance with physician orders.R7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, type II diabetes, anxiety disorder, history of cerebral infarction, osteoarthritis of knee, history of right hip fracture with ORIF (Open Reduction Internal Fixation), hypertension and depression. R7's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) coded R7 as having a BIMS (Brief Interview of Mental Status) score of 11 out of a possible 15 indicating moderate cognitive impairment. R7 requires physical assistance of one staff member for all aspects of ADLs (Activities of Daily Living) care.On 5/18/25 at approximately 1:00 pm R7 was observed in bed dressed in a hospital gown watching television. An interview was conducted with R7 who stated that she did not remember much about the fall except that she was in a wheelchair and the CNA (Certified Nursing Assistant) attempted to assist her with transferring to the bed and fell to the floor. She stated that she remembered the fall and not much else until she woke up in the hospital. R7 stated she knows she sustained a broken left hip and had to have surgery.On 5/18/26 a review of the clinical record revealed that R7 had a fall at the facility on 4/14/26 while being transferred. The progress notes were not entered on the day of the fall. The following day, on 4/15/26 the progress notes read: 4/15/26 11:36 a.m. Resident stated that she had a fall on yesterday and now complains of left hip and back pain resident hit her head but denies and headache or dizziness at the time. Incident was reported to nursing manager.On 4/16/26 R7 was seen by the NP (Nurse Practitioner). Excerpts from the NP notes are as follows: 4/16/26-12:30 p.m. - Acute Visit [NP and Facility names redacted] History of present illness: [R7's name redacted] seen today for complaint of left hip pain. Nursing staff reports that the patient fell while trying to transfer. The patient reports she fell to the floor and did not hit her head. She denies any loss of consciousness. Since the fall the patient has experienced left groin and hip pain and reports difficulty moving the leg due to pain . Assessment and Plan: Pain in left hip ordered X-ray of left hip and pelvis, Ordered Tylenol 650 mg three times per day for 7 days, Position for comfort.On 4/17/26 the nursing progress notes read: 4/17/26 at 2:20 P.M. left hip and pelvis X-ray due to fall, one time only for fall 3 days not done.A review of the clinical record revealed there were no radiology results present for the left hip and pelvis.On 5/20/26 at 11:40 AM an interview was conducted with the DON (Director of Nursing) who stated that Resident #7 sustained a fall on 4/14/26 and got order for x-ray on 4-16-26. She stated that the x-ray was not obtained due to the mobile radiology service not coming when they were sent the order on 4/16/26. The DON stated that the order was for 3 days and it would have fallen off the MAR / TAR (Medication Administration Report / Treatment Administration Report) after 3 days. She stated that the nurses must have missed the fact that it was not done, until the resident was noted by family to have increased pain and altered mental status on 4/19/26 and was subsequently sent to the ER (Emergency Room) found to have a fractured left hip and a urinary tract infection. On 5/21/26 at approximately 2:30 pm an interview was conducted with the Administrator who stated that they realized the resident had a delay in treatment because of the X-ray order not being carried out. On 5/21/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement care interventions regarding dialysis for one of thirty-seven residents in the survey sample (Resident #84).The findings include:Pre- and post-dialysis weights for Resident #84 were inaccurate and/or missing and were not obtained from the dialysis treatment center as ordered by the physician.Resident #84 (R84) was admitted to the facility with diagnoses that included end stage renal disease with hemodialysis, congestive heart failure, atrial fibrillation, anemia, epilepsy, cerebrovascular accident (stroke) with hemiplegia and depression. The minimum data set (MDS) dated [DATE] assessed R84 as cognitively intact.R84's clinical record documented the resident had physician ordered dialysis treatments at an outside facility each Tuesday, Thursday and Saturday. The record documented physician orders dated 5/7/25 to obtain pre-dialysis weight and post-dialysis weight for each dialysis treatment with instructions to input weights as documented from the communication form provided by the dialysis center.R84's clinical record was reviewed on 5/19/26 and documented the resident had dialysis treatments on 5/9/26, 5/12/26, 5/14/26, 5/16/26 and 5/19/26.R84's clinical record documented pre- and post-dialysis review forms under the assessment section of the electronic clinical record. R84's clinical record documented pre-dialysis review forms on 5/9/26, 5/12/26 and 5/16/26. There was no pre-dialysis review form documented for 5/14/26 or 5/19/26. Post-dialysis review forms were documented on 5/9/26, 5/16/26 and 5/19/26 with no post-dialysis reviews documented for 5/12/26 or 5/14/26. Communication forms completed by the dialysis center, listed pre- and post-weights, vital signs, and any applicable notes. R84 had no dialysis communication form available for the 5/16/26 or 5/19/26 treatments.The pre- and post-dialysis review forms in R84's clinical record documented inaccurate pre- and post-weights with the weights listed not matching those on the communication forms provided by the dialysis. The inaccurate/discrepant weights were as follows.5/9/26 - facility documented pre-weight as 101.4 lbs. and post-weight as 101.4 lbs.; dialysis communication form listed 108.2 lbs. (pre-) and 106.3 lbs. (post-).5/12/26 - facility documented pre-weight as 101.4 lbs. (listed as obtained on 5/9/26) with no post-weight listed; dialysis communication form listed 107.8 lbs. (pre-) and 106.3 lbs. (post-).5/14/26 - facility documented no dialysis review form with pre- or post-dialysis assessment; dialysis communication form listed weight as 107.6 lbs. (pre-) and 106.3 lbs. (post-).5/16/26 - facility documented pre- and post-weight as 106.5 lbs. (listed as obtained 5/12/26); no dialysis communication form was provided for this treatment.5/19/26 - facility documented no pre-dialysis review form. The post-dialysis review form listed the resident's weight as 111.2 lbs. documenting this weight was obtained 5/19/26 at 10:43 a.m., prior to dialysis, not after. There was no communication form provided by dialysis for this date.On 5/20/26 at 8:25 a.m., the registered nurse unit manager (RN #1) was interviewed about the inaccurate and/or missing before and after dialysis weight monitoring for R84. RN #1 stated nurses were expected to assess R84 before and after dialysis treatments and that a communication form was supposed to be provided by the dialysis center following each treatment. RN #1 stated weights entered on the review forms were supposed to be the weights provided by the dialysis center. RN #1 stated the physician's order required that the pre- and post-weights be obtained from the dialysis communication form.On 5/20/26 at 9:28 a.m., RN #1 stated she reviewed the clinical record and did not see a communication form from dialysis for 5/16/26 or 5/19/26. RN #1 stated that nursing had called about the missing communication form on 5/19/26 but did not see where anyone called about the missing 5/16/26 communication form. RN #1 stated there was a communication form from dialysis on 5/14/26 but that information was not entered in R84's clinical record. RN #1 stated the pre- and post-dialysis review forms should be completed on the resident's dialysis day and the information should accurately reflect weights as provided by the dialysis center.R84's plan of care (revised 5/12/26) documented the resident received dialysis treatment each Tuesday, Thursday and Saturday. Interventions to prevent dialysis complications included obtaining weights before and after dialysis treatments.The facility's policy titled End Stage Renal Disease - Care of Resident (revised 10/1/23) documented, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to .the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration .The nursing facility staff will provide immediate monitoring and documentation of the status of the resident's condition and resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications .This finding was reviewed with the administrator and director of nursing during a meeting on 5/20/26 at 3:45 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain and provide appropriate oxygen treatment for one Resident (Resident #100) in a survey sample of 13 Residents.The findings included;Resident #100 was admitted to the facility on [DATE] with diagnoses including; encephalopathy, heart attack, hypertension, diabetes, chronic kidney disease stage 3, dysphagia, sick sinus cardiac syndrome, transient Ischemic attack [TIA], bradycardia, atherosclerotic cardiovascular disease, heart failure, and cerebral atherosclerosis.The Resident's most recent Minimum Data Set [MDS] assessment was a five day assessment and coded the Resident with severe cognitive impairment, memory problems, completely incontinent, and completely dependent on staff for all activities of daily living with the exception of eating which required only set up and clean up assistance from staff.Review of physician and nursing progress notes revealed an uncomplicated 3 day stay culminating in discharge on [DATE] at 2:17 PM. The chronological order of events for that day follows below;On 6-29-26 at 8:30 AM the Registered Nurse Practitioner saw and evaluated the Resident with no signs of a worsening condition noted.At 1:45 PM nursing notes documented vital signs as Blood pressure 60/41, heart rate 46, respirations 14, temperature 97.5, pulse oximetry 78% on nasal cannula oxygen, blood sugar 201. At 2:04 PM an eInteract {SBAR} nursing change in condition evaluation was documented as Abnormal vital signs, altered mental status An order was received from the physician to send the Resident out to the emergency room for evaluation, and the nurse on duty called 911. The eInteract document revealed steps taken to improve the Resident's condition prior to Ems arrival, and Oxygen was listed as administered via nasal cannula at 4 liters per minute, however, this was insufficient.At 2:10 PM the Ems [emergency medical services] ambulance arrived, and at 2:17 PM the Resident was discharged to the hospital with EMS and a report to the emergency room was made via telephone by facility nursing staff. EMS records indicated that upon arrival they found the Resident hypoxemic with oxygen saturation remaining at 78%, and they immediately instituted a non-rebreather mask with high flow oxygen which improved the Resident's oxygen saturation status.Interviews were conducted with nursing staff and the Administrator on 7-9-26 who stated that non-rebreather masks and high flow oxygen were available in the facility to be used emergently for this Resident. The facility policy on oxygen was requested and received. The facility policy stated that physician's orders would be obtained and oxygen therapy would be administered as needed.Physician orders and the nursing care plan were reviewed and revealed that the Resident had no standing order for oxygen and the Resident did not require oxygen prior to this incident. Staff had no guidelines nor standing orders from the doctor to provide oxygen, nor high flow oxygen when the incident occurred.It is unknown why the physician did not request high flow oxygen for the hypoxemic Resident when the oxygen saturation was known at 78%, and high flow oxygen masks and supplies were available for use in the facility.Hospital records were requested and supplied. Review of those records indicated that the Resident improved only slightly in the hospital with intravenous [IV] blood pressure increasing medications [Levophed], body temperature increasing Bair Hugger apparatus, IV fluids, and high flow oxygen via nasal cannula, as the mask was removed. The hospital records further indicated that the family was at bedside and stated that the Resident had an altered level of consciousness on Friday when admitted to the nursing facility and had remained so during the 3 day stay there. The [AGE] year-old Resident had been admitted to the nursing facility after a heart attack and severe hyponatremia for which she was initially hospitalized . Hospital records on 6-29-26 go on to diagnose the Resident with hypomagnesemia, altered mental status, hypotension, hypothermia, non ST elevated Myocardial infarction [NSTEMI Heart attack], and shock.Doctors notes described Pressor requirements have gone up significantly in the past 3 hours, Patient has demand [heart] [loss of blood flow to heart tissue] ischemia, acute hypoxic respiratory failure, mild pulmonary edema, oxygen saturation with high flow oxygen fell to a low of 64%, metabolic and lactic acidosis, and the physician told the family the Resident appears to be actively dying.On 6-29-26 after the Resident was stabilized in the community hospital, she was then transferred to a larger hospital for further treatment and care as the community hospital was full and on diversion The Administrator and Director of Nursing [DON] stated education would be provided again to staff as a reminder of the oxygen order process and to improve skills for providing pulmonary resuscitation and oxygen support even when CPR compression is not warranted. At the end of day debrief on 7-10-26 the Administrator and DON were made aware of findings and stated they had nothing further to provide.

Based on interview clinical record review and facility documentation the facility staff failed to provide emergency dental services for 1 Resident (#1) in a survey sample of 9 Residents. The findings included For Resident #1 the facility failed to provide emergency dental services to replace denture lost at the facility, and subsequently changed her diet to chopped to accommodate the missing bottom denture. On 7/31/23, a review of the clinical record revealed that Resident #1 was admitted to the facility with a top and bottom denture in place. According to the Admission Assessment the Resident had upper and lower denture and wears all the time. Also, on an assessment dated [DATE] the diet was listed as, Regular diet, regular consistency, regular thin liquids. Swallowing problem? No. A review of the Physician orders revealed that on 3/24/23 at 5:57 PM the diet order was changed as follows: Regular diet, Mechanical Chopped texture, Regular/Thin consistency for family request; no denture The following is an excerpt from the nutritionist notes dated 3/29/23 at 7:43 AM.: Diet: Regular diet, Mechanical Chopped texture, Regular/Thin consistency, per family request d/t no denture. A review of the progress notes revealed the following excerpt from the nurse practitioner note on 3/31/23: Denture Use: Meats changed to minced to help with chewing due to loss of denture. On 7/31/23 at approximately 11:00 AM, an interview was conducted with the DON who stated she was unaware of the denture being missing until after the Resident was discharged and the family contacted the DON via email. When asked if the physician orders reflect the change in diet by the dietician due to not having the denture would that indicate that someone on staff knew the denture was missing, she stated it would. On 8/1/23 during the end of day meeting the Administrator was made aware of the findings and no further information was provided

Based on interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene, for 1 Resident (#1) in a survey sample of 9 Residents. The findings included: For Resident #1 the facility failed to provide adequate hygiene and incontinent care. Resident #1 was a Resident at the facility from 3/22/23 until 4/20/23, she was at the facility for rehabilitation after a post fall fractured hip. Resident #1 had a BIMS (Brief Interview of Mental Status) score of 3 out of a possible 15 indicating severe cognitive impairment. A review of the Clinical record revealed that Resident #1 was incontinent of bowel and bladder. A review of the ADL (Activity of Daily Living) sheets in the POC (Point of Care) system revealed that Resident #1 was not charted or documented on by CNA's from 03/22/23 until 3/27/23. On 8/01/23 at 10 AM, an interview was conducted with the DON who was asked when a Resident is admitted how long is it before the care is documented in POC (Point of Care the CNA documentation system), the DON stated that it should not take more than the time it takes to get the admission completed . When asked would that be 24 hours? She stated that it would not even be that long. A review of the ADL sheets for March revealed the following: Personal Hygiene - 3/28/22 - 11 pm-7 am was marked N/A. On 3/29/23 - 3 pm -11 pm & 11 pm -7 am were marked N/A. For April 2023 - 3 pm -11 pm was marked N/A = 4 times and 11 pm -7 am shift was marked N/A =16 times On 8/1/23 at approximately 11:00 AM an interview was conducted with CNA B who stated that N/A would mean they didn't have to provide that type of care. When asked do you provide personal hygiene if a resident is incontinent has dementia and has a hip fracture CNA B stated that they would most probably need assistance if they had both of those issues. She further stated, Even if they don't need to be changed you still have to check on them so if you put N/A it's like saying didn't need to check them. On 8/1/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to report an allegation of abuse to Adult Protective Services for 1 of 2 allegations of abuse reviewed. The findings included: For two Residents involved in an altercation resulting in one of the Residents being slapped in the face, the facility staff failed to report the incident of abuse to adult protective services. On 8/1/23, the survey team reviewed facility records with regards to Resident allegations of abuse and/or neglect. During this review, it was noted that on 6/26/23, there was an incident involving two Residents which resulted in one of the Residents slapping the other in the face. The facility provided a form that was completed with regards to the incident and an excerpt from the document read, If applicable, date notification provided to: APS: N/A [adult protective services: not applicable]. On the afternoon of 8/1/23, an interview was conducted with the facility Administrator. The Administrator stated that all allegations of abuse are to be reported to adult protective services. When asked why this wasn't done in the instance on 6/26/23, the Administrator stated he wasn't employed at the facility at the time and couldn't answer why it was not done. The Administrator further acknowledged that it should have been reported. The facility policy titled, Abuse Investigating and Reporting was received and reviewed. This policy read, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies . An additional facility policy titled; Abuse was provided to the survey team. This policy read, . 5. Investigation: Designated staff will immediately review and investigate all allegations or observations of abuse. a. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law . On 8/15/23, during end of day meeting the facility Administrator and Director of Nursing were made aware of the findings. No further information was received.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store medications in accordance with currently accepted professional principles in 1 of 1 medication room inspected. The findings included: 1. The facility staff failed to ensure medications and supplies stored in the medication room were not expired in 1 of 1 medication rooms inspected. On [DATE] at 10:22 AM, the medication room on the Dogwood unit was inspected in the presence of LPN F. The following items were noted to be available for facility staff's use and were expired: Vacuette Safety Blood collection set + Luer Adapter. Four (4) boxes, 50 count each for a total of 200, were all noted to be expired. The various expiration dates on each box were: [DATE], [DATE], [DATE], and [DATE]. Mantacc: Miraclean Technology Co. Disposable sampling swab, 7 of 7 on-hand were expired. with an expiration date of [DATE]. There was a single BD Bactec Lytic/10 anaerobic culture vial, 40 ml, that expired [DATE], There was a single BD Bactec plus aerobic culture vial, which expired [DATE]. In the fridge, within the medication room, there was a vial of Tuberculin Purified Protein Derivative, 5 TU/0.1 mL, that had on the box that it was opened [DATE]. The box read, Once entered, vial should be discarded after 30 days. LPN F confirmed all the above findings and expiration dates and removed each of the expired items from the medication storage room. On [DATE] at 11:24 AM, an interview was conducted with the facility's Director of Nursing (DON). The DON said that she has facility management check the medication carts weekly and the medication room monthly to ensure expired items are not available for use. A review was conducted of the facility policy titled, Medication Storage. This policy read, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . On [DATE] at 11:30 AM, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, staff interview, resident interview and clinical record review, the facility staff failed to provide respiratory care consistent with professional standards of practice for one Resident (Resident # 53) in a survey sample of 31 residents. Findings included: On initial tour on 3/13/2023 at 7:45 a.m., on Resident # 53's nightstand, a plastic bag with CPAP (Continuous Positive Airway Pressure) tubing and mask inside were observed with the date 2-6-23 on the outside of the bag. Resident # 91 was asked what was in the plastic bag. Resident # 53 stated it was her CPAP. When asked how often the CPAP was used, Resident # 91 stated she used it every night. Resident # 91 also stated If I don't use it, I won't be able to sleep Review of the clinical record revealed an order for BiPAP. The order read: (Bi-level Positive Airway Pressure) BI-PAP - WHILE SLEEPING WITH THE FOLLOWING SETTINGS: USE HOME SETTINGS at bedtime for AIRWAY PATENCY/ COPD OSA (Chronic Obstructive Pulmonary Disease/Obstructive Sleep Apnea). On 3/15/2023 at approximately 3:10 p.m., the Director of Nursing went to the room with the surveyor and observed the date of 2-6-23. The Director of Nursing stated the mask and tubing should be changed weekly and the date on the plastic bag should have the date it was changed. A copy of the Facility's Oxygen Administration Policy was requested and received Review of the facility's Oxygen Administration-CPAP/BiPAP Guidance policy revealed no documentation that the mask and tubing should be changed weekly. On 3/16/2023 at 1:00 p.m., an interview was conducted with Licensed Practical Nurse B who stated tubing and masks should be changed weekly. Licensed Practical Nurse B stated it was important due to infection control concerns. During the end of day debriefing on 3/15/2023 and 3/16/2023, the Administrator and Director of Nursing were informed of the findings. The Director of Nursing again stated the tubing should be changed weekly and dated. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to care for Residents with dignity and respect for 1 Resident (#3) in a survey sample of 31 Residents. The findings include: For Resident #3 the facility staff failed to cover the urine drainage system bag. On 3/14/23 the following observations were made: 8:45 AM, Resident was observed in his room, the door was open, and the Resident privacy curtain was open. Resident #3 was in bed, urine drainage system bag (Foley bag) was uncovered and attached to the side of the bed visible from the hallway. 11:45 AM, Resident #3 was observed in his room sitting up in the wheelchair urine drainage bag uncovered and hanging on side of the wheelchair. On 3/14/23 at 12:15 PM, an interview was conducted with Resident #3 who stated that A lot of times they forget to put the cover over the drainage bag. On 3/14/23 at 12:00 PM, an interview was conducted with CNA B who stated that the Foley bag should have a dignity bag to cover it even if they are in their room. On 3/15/23 an interview was conducted with LPN D who stated that the CNA's should cover the Foley bag when they are providing care and emptying the bag. On 3/15/23 a review of the care plan revealed the following interventions for Resident #3's urine drainage system: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 03/10/2021 Revision on: 06/03/2022 Check tubing for kinks each shift. Date Initiated: 03/10/2021 Revision on: 03/10/2021 Dignity bag to cover drainage bag contents Date Initiated: 06/03/2022 CNA Catheter care Q shift and PRN Date Initiated: 06/03/2022. On 3/16/22 at approximately 11:00 AM, an interview was a conducted with the DON who stated it was the expectation that the Foley bags are covered. On 3/16/23 the Administrator was made aware of the concerns and no further information was provided

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to follow standards of nursing practice for 2 Residents (Resident #70 & #19) in a survey sample of 31 Residents. The findings included: 1. For Resident #70, the facility staff failed to administer medications, that were available for administration, as ordered by the physician. On 3/14/23 at 7:47 AM, LPN C was observed during medication administration of Resident #70's medication. LPN C administered the following medications to Resident #70, Eliquis/Apixaban, Losartan, Tamsulosin/Flomax, Miralax, Thiamin Mononitrate, multiple vitamin, and Levetiracetam/Keppra. Prednisone and Ativan were not administered to the Resident. Review of the clinical record of Resident #70 was conducted. This review revealed Resident #70 had physician orders dated 3/14/23, that read, Prednisone Tablet- Give 40 mg by mouth one time a day for pain for 7 Days and an order that read, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth two times a day for anxiety for 5 Days. Review of the clinical record/medication administration record revealed that LPN C had marked a 9 for the administration of the prednisone and Ativan. The legend on the medication administration record indicated the following, 9=Other / See Progress Notes. Review of the progress notes revealed that an entry had been made into the nursing notes by LPN C that read, med on order. On 3/14/23 at 10:39 AM, an interview was conducted with LPN C. Surveyor F indicated that a physician order for prednisone and Ativan had been noted and these medications were not observed to be administered. LPN C confirmed they were not administered and said, it's still on order, it was ordered yesterday, I put in that it was on order. LPN C was asked what the process is when medications are not available. LPN C stated, depending on how long it has gone without coming we would call the pharmacy to see what the ETA [estimated time of arrival] is. LPN C confirmed she had not called the pharmacy to follow-up at this time. On 3/16/23 at 10:03 AM, another interview was conducted with LPN C. LPN C was asked when the Omnicell can be used, LPN C said, You can use the Omnicell at any time. When asked why she had not accessed the prednisone and Ativan for Resident #70 from the Omnicell on 3/14/23, LPN C said, When I saw in the computer it was on order, I was assuming it would come that morning. I did access it that evening once I was made aware for the evening dose of Ativan. LPN C confirmed she had not notified the doctor of the doses not administered. During the above call, Surveyor F explained that Resident #70's order for the prednisone was for 7 days and was noted on the MAR as being available to be administered 3/14/23-3/20/23, since he missed doses on 3/14 and 3/15, he would only receive 5 days vs. the ordered 7 days. LPN C said, We can get the doctor to extend the order, they are here today so I will take care of that. The facility had an Omnicell (dispensing system of on-hand medications available for administration) on-site. A listing of the Omnicell contents was provided to the survey team. Review of this document revealed that five (5) tablets of Prednisone 20mg were available in the Omnicell for administration. Additionally, nine (9) tablets of Lorazepam/Ativan 0.5mg were available in the Omnicell and available for administration. On 3/16/23 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected the nursing staff to check to see if medications are available for administration in the Omnicell anytime they find something not on the medication cart while administering medications. If not available in the Omnicell, then she would expect them to call the pharmacy to let them know the medication is needed and then notify the doctor for further orders/direction. Review of the facility policy titled; Administration Procedures for All Medications was conducted. This policy read, .III. 5 Rights (at a minimum). At a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. Check the MAR/TAR [medication administration record/treatment administration record] for the order .IV. Administration .13. Notify the attending physician and/or prescriber of: . b. Held medications . The facility policy titled; Electronic Interim Box was reviewed. This policy read, The provider pharmacy will utilize an electronic interim box (i.e.Omnicell .) to provide an interim supply of medications for use in emergency and non-emergency dosing for nursing facility residents until the pharmacy is able to provide a regular supply of medication to the nursing facility resident . On 3/16/23 at 11:30 AM, the Administrator and Director of Nursing (DON) were made aware of the above findings. No additional information was provided. 40026 2. For Resident #19 the facility staff administered Tylenol two times without documenting it in the MAR (Medication Administration Record). On 3/15/23 at 1:00 PM, during clinical record review it was discovered the Resident #19 was found on the floor on 12/22/22 at 2:30 PM and was medicated for headache twice with Tylenol. A review of the progress notes read: 12/22/22 3PM - Patient c/o (complaining of) headache since morning Tylenol were given and c/o headache after the fall Tylenol were given second dose. No sign of bruise and any bump on the head. On 3/15/23 3:00 PM, a review of the MAR revealed that no initials were present to indicate administration of Tylenol given on that day. On 3/16/23 at approximately 10:00 AM, an interview was conducted with LPN D who stated that all medications should be signed out on the MAR when given. When asked the danger of not signing off medications she stated that another nurse or the physician will not know if a medication was received or not. On 3/16/23 at approximately 1:00 PM, an interview was conducted with the DON who was asked the expectation of nurses when administering medications, she stated that rights of medication administration should be followed and that medications should be signed off after administering the medication. When asked why this is and she stated if you sign medications off before you give them hand and the Resident does not take them the MAR will not be accurate. If you give the medications without signing it off on the MAR, no one will know the meds have been given. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On 3/16/23 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to provide routine drugs and biologicals to meet the needs of 1 Resident (#19) in a survey sample of 31 Residents. The findings included: For Resident # 19 the facility staff failed to obtain and administer Marinol (a cannabis derivative used for appetite stimulation as well as for nausea), causing Resident #19 to miss 7 doses of her ordered medication. On 3/15/23, during a clinical record review, it was found that Resident #19 had issues with weight loss. The Resident had been followed by the Dietician and the Nurse Practitioner for this issue. A review of the NP notes revealed that on 12/21/22, the Nurse Practitioner saw Resident #19 due to weight loss. This Resident had been ordered supplements prior to this date and continued to lose weight. The NP prescribed Marinol 2.5 mg before lunch and before dinner for appetite stimulation. On 3/15/23 during clinical a review of the progress notes the following notes were found regarding the order for Marinol 2.5 mg: 12/22/22 at 8:58 AM -Not given wait for pharm. 12/22/22 at 4:54 PM - Med unavailable. 12/24/22 at 3:32 PM - Not on hand 12/25/22 at 12:08 PM - On order 12/25/22 at 7:21 PM - Med on order 12/26/22 at 12:21 PM - Med on back order from pharm. NP/RP aware med being delivered today. 12/26/22 at 4:34 PM - Unavailable. On 3/15/23 at approximately 1:30 PM, an interview was conducted with LPN C who stated that if meds were not available the nurse was supposed to check the stat box if it is not in there then call the pharmacy, and find out when it will be available. Then call the Nurse Practitioner or MD and let them know it's not available and ask if there is something else they would like to try until the medication becomes available. A review of the clinical record documented notification of NP / RP one time out of 7 missed doses of medication. On 3/16/23 at approximately 11:30 AM, an interview was conducted with the DON who stated that it is the expectation that nurses document any medications that are unavailable, call the pharmacy to see if it can come on the next run, call the MD ask if they want to substitute the med, and notify the Resident or the Resident Representative. On 3/16/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review, and facility documentation, the facility staff failed to immediately notify the resident representative when there was a significant change in the Resident's condition for 1 Resident (#375) in a survey sample of 31 Residents. The findings included: For Resident #375 the facility staff failed to immediately notify the Resident Representative when Resident #375 tested COVID positive. On 3/15/23 at 3:00 PM, a review of the clinical record revealed that Resident #375 was seen by the Nurse Practitioner (NP) on 2/22/23 and a COVID test was ordered due to cough and respiratory symptoms. The clinical record contained a document entitled Covid 19 Rapid Test Site Result Data Form, excerpts are as follows: Lab Result Information Date Specimen Collected: 2-22-23 Specimen Source: Nares Performing Facility: [name redacted] Test Type: Rapid. Test Result Date: 2-22-23 Result (circle): Negative Patient is informed of results: Yes. Ordering Provider [ name redacted.] Comments: RR made aware. A review of the progress notes revealed Resident #375 continued to have respiratory symptoms and was subsequently retested for COVID on 2/24/23 excerpts from Covid 19 Rapid Test Site Result Data Form, are as follows: Lab Result Information Date Specimen Collected: 2-24-23 Specimen Source: Nares Performing Facility: [name redacted] Test Type: Rapid. Test Result Date: 2-24-23 @ 1700 Result (circle): Positive Patient is informed of results: [this section left blank]. Ordering Provider [ name redacted] Comments: [comments section left blank] A review of the clinical record revealed a document entitled SNF / NF to Hospital Transfer Form, excerpts are as follows: Page 1 Resident Representative: [name redacted] Tel. [phone number redacted] Notified of transfer? Yes Aware of clinical situation? Yes A review of the Transfer Form revealed that nowhere on the form did it state the Resident's COVID positive Status. The SNF/NF Transfer to Hospital Form under the section entitled Respiratory, there is no mention of Oxygen, under the section for Isolation Precautions, the box is checked yes. The box for Multiple Drug Resistant Organism, is checked no and the space for other communicable diseases, was left blank. Excerpts from the progress notes are as follows: 2/24/23 at 1:33 PM - Resident not herself today. She refuses to eat and will open eyes when trying to arouse her but will not talk. VS [vital signs] 150/71 [blood pressure] 59, [pulse], 19[Respirations] 93% [oxygen saturation]. RR [Resident Representative] and NP [Nurse Practitioner] notified. 2/24/23 3:30 PM -Resident O2 stats [sic] [oxygen saturation] 79% on 2 liters oxygen bumped O2 up to 3 liters with no improvement. Spoke with on call Verbal order for Stat X-ray and Duo Neb treatment and place resident on 5 liters. 2/24/23 3:50 PM- upon finish neb treatment resident O2 stats [sic] are at 92% on 5 liters. 2/24/23 17:02 Resident sent to the ER for SOB and Low 02 saturation per on call physician [name redacted]. RP (Responsible Party) [RP name redacted] notified. NOTE: there is no mention of informing the RP of COVID Positive status. A review of the SBAR (Situation- Background-Appearance- Review) form sent to the MD the Resident COVID status did not appear on the form. The on-call physician gave an order to send to the ER. According to the SBAR the Resident was transported to theER on [DATE] at 5:24 PM. 2/24/23 at 5:36 PM - Verbal orders from NP Duo neb Q 6 for wheezing and SOB (shortness of breath) Stat chest X ray, Pensioned 40 mg now and every day for 5 days, Paxlovid 300/100 BID x 5 days for Covid. A review of the facility Covid policy revealed: 7. Procedure when COVID-19 is suspected or confirmed: a. Notify physician, Director of Nursing, Infection Preventionist, and family. On 3/16/23 at approximately 2:00 PM, an interview was conducted with the DON who stated that she could not provide any documentation that showed the Resident's Representative was notified of Resident #375's COVID positive status. On 3/16/23 during the end of day meeting the Administrator was made aware of the concerns and no further documentation was provided.

Based on staff interview and clinical record review, the facility staff failed to review and revise the care plan for 2 (Resident #19 & #3) of 31 sampled residents. The findings include: 1. For Resident #19 the facility staff failed to review and revise the care plan after each fall. On 3/15/23 a review of the clinical record revealed that Resident #19 had post fall Morse Fall Risk Assessments on 2 occasions, 3/16/22 and again on 12/22/22. The Resident scored a 55 on both assessments. (Please note a score > 45 is high fall risk) A review of the care plan read: FOCUS [Resident #19 name redacted] has a diagnosis of Parkinson's, dementia, Bipolar, anxiety, MDD [major depressive disorder] and osteoporosis. She utilizes assistance with ADL, exhibits with incontinence and utilizes antidepressants. date initiated 9/26/22. revision 12/23/22 Fall 12/22 GOAL Resident will be free of falls through the review date initiated 9/26/22 revision on 9/27/22 Target date 5/7/23. Interventions MD / NP to evaluate medications date initiated 12/23/22. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance date initiated 9/26/22. Anticipate and meet the resident's needs date initiated 9/26/22. Follow Facility fall protocol 9/26/22. On 3/16/23 at 10:45 AM, an interview was conducted with LPN B (unit manager) who stated that care plans are used to let staff know how to care for each Resident. When asked how often they should be updated she stated quarterly and with any changes. When asked who updates the care plans, she stated that the MDS Nurse updates them. When asked if a fall should be listed on the care plan, she stated that it should. When asked what else should be on the care plan when a resident has a fall, she stated the care plan should show the new interventions for that fall. On 3/16/23 at 11:00 AM, an interview was conducted with the DON who stated that care plans are updated quarterly and with any changes that affect the care of the Resident. When asked if falls should be included, she stated that they should. When asked if new interventions should be added with each fall, she stated that they should. When asked to review the Residents care plan and show where the interventions were for the fall on 3/16/22 she stated there were not interventions added after that fall. A review of the care plan policy read: 16. The care planning / Interdisciplinary Team is responsible for the review and updating of care plans: a. When requested by the resident / resident representative b. When there has been a significant change in the resident's condition c. When the desired outcome is not met; d. When goals, needs and preferences change? e. When the resident has been readmitted to the facility from a hospital stay f. At least quarterly and after each OBRA and MDS assessment. On 3/16/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #3 the facility staff failed to review and revise the care plan to include the re-opening of a pressure ulcer. On 3/14/23 at approximately 2:00 PM, an interview was conducted with Resident #3 who stated that he has a pressure ulcer to the left ankle. Resident #3 stated that it was healed up in January 2023 however, it has reopened now. The Resident stated that when the wound healed, he switched from wearing the cushion boots. to his regular shoes. He stated that he is quadriplegic and cannot feel his legs, so he was not aware that his foot was rubbing against the wheelchair. He stated that the wound is now infected, and he is taking antibiotics for it. He stated that he started taking Doxycycline for a staph infection in the wound. A review of the wound care doctor's notes on 1/3/23 stated that the left ankle wound was resolved. A review of the progress notes revealed a Nurse Practitioner note that read: 3/1/23 at 12:00 AM - The patient is a long-term care resident of [facility name redacted]. Patient seen today by nursing request for complaint of left ankle swelling and wound. Nursing staff reports patient's ankle had healed well and patient begin wearing shoes instead of cushion boot. Patient denies any injury. Staff concerned patient's ankle may be rubbing against wheelchair causing friction. At this time left lateral ankle wound with erythematous wound bed surrounding maceration. Ordered consult with wound care specialist and wound culture. Patient to continue wearing cushion [sic] boot at this time to minimize pressure. Continue wound care orders. A review of the physician orders revealed: Doxycycline Hyclate Tablet 100 MG (milligrams) Give 1 tablet by mouth two times a day for staph infection for 10 Days. The Doxycycline was started on 3/14/23 at 6:00 AM. A review of the care plan for Resident #3 read: FOCUS: The resident has potential/actual impairment to skin integrity r/t decreased mobility Date Initiated: 06/03/2022 Revision on: 09/08/2022. GOAL: The resident will have no complications r/t ankle wound through the review date. Date Initiated: 06/03/2022 Revision on: 09/08/2022 Target Date: 02/23/2023. INTERVENTIONS: Follow facility protocols for treatment of injury. Date Initiated: 06/03/2022. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Date Initiated: 06/03/2022. On 3/16/23 at 10:45 AM, an interview was conducted with LPN B (unit manager) who stated that care plans are used to let anyone know how to care for each Resident. When asked how often they should be updated she stated quarterly and with any changes. When asked who updates the care plans, she stated that the MDS Nurse updates them. When asked if wounds should be addressed on the care plan she stated that they should. On 3/16/23 at 11:00 AM, an interview was conducted with the DON who stated that care plans are updated quarterly and with any changes that affect the care of the Resident. When asked if wounds and wound care should be included, she stated that they should. A review of the care plan policy read: 16. The care planning / Interdisciplinary Team is responsible for the review and updating of care plans: a. When requested by the resident / resident representative b. When there has been a significant change in the resident's condition c. When the desired outcome is not met; d. When goals, needs and preferences change e. When the resident has been readmitted to the facility from a hospital stay f. At least quarterly and after each OBRA and MDS assessment. On 3/16/23 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure three Residents (Resident #3, #7 and #11) in a survey sample of 19 Residents were free from significant medication error. 1. For Resident #3, the facility staff failed to administer [MEDICATION NAME], a medication administered to treat hypertension, resulting in hospitalization . 2. For Resident #7, the facility staff failed to administer Losartan (a medication for hypertension) for three days. 3. For Resident #11, the facility staff failed to administered a 0.4-milliliter injection of [MEDICATION NAME] (a medication used to prevent blood clots) every 72 hours. The findings included: Resident #3, an [AGE] year old female was initially admitted to the facility 9/25/09 and readmitted after a hospitalization , 11/13/11. Her [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/18/11 was coded as an admission assessment. Resident #3 was coded as having short and long term memory deficits and required moderate assistance in making daily life decisions. Resident #3 was coded as requiring total physical assistance with her activities of daily living. Resident #3 was observed sitting in the dining room beginning her breakfast, 1/11/12 at 8:45 a.m. She was sitting in her wheelchair with a personal alarm in place. Resident #3 was alert however only verbalized a few words and sounds. She was appropriately dressed. Documentation revealed Resident #3 fell [DATE] forward from her wheelchair. She was transported to the emergency room for a workup due to shoulder pain and a tremor. Resident #3 had been diagnosed with [REDACTED]. Upon admission to the hospital the CTs (computerized tomography) showed no abnormality. A urinalysis obtained in the ER revealed continued leukocytosis and bacteria in the urine so she was admitted with a [DIAGNOSES REDACTED]. Resident #3 was discharged back to the facility on [DATE]. Her discharge summary included the following medications for Resident #3: [MEDICATION NAME] 200 mg one tablet daily (for irregular heart beat), [MEDICATION NAME] 0.25 mg one tablet twice daily (anxiety), [MEDICATION NAME] 25 mg-200 mg capsule one capsule daily (to prevent blood clots), [MEDICATION NAME] 0.1 mg 2 tablets twice a day (hypertension), [MEDICATION NAME] 1 ml (milliliter) IM (intramuscular) every 30 days, [MEDICATION NAME] 150 mg one tablet twice a day ( GERD), [MEDICATION NAME] 100 mg one tablet twice a day (hypertension), [MEDICATION NAME] 100 mg one capsule at bedtime (constipation), [MEDICATION NAME] sulfate 325 mg one tablet daily ([MEDICAL CONDITION]), [MEDICATION NAME] 25 mg 2 tablets four times daily (hypertension), Human regular insulin per sliding scale (diabetes), [MEDICATION NAME] 20 mg 2 tablets daily, Potassium chloride 20 meq (milliequivalent)/15 ml liquid 7.5 ml daily (supplement), Polyethylene [MEDICATION NAME] 1 packet at bedtime (constipation), Simvastin 20 mg one tablet at bedtime ([MEDICAL CONDITION]), [MEDICATION NAME] LA (long acting) 2 mg 2 capsules daily (urinary incontinence), [MEDICATION NAME] 80 mg 4 tablets daily (hypertension), [MEDICATION NAME] 1 gram IM daily x 3 days (infection). Upon returning to the facility, the staff contacted Resident #3 physician and obtained readmission orders [REDACTED]. Review of the MAR (medication administration record) for 5/4/11 revealed the MAR had been preprinted and included all of the medications on the discharge summary from the hospital and the readmission physician's orders [REDACTED]. and "Duplicate" on the other entry. No nurses' initials were evident that Resident #3 had been administered [MEDICATION NAME] 100 mg from 5/4/11- 5/8/11. Her blood pressures were taken daily as part of her skilled nursing care, no specific physician's order [REDACTED]. Her blood pressures were taken 5/5/11 (after returning from the hospital on [DATE] and the [MEDICATION NAME] was not restarted) The B/P was 151/103 (retaken 108/90). On 5/6/11 Resident #3 began to experience chest pain. An IV was inserted in her hand at the facility and she was transported to the ER via EMS. The ER documentation from that visit included Resident #3's blood pressure was 180/99 with a heart rate of 106, 192/116 with a heart rate of 128, and 161/105 with a heart rate of 125. Resident #3's medication list included "[MEDICATION NAME] tab: 100 milligram(S) PO (by mouth) BID (twice daily)." The "DOCTOR NOTES" included: "old records reviewed pt (patient) unchanged from baseline from past admission." A cardiac workup was done with negative cardiac enzymes. Resident #3 was diagnosed with [REDACTED]. On 5/7/11 her B/P was 173/86 at 6 a.m. and at 10:45 p.m. her B/P was 194/91. On 5/8/11 (the day she was readmitted to the hospital) her B/P was 186/103 at 4 am, the physician was informed and ordered a onetime dose of [MEDICATION NAME], and then was 170/100 at 8:45 a.m. After that, she was sent to the ER. Resident #3 continued to experience tremors, was [MEDICAL CONDITION] (rapid heart rate), and low oxygen saturation rates (the circulating oxygen in her blood was low) so she was transported back to theER on [DATE]. She was admitted with rapid A fib (rapid and irregular heart rate) and [MEDICAL CONDITIONS]. Resident #3 was admitted to the telemetry unit for treatment. Documentation on the admission history and physician for her admission to the hospital on [DATE] revealed, "Apparently there was some confusion regarding her medications and she was not started back on her [MEDICATION NAME] despite the fact that it was ordered at discharge. Returned to the ED (emergency department) on 05/06 with the complaint of chest pain with negative cardiac enzymes at that time but noted to be in some mild [MEDICAL CONDITION] with rapid heart rate. Thinking that she was actually on the [MEDICATION NAME] her medications were not adjusted at that point. While in theER on [DATE], Resident #3's blood pressure was documented as being 194/118 and her heart rate was 110 and irregular. Resident #3 was admitted to the telemetry unit, required venipunctures for blood testing and an IV was inserted to administer medications. The admitting summary included, "The patient is DNR (do not resuscitate). Prognosis is guarded at this time." Resident #3's medications were changed, her condition improved and she was readmitted to the facility 5/12/11. Adm F, a corporate consultant, was informed of the failure of the staff to administer [MEDICATION NAME] to Resident #3 from 5/4-5/8/11 resulting in her hospitalization , 1/11/11 at 11:50 a.m. Adm F related he would investigate and present further information. The administrator, DON, and corporate consultant (Adm B) were informed of the significant medication error for Resident #3 by the failure of the staff to restart Resident #3's [MEDICATION NAME] upon readmission 5/4/11, 1/11/12 at 5:02 p.m. Adm B related she would investigate and present further information. When interviewed, Adm B, the corporate consultant, stated 1/12/12 at 11:50 a.m. the facility had not been aware of the staff's failure to continue Resident #3's [MEDICATION NAME] after her readmission to the facility 5/4/11. Adm B stated, "To my knowledge we were unaware a medication error occurred until this survey." When interviewed regarding the orders faxed to the pharmacy and [MEDICATION NAME] being delivered to the facility, Adm B stated the pharmacy would have delivered the medications but, "I don't know what happened after that..." LPN B, a unit manager, stated 1/12/12 at 11:50 a.m., the nurse would have obtained the orders from the physician. The orders are placed on the MAR and faxed to the pharmacy. LPN B further stated, "Nurses are responsible for taking care of implementing orders." Review of the facility's policy entitled, "Medication Administration," revealed "F. CHECK LABELED DIRECTIONS AGAINST THE "MAR" PRIOR TO GIVING MEDICATION: *Refer to the Medication Administration Record (MAR) to review drugs; verify medication strength, dose, and labeled directions. N. MEDICATION ERROR REPORTING AND MONITORING: *Medications must be given accurately and appropriately for the resident to receive the intended therapeutic effect. *Incorrect administration of certain drugs can result in harmful side effect." Guidance for nursing practice for the administration of medications was included in, "Fundamentals of Nursing 7th Edition, p 336, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]." Same source, p. 699, "The physician, nurse practitioner, or physician's assistant prescribes medications by writing a medication order on a form in the client's medical record. Sometimes they prescribe orders for a medication by talking directly to the nurse or by telephone...When a verbal or telephone order is received, the nurse who took the order writes the complete order or enters it into a computer and then reads it back and receives confirmation from the prescribe to confirm accuracy. " Same source, p. 706, "Responsibility and accountability are other critical thinking attitudes essential to safe medication administration. Accept full accountability and responsibility for all action surrounding the administration of medications. When administering medications to a client, do not assume that the medication that is ordered for the client is the correct medication or the correct dose. Be responsible for knowing that the medication ordered for clients are the correct medications and the correct doses. You are responsible for administering an ordered medication that is knowingly inappropriate." Same source, p. 707, "A medication orders required for every medication you administer to a client...Regardless of how you receive an order, compare the prescribe's written orders with the medication administration record (MAR) when the medication is initially ordered. Verify medication information whenever new MARs are written or distributed or when clients transfer from one nursing unit or health care setting to another. Once you determine that information on the client's MAR is accurate, use the MAR to prepare and administer medications." The administrator, DON, and corporate consultants were informed of Resident #3's significant medication error resulting in harm as evidenced by two hospitalization s (one ER visit and one 4 day stay), 1/12/11 at 11:50 a.m. COMPLAINT DEFICIENCY 2. For Resident #7 the facility staff failed to administer Losartan (a medication for hypertension) for three days. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7 did not have a Minimum Data Set (an assessment protocol) completed because Resident #7 was a new admission. A review of Resident #7's clinical record was conducted during the survey. The review showed a hand written physician order [REDACTED]. The order read that Resident #7 was to get 100-milligrams of "lsoartan (sic)" every day. The review showed a clarification order dated 01/10/2012 that said Resident #7 was to get 100-milligrams of Losartan (not "lsoartan (sic)"). The review also showed discharge orders from the hospital (that were typed) that showed Resident #7 was to get 100-milligrams of Losartan every day. A review of Resident #7's Medication Administration Record was conducted. The review showed Resident #7 did not get Losartan on 01/08/2012, 01/09/2012, and 01/10/2012. The facility administration was informed of the findings during a briefing on 01/11/2012 at approximately 4:36 p.m. During a briefing on 01/12/2012 at approximately 12:30 p.m., the Director of Nursing stated that the 3 p.m. to 11 p.m. shift nurse was supposed to clarify the order but did not. The facility did not present any further information about the findings. 3. For Resident #11, the facility staff administered a 0.4-milliliter injection of [MEDICATION NAME] (a medication used to prevent blood clots because of Resident #11 inability to move due to a left [MEDICAL CONDITION]) two days in a row instead of every 72 hours (i.e. every three days). Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #11 did not have a Minimum Data Set (an assessment protocol) completed because Resident #11 was a new admission. A review of Resident #11's clinical record was conducted during the survey. The review showed a physician order [REDACTED]. A review of Resident #11's discharge orders from the hospital showed Resident #11 received an [MEDICATION NAME] injection on 01/09/2012 at 8:21 a.m. However, a review of Resident #11's Medication Administration Record showed Resident #11 received the [MEDICATION NAME] on 01/11/2012 and 01/12/2012. The facility administration was informed of the findings on 01/12/2012 at approximately 1:15 p.m. The facility did not present any further information about the findings.