Every finding on record at Oakwood Health and Rehab Center

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of six residents in the survey sample (Resident #2).The findings include:Resident #2's closed clinical record did not include two physician progress notes and documented an inaccurate date/time on the resident's discharge summary.Resident #2 (R2) was admitted to the facility with diagnoses that included severe COPD (chronic obstructive pulmonary disease), anemia, non-infectious systemic inflammatory response syndrome, hypomagnesemia, chronic pain, lung nodule, acute and chronic respiratory failure, osteoporosis, emphysema, history of thyrotoxicosis, non-ischemic myocardial injury, anxiety and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact.On 3/17/25 at 3:45 p.m., the nurse practitioner (NP) was interviewed about assessment of R2. The NP stated that he assessed the resident several times during her stay. Review of R2's clinical record revealed one NP progress note on 7/3/25. The clinical record documented R2's discharge summary, describing an emergent transfer to the emergency department, was documented with date/time of 7/8/25 at 1:43 p.m. R2's change in condition and transfer from the facility was listed as 7/8/25 at 10:45 p.m. On 3/18/26 at 9:00 a.m., the director of nursing (DON), regional nurse consultant and administrator were interviewed about R2's clinical record. The DON presented two NP progress notes dated 6/20/25 and 6/30/25 that had not been scanned/uploaded to R2's clinical record. The administrator stated the facility started with new providers in June 2025 and transitioned to a new document system. The administrator stated the NP progress notes dated 6/20/25 and 6/30/25 had not been scanned and uploaded to R2's clinical record. The administrator stated that staff had not realized that the progress notes had not been uploaded to the record.On 3/18/26 at 1:05 p.m., the regional nurse consultant stated the discharge summary on 7/8/25 listed the wrong time. The regional nurse consultant stated the resident was transferred to the hospital on 7/8/25 at 10:45 p.m. The regional nurse consultant stated nursing had documented a note with the incorrect time previously that day and then made a note regarding the correction. The regional nurse consultant stated the NP's note had the incorrect time based upon the nursing note and that the NP did not go back and correct the error. The regional nurse consultant stated the discharge summary date/time should have been corrected or an addendum note made indicating the error.This finding was reviewed with the administrator, DON and regional nurse consultant on 3/18/25 at 1:00 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to complete a thorough investigation of an alleged violation (resident elopement) for one of six residents in the survey sample (Resident #1). The findings include:On 3/17/2026 a review of Resident #1 clinical record was conducted. Resident #1 had a diagnosis of Dementia and the Minimum Data Set (MDS), dated [DATE], assessed Resident #1 with severely impaired cognition. A facility incident form dated 2/11/2025 documented staff witnessed Resident #1 go out the exit door on the evening of 2/11/2025. Staff spreading salt on the sidewalks observed Resident #1 going down the ramp and advised staff in the parking lot. The resident was assisted by staff back into the building and was assessed by nursing with no injuries. The facility's investigation dated 2/19/2025 documented the door alarm was sounding as the resident exited the building and the resident had on a functional wander prevention device at the time of the incident. Review of the facility's investigation of the elopement incident revealed there were no documented witness statement or documented interviews from staff that witnessed or were working at the time of the incident. The investigation included an initial report of the incident and a summary of the investigation findings. On 3/17/2026 at 1:55 PM the administration was interviewed about the investigation of the elopement incident for Resident #1. The Administrator stated that the facility investigation did not include staff member names that witnessed or were working at the time of the incident and that no written statements or interviews were obtained. No statements from staff or other witnesses were documented. The Administrator stated that shortly after Resident #1 was back inside, a phone interview was conducted with the maintenance staff member about the incident. On 3/18/2026 at 9:20 AM the Administrator presented facility policies titled, Elopement/Missing Person and Accidents and Incidents - Investigating and Reporting. The Accidents and Incidents - Investigating and Reporting policy described specific procedures and guidance that is to be included on the Report of Incident/Accident Form. The procedures listed included obtaining the names of witnesses and their accounts of the incident. These findings were reviewed with the administrator and director of nursing on 3/18/26 at 1:00 p.m. with no further information provided.

Based on staff interview and clinical record review, the facility staff failed to develop a baseline care plan for one of 3 residents in the survey sample. Resident #3 (R3) did not have an accurate or timely baseline care plan for immediate care. The Findings Include: Diagnoses for R3 included: Coronary artery disease, end stage renal disease with dialysis (ESRD), hypertension, anxiety, chronic pain, neuropathy, and ischemia. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 10/15/23. R3 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of R3's clinical record indicated R3 was admitted to the facility on [DATE]. The Admission Evaluation was reviewed and documented R3's full assessment was not completed until 10/14/23 (4 days after admission). The baseline care plan (also a part of the Admission Evaluation) was reviewed and did not show that a care plan was initiated for code status, pain, skin integrity, and nutrition. Review of admission orders and diagnoses indicated R3 was a full code, had a history of chronic pain syndrome with long-term opioid use, post-op surgical wounds, and had ESRD requiring a renal diet. On 11/28/23 at 10:40 AM, registered nurses (RN #2 and RN#3, MDS coordinators) were interviewed. RN #2 verbalized that the Admission Evaluation should be completed within 24 hours of admission and what is entered into the evaluation will populate a baseline care plan. Both RN's then reviewed R3's Admission Evaluation and agreed the evaluation was not completed timely and the above mentioned care areas should have been care planned. On 11/28/23 at 11:00 AM, the above information was presented to the administrator, DON and nurse consultant. The administrator reviewed R3's baseline care plan and agreed the areas in question should have been care planned. No other information was presented prior to exit conference on 11/28/23.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure one of twelve residents in the survey sample (Resident #1) was free from a significant medication error. Facility staff entered an erroneous order to administer an 100-unit dose of short-acting insulin with meals, when Resident #1 was intended to get 20 units with meals. Resident #1 (R1) was administered a total of 200 units of short-acting insulin in a 4-hour period based upon this order, leading to life-threatening hypoglycemia (low blood sugar) requiring immediate treatment of the insulin overdose and subsequent hospitalization in the intensive care unit (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency. The findings include: Resident #1 was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a physician's order dated 10/12/23 for insulin lispro [NAME] kwik pen subcutaneous solution pen-injector 100 units/ml (milliliter) with instructions to inject 20 units with meals for treatment of diabetes. R1's clinical record documented a physician's order dated 10/14/23 to discontinue the lispro [NAME] kwik pen 20 units with meals and a new order was entered for lispro insulin injection solution with instructions to inject 100 units subcutaneously with meals. R1's medication administration record (MAR) documented the new order for lispro 100 units with meals was added to the MAR starting on 10/16/23. The October 2023 MAR documented 100 units of lispro insulin was administered to R1 on 10/16/23 at 8:00 a.m. and another 100-unit dose at 12:00 p.m. R1's clinical record included a nursing note dated 10/16/23 at 5:15 p.m. documenting, Cna [certified nurses' aide] came to get nurse because resident skin felt clammy. Nurse checked resident bs [blood sugar] which read 20 [mg/dL]. Nurse tried to administer glucose gel unsuccessfully. Nurse administered 2 vials of glucagon due to bs not increasing with multiple attempts to raise it up. On call was contacted and an order was given to administer Dextrose 5% at 100 ml v/ picc line [via peripherally inserted central catheter]. The decision to send resident out to .[hospital] came when resident 02 [oxygen] level dropped in the 80's. Oxygen was immediately placed on resident .An order was given to send resident to ER [emergency room ]. Resident BS [blood sugar] was up to 261 at the time the rescue came to pick him up . (Sic) R1's medical record revealed a change in condition form/transfer form which documented that R1 was sent to the emergency roiagnom on [DATE] at 5:15 p.m., after developing increased confusion, general weakness, need for increased assistance, and shortness of breath with oxygen saturations ranging from 74% to 84% (normal ranging between 90-100%). This transfer form also documented R1's blood sugar reading at approximately 3:15 p.m. was 21 [mg/dL] but increased as treatments were implemented to 64, 76, 207, and then 261 just prior to transfer to the emergency room . Normal blood sugar levels range between 60 to 99 mg/dL. R1's emergency room note dated 10/16/23-10/17/23 documented that R1 was assessed with Accidental overdose of insulin . and diagnosed with hypoglycemia, encephalopathy in addition to exacerbation of congestive heart failure. The history and physical documented, .arrived from [nursing facility name redacted] where he reportedly . became unresponsive. Glucose was evaluated and found to be in the 20s. He was given dextrose through his central line. He was noted to be hypoxic . patient encephalopathic with hypoglycemia. He was given an amp of dextrose . I was informed that patient was ordered and given 100 units of short acting insulin. After amp of dextrose, repeat glucose in the 50s. He was initiated on D10W [dextrose 10% in water] infusion . R1 was transferred on 10/17/23 to the intensive care unit at a larger hospital facility for treatment of diagnoses that included accidental insulin overdose. The hospital report dated 10/17/23 documented, Per report, he [R1] became unresponsive . Blood sugar was checked and it was found to be quite hypoglycemic in the 20s. He was given D10 [dextrose 10%] and taken to the emergency department . he remained hypoglycemic and was initiated on a D10 infusion. He also was having some respiratory failure requiring a higher level of oxygen supplementation than at his baseline . Per reports he received 100 units of short acting insulin at 0800 [8:00 a.m.] the 46 units of Lantus at 0900 [9:00 a.m.] and an additional 100 units of short acting insulin at 12 PM . Given his severe hypoglycemia he was transferred to [larger hospital facility] and critical care team was asked to admit . He initially required D10 but this has since been discontinued and his glucose levels have been in the normal range . Resident #1's clinical record documented no clinical justification or explanation for changing R1's insulin dose from 20 units to 100 units with each meal. The clinical record documented no evidence any facility staff, including pharmacy or nursing, questioned or attempted to get clarification from the provider or pharmacy prior to administration of the 100-unit doses on 10/16/23. On 10/24/23 at 12:35 p.m., the nurse practitioner (NP - other staff #1) that ordered the 100-unit insulin doses for R1, was interviewed. The NP stated R1 was admitted to the facility on [DATE] with orders for lispro insulin 20 units with each meal with use of insulin pens. The NP stated an insurance review requested the lispro insulin be switched from the insulin pens to vials for cost savings. The NP stated on 10/14/23 she accessed the order entry system in the electronic health record and used a template for the medication that was prefilled with a 100-unit dose twice per day. The NP stated she changed the order to 20 units with each meal. The NP stated when she clicked ok to finalize the order, that the dose reverted back to 100 units instead of the 20 units that she entered. The NP stated she had no intention of changing the resident's insulin dosages. The NP stated she was only attempting to change from the insulin pens to use of insulin in vials. The NP stated after providers entered orders, nursing was required to review/confirm the order before it became active on the MAR. The NP stated, No nurse notified me or asked for a clarification of the order. The NP stated she thought she had entered a 20-unit dose. The NP stated she had never had this issue before with insulin or any other medication. The NP stated there was nothing new about the order entry system. The NP stated the only vial option in the ordering system was for the 100-unit dose. The NP stated when she finalized the order the frequency with meals was retained but again stated the dose reverted back to 100 units. The NP stated she did not realize and did not intend to enter an order for R1 to get an 100-unit dose of insulin. The NP stated she was notified on the afternoon of 10/16/23 that R1 was lethargic, confused and had a blood sugar reading in the 20s. The NP stated glucagon treatment was attempted and then intravenous dextrose was administered, which was what brought the blood sugar up above 200. The NP stated R1 developed respiratory distress with low oxygen saturations, so she ordered the transfer to the emergency room . On 10/24/23 at 2:50 p.m., the administrator, director of nursing (DON), and regional nurse consultant (administration staff #3) were interviewed about the insulin dosing error with R1. The administrator stated she was notified on 10/16/23, corporate was immediately contacted, and the template with the 100-unit dose was removed from the ordering system. The administrator stated there had been no significant medication errors before or since this incident. The DON stated the order changes were prompted by an insurance review requesting change from insulin pens to vials. On 10/24/23 at 3:20 p.m., licensed practical nurse (LPN #1) that administered the two 100-unit doses of insulin to R1 on 10/16/23, was interviewed. LPN #1 stated 10/16/23 was the first day she had cared for R1 and when she saw the order for insulin 100 units with meals, she questioned R1 about insulin doses he had taken in the past. LPN #1 stated the resident stated he had taken 80 to 85 units of insulin with meals prior to his hospitalization . LPN #1 stated the order for 100 units with meals had been confirmed by the unit manager around 3:00 a.m. on 10/16/23 so she thought someone had already reviewed the order. LPN #1 stated she had not worked the weekend and did not know if R1 had something happen that prompted the dose change. Questioned further, LPN #1 stated she had given as much as 60 units of insulin before but never 100 units. LPN #1 stated when R1 told her he had gotten 85 units of insulin before, the 100 units had not seemed that off. So I gave it. LPN #1 stated, In hindsight, I should have followed my instincts . I should have called the doctor. LPN #1 stated she gave the doses on 10/16/23 at 8:00 a.m. and again at 12:00 p.m. with meals as ordered. LPN #1 stated on the afternoon of 10/16/23 around 3:00 p.m., the CNA came to her and stated R1 was clammy and confused. When she assessed R1's blood sugar, LPN #1 stated that it was at 21. LPN #1 stated that R1 was immediately treated with glucose gel, glucagon, intravenous dextrose, and oxygen prior to transferring to the emergency room . LPN #1 stated she had not had problems with the order entry system or with inaccurate orders prior to this incident. On 10/24/23 at 4:30 p.m., the consultant registered pharmacist (Rph - other staff #2) responsible for pharmacy quality assurance (QA) was interviewed about R1's insulin order changing from 20 units to 100 units with meals. The Rph stated no clarification request was initiated by the pharmacist prior to filling this order. The Rph stated in hindsight, the dose was unintentional and probably should have been clarified. The Rph stated while 100 units was . a possible dose, it was not typical to see 100 units of fast-acting insulin ordered for an ongoing time frame, such as 'with meals.' The Rph again stated, There was no clarification of this order by pharmacy. On 10/24/23 at 4:45 p.m., the unit manager (LPN #2) that reviewed and confirmed the insulin order on 10/16/23 was interviewed. LPN #2 stated the nurse practitioner (other staff #1) entered the 100-unit dose order for R1 on 10/14/23. When questioned about the current process, LPN #2 stated when orders were entered, they remained in a pending status until a nurse reviewed/confirmed the order, which then placed it on the MAR. LPN #2 stated she reviewed pending orders in the early morning of 10/16/23 and saw the order for R1's insulin. LPN #2 stated she questioned the order when she saw it and asked the resident about his usual dose of insulin. LPN #2 stated when the resident stated he had previously taken doses in the 80s, she assumed the order was correct. LPN #2 stated, It [100 units] was a high amount and she had never seen a 100-unit dose order in this facility. When questioned further about the 100-units/dose of insulin, LPN #2 stated, No, I did not clarify. I thought it was ok. LPN #2 then stated that in hindsight, she should have confirmed/clarified the order with the NP or on-call provider. On 10/24/23 at 5:00 p.m., the administrator, DON, and regional nurse consultant stated the order entry system was reviewed shortly after the incident and no software or system malfunction had been identified that resulted in entered dosages not saved in the system. On 10/25/23 at 8:15 a.m., the administrator and DON were interviewed again about R1's insulin dosage error. The DON stated expectations for proper medication administration required that the provider enter/transcribe orders accurately into the electronic health record and that the nurses should always question/clarify physician orders, especially concerning insulin. The DON stated their electronic health record had a system for alerts from the pharmacy but there was no alert issued from pharmacy regarding this insulin dose. The DON stated the nurse that confirmed the order (LPN #2) and the nurse that administered the insulin (LPN #1) both questioned the resident about the dose but should have contacted the provider or pharmacy for clarification/confirmation. The DON stated that the nurses .did not question as thoroughly as they should have. The DON stated it was Nursing 101 to question and get clarification from the physician about any questionable order. The administrator and DON stated there had been no previous problems with medication errors from this provider and an audit of their order entry system found no problem with medication doses not being saved as entered. On 10/25/23 at 12:20 p.m., the chief medical director/physician (other staff #3) was interviewed about R1's insulin overdose. The physician stated he had talked with the NP that ordered the insulin and that she had intended to order 20 units with meals and somehow ended up with 100 units ordered. The physician stated the new orders were entered only to switch the method of dosing from insulin pens to vials, describing the error as a transcription mistake. Other staff #3 stated 100 units was not a typical dose for insulin and the dose absolutely should have been questioned. The physician further stated all involved including his provider team, nursing, and pharmacy should have questioned a 100-unit dose of insulin. The physician stated there had been no previous problems with any orders from this or other providers in the facility, adding that he considered this error an isolated event. The physician stated insulin doses were individual and varied depending on the patient's condition but an 100-unit dose definitely should have been questioned. On 10/25/23 at 12:35 p.m., the DON stated she reviewed her records since the last standard survey (July 2023) and there had been no other significant medications errors with any medications in the facility. The facility's policy titled General Guidelines for Medication Administration (revised 08/2020) documented, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . Under guidelines for administration the policy stated, If a dose seems excessive considering the resident's age and condition, or if a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse obtains clarification from the prescriber of [or] the providing pharmacy and documents the clarification in the nursing notes and elsewhere in the medical record as appropriate . On 10/25/23 the administrator stated corrective actions had already been taken in response to R1's insulin error and presented the following plan of correction. The correction plan documented, R1 was administered Insulin Lispro 100 units 10/16/2023 for 0800 [8:00 a.m.] and 1200 [12:00 p.m.] dose. The medication was provided as ordered due to a transcription error. The intended order was Insulin lispro 20 units with meals. R1 was transferred to the hospital where he remains at this time. Correction actions taken in response to the medication error were as follows. -An audit was conducted by the DON of all current residents receiving insulin to ensure proper dosages were ordered with orders verified by the physician/provider. -Order entry template was modified with deletion of insulin template with 100-unit dose. -All residents with orders for short-acting insulin were ordered blood sugar monitoring, if not already in place. -Insulin administration competency was conducted with LPN #1 that administered the 100-unit doses to R1. -Education provided to all licensed nursing staff regarding short and long-acting insulin administration, 5-rights of medication administration, and need to clarify any questionable orders. -QAPI (quality assurance process improvement) meeting conducted on 10/19/23 for continued actions/follow up on the error. The date of compliance was listed as 10/19/23. Staff education and competency completion were verified by the survey team with document review and staff interviews. The template modification was verified in the electronic health record. Additional blood glucose monitoring orders were entered as needed based upon the audit. Ten current diabetic residents were added to the survey sample, resulting in no identified concerns with insulin orders/administration or order clarification. Nurses interviewed from each unit identified no knowledge deficits or problems with the order entry portion of the electronic health record prior to or since the insulin error. After consulting with the state agency supervisory team, immediate jeopardy was identified regarding the inaccurate insulin order for R1 and failure of facility staff to question/clarify the order prior to administration, which indicated a significant medication error. This error resulted in R1 experiencing life-threatening low blood sugar levels and subsequent hospitalization in the intensive care unit for treatment of the insulin overdose. Immediate jeopardy was identified starting on 10/14/23 until 10/19/23. The action plan inplemented by the facility was verified and deemed acceptable with a correction date of 10/19/23. Thus, this deficiency was cited as past non-compliance. The Lippincott Manual of Nursing Practice 11th edition on page 739 describes hypoglycemia as an acute complication of diabetes. This reference documents, .Hypoglycemia (blood glucose [less than or equal to] 70 mg/dL [milligrams per deciliter] occurs because of an imbalance in food, activity, and insulin/oral antidiabetic agent. Blood glucose less than 54 mg/dL is considered serious, clinically important hypoglycemia . This reference lists the normal adult range for fasting blood glucose as 60-99 mg/dL. Page 15 of this reference documents a common departure from standards of care includes following physician's orders that should have been questioned or not followed, such as orders containing medication dosage errors. (1) The Nursing 2022 Drug Handbook on page 794 describes lispro insulin as a rapid-acting insulin used for the treatment of glycemic control in patients with diabetes. Page 797 of this reference documents, Hypoglycemia is the most common adverse reaction. Severe hypoglycemia can cause seizures, and may be life-threatening or fatal .Mild episodes of hypoglycemia may be treated with oral glucose. More severe episodes of hypoglycemia, such as coma, seizure, or neurologic impairment, may be treated with IM [intramuscular] or subcut [subcutaneous] glucagon or concentrated IV [intravenous] glucose . Page 1588 of this reference documents best practices to avoid common drug errors, .Don't rely on the pharmacy computer system to detect all unsafe orders. Before giving a drug, understand the correct indication, dosage, route, and potential adverse effects. Consult the pharmacist if there is any question . (2) These findings were reviewed with the administrator, DON, regional nurse consultant and regional director of operations during a meeting on 10/25/23 at 4:00 p.m. with no further information presented prior to the end of the survey. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019. (2) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of twelve residents in the survey sample (Resident #1). Facility staff failed to clarify with the provider a new order to administer 100 units of short-acting insulin at each meal, when Resident #1 was intended to receive 20 units with meals. Resident #1 received a total of 200 units of short-acting insulin in a 4-hour period leading to life-threatening hypoglycemia, requiring hospitalization in the intensive care unit for treatment of the insulin overdose (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency. The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a physician's order dated 10/12/23 for insulin lispro [NAME] kwik pen subcutaneous solution pen-injector 100 units/ml (milliliter) with instructions to inject 20 units with meals for treatment of diabetes. R1's clinical record documented a physician's order dated 10/14/23 to discontinue the lispro [NAME] kwik pen 20 units with meals and a new order was entered for lispro insulin injection solution with instructions to inject 100 units subcutaneously with meals. R1's medication administration record (MAR) documented the new order for lispro 100 units with meals was added to the MAR starting on 10/16/23. The October 2023 MAR documented 100 units of lispro insulin was administered to R1 on 10/16/23 at 8:00 a.m. and another 100-unit dose at 12:00 p.m. R1's clinical record documented a nursing note dated 10/16/23 at 5:15 p.m. stating, Cna [certified nurses' aide] came to get nurse because resident skin felt clammy. Nurse checked resident bs [blood sugar] which read 20 [mg/dL]. Nurse tried to administer glucose gel unsuccessfully. Nurse administered 2 vials of glucagon due to bs not increasing with multiple attempts to raise it up. On call was contacted and an order was given to administer Dextrose 5% at 100 ml v/ picc line [via peripherally inserted central catheter]. The decision to send resident out to .[hospital] came when resident 02 [oxygen] level dropped in the 80's. Oxygen was immediately placed on resident .An order was given to send resident to ER [emergency room ]. Resident BS [blood sugar] was up to 261 at the time the rescue came to pick him up . (Sic) A change in condition form/transfer form documented R1 was sent to the emergency roiagnom on [DATE] at 5:15 p.m. The transfer form dated 10/16/23 documented that R1 developed increased confusion, general weakness, need for increased assistance, and shortness of breath with oxygen saturations ranging from 74% to 84%. The transfer form documented R1's blood sugar reading at approximately 3:15 p.m. was 21 [mg/dL] and increased as treatments were implemented to 64, 76, 207 and then 261 just prior to transfer to the emergency room . Normal blood sugar range between 60 and 99 mg/dL. R1's emergency room note dated 10/16/23-10/17/23 documented that R1was assessed with Accidental overdose of insulin . and diagnosed with hypoglycemia, encephalopathy in addition to exacerbation of congestive heart failure. The history and physical documented, .arrived from [nursing facility name redacted] where he reportedly .became unresponsive. Glucose was evaluated and found to be in the 20s. He was given dextrose through his central line. He was noted to be hypoxic .patient encephalopathic with hypoglycemia. He was given an amp of dextrose .I was informed that patient was ordered and given 100 units of short acting insulin. After amp of dextrose, repeat glucose in the 50s. He was initiated on D10W [dextrose 10% in water] infusion . R1 was transferred on 10/17/23 to the intensive care unit at a larger hospital facility for treatment of diagnoses that included accidental insulin overdose. The hospitalreport dated 10/17/23 documented, Per report, he [R1] became unresponsive . Blood sugar was checked and it was found to be quite hypoglycemic in the 20s. He was given D10 [dextrose 10%] and taken to the emergency department . he remained hypoglycemic and was initiated on a D10 infusion. He also was having some respiratory failure requiring a higher level of oxygen supplementation than at his baseline . Per reports he received 100 units of short acting insulin at 0800 [8:00 a.m.] the 46 units of Lantus at 0900 [9:00 a.m.] and an additional 100 units of short acting insulin at 12 PM . Given his severe hypoglycemia he was transferred to [larger hospital facility] and critical care team was asked to admit . He initially required D10 but this has since been discontinued and his glucose levels have been in the normal range . Resident #1's clinical record documented no clinical justification or explanation for changing R1's insulin dose from 20 units to 100 units with each meal. The clinical record documented no evidence any facility staff, including pharmacy or nursing, questioned or attempted to get clarification from the provider or pharmacy prior to the administration of the 100-unit doses on 10/16/23. On 10/24/23 at 12:35 p.m., the nurse practitioner (NP - other staff #1) who ordered the 100-unit insulin doses for R1 was interviewed. The NP stated that R1 was admitted to the facility on [DATE] with orders for lispro insulin 20 units with each meal via the use of insulin pens. The NP stated an insurance review requested the lispro insulin be switched from the insulin pens to vials for cost savings. The NP stated on 10/14/23 she accessed the order entry system in the electronic health record and used a template for the medication that was prefilled with a 100-unit dose twice per day. The NP stated she changed the order to 20 units with each meal. The NP stated when she clicked ok to finalize the order, that the dose reverted back to 100 units instead of the 20 units that she entered, which was unnoticed at the time. The NP stated she had no intention of changing R1's insulin dosages. The NP stated she was only attempting to change the method of administration from the insulin pens to use of insulin in vials. The NP stated after providers entered orders, nursing was required to review/confirm the order before it became active on the MAR. The NP stated, No nurse notified me or asked for a clarification of the order. The NP stated she thought she had entered a 20-unit dose. The NP stated she had never had this issue before with insulin or any other medication. The NP stated there was nothing new about the order entry system. The NP stated the only vial option in the ordering system was for the 100-unit dose. The NP stated when she finalized the order the frequency with meals was retained but again stated the dose reverted back to 100 units. The NP stated she did not realize and did not intend to enter or order R1 to get a 100-unit dose of insulin. The NP stated she was notified on the afternoon of 10/16/23 that R1 was lethargic, confused, and had a blood sugar reading in the 20s. The NP stated glucagon was attempted and then intravenous dextrose was administered that brought the blood sugar up above 200. The NP stated that R1 also developed respiratory distress with low oxygen saturations, so she ordered the transfer to the emergency room . On 10/24/23 at 2:50 p.m., the administrator, director of nursing (DON), and regional nurse consultant (administration staff #3) were interviewed about the insulin dosing error with R1. The administrator stated she was notified of the med error on 10/16/23, corporate was immediately contacted, and the template with the 100-unit dose was removed from the ordering system. The administrator stated there had been no significant medication errors before or since this incident. The DON stated the order changes were prompted by an insurance review requesting change from insulin pens to vials. On 10/24/23 at 3:20 p.m., licensed practical nurse (LPN #1) who administered the two 100-unit doses of insulin to R1 on 10/16/23 was interviewed. LPN #1 stated 10/16/23 was the first day she had cared for R1 and when she saw the order for insulin 100 units with meals, she questioned R1 about insulin doses he had taken in the past. LPN #1 stated R1 stated he had taken 80 to 85 units of insulin with meals prior to his hospitalization . LPN #1 stated she had not worked the weekend and did not know if the resident had something happen that prompted the dose change. LPN #1 stated the order for 100 units with meals had been confirmed by the unit manager around 3:00 a.m. on 10/16/23 so she thought someone had already reviewed the order. When questioned further, LPN #1 stated she had given 60 units of insulin before but never 100 units. LPN #1 stated that when R1 told her he had gotten 85 units of insulin before, she did not think it was that off. So I gave it. LPN #1 stated, In hindsight, I should have followed my instincts . I should have called the doctor. LPN #1 stated she gave the doses on 10/16/23 at 8:00 a.m. and again at 12:00 p.m. with meals as ordered. LPN #1 stated on the afternoon of 10/16/23 around 3:00 p.m., the CNA came to her and stated R1 was clammy and confused. When she assessed R1's blood sugar, LPN #1 stated that it was at 21. LPN #1 stated that R1 was immediately treated with glucose gel, glucagon, intravenous dextrose, and oxygen prior to transfer to the emergency room . LPN #1 stated that she had not had problems with the order entry system or with inaccurate orders prior to this incident. On 10/24/23 at 4:30 p.m., the consultant registered pharmacist (Rph - other staff #2) responsible for pharmacy quality assurance (QA) was interviewed about R1's insulin order changing the dosage from 20 units to 100 units with meals. The Rph stated no clarification request was initiated by the pharmacist prior to filling this order. The Rph stated in hindsight, the dose was unintentional and probably should have been clarified. The Rph stated while 100 units was a possible dose, it was not typical to see 100 units of fast-acting insulin ordered for an extended time such as with meals. The Rph stated, There was no clarification of this order by pharmacy. On 10/24/23 at 4:45 p.m., the unit manager (LPN #2) that reviewed and confirmed the insulin order on 10/16/23 was interviewed. LPN #2 stated the nurse practitioner (other staff #1) entered the 100-unit dose order for R1 on 10/14/23. LPN #2 stated when orders were entered, they remained in a pending status until a nurse reviewed/confirmed the order, which then placed it on the MAR. LPN #2 stated she reviewed pending orders in the early morning of 10/16/23 and saw the order for R1's insulin. LPN #2 stated she questioned the order when she saw it and asked the resident about his usual dose of insulin. LPN #2 stated when the resident stated he had previously taken doses in the 80s, she assumed the order was correct. LPN #2 stated, It [100 units] was a high amount and she had never seen a 100-unit/dose insulin order in this facility. LPN #2 stated concerning the 100-unit dose order, No, I did not clarify. I thought it was ok. LPN #2 stated in hindsight she should have confirmed/clarified the order with the NP or on-call provider. On 10/24/23 at 5:00 p.m., the administrator, DON and regional nurse consultant stated the order entry system was reviewed shortly after the incident and no software or system malfunction had been identified that resulted in entered dosages not saved in the system. On 10/25/23 at 8:15 a.m., the administrator and DON were interviewed again about R1's insulin dosage error. The DON stated expectations for proper medication administration required that the provider enter/transcribe orders accurately into the electronic health record and nurses should always question/clarify orders especially concerning insulin. The DON stated their electronic health record had a system for alerts from the pharmacy but there was no alert issued from pharmacy regarding this insulin dose. The DON stated that both the nurse that confirmed the order (LPN #2) and the nurse that administered the insulin (LPN #1) questioned the resident about the insulin dose but should have contacted the provider or pharmacy for clarification/confirmation. The DON stated the nurses did not question as thoroughly as they should have. The DON stated it was Nursing 101 to question and get clarification from the physician about any questionable order. The administrator and DON stated there had been no previous problems with medication errors from this provider and an audit of their order entry system found no problem with medication doses not being saved as entered. On 10/25/23 at 12:20 p.m., the chief medical director/physician (other staff #3) was interviewed about R1's insulin overdose. The physician stated he had talked with the NP that ordered the insulin and that she had intended to order 20 units with meals and somehow ended up with 100 units ordered. The physician stated that the new orders were entered only to switch the method of insulin administration from pens to vials, describing the error as a transcription mistake. The physician stated 100 units was not a typical dose for insulin and the dose absolutely should have been questioned. The physician stated all those involved including his provider team, nursing, and pharmacy should have questioned an 100-unit dose of insulin. The physician stated there had been no previous problems with any orders from this or other providers in the facility, considering this error to be an isolated event. The physician stated insulin doses were individual and varied depending on the patient's condition but an . 100-unit dose definitely should have been questioned. On 10/25/23 at 12:35 p.m., the DON stated she reviewed her records since the last standard survey (July 2023) and there had been no other significant medications errors with any medications in the facility. The facility's policy titled General Guidelines for Medication Administration (revised 08/2020) documented, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . Under guidelines for administration the policy stated, If a dose seems excessive considering the resident's age and condition, or if a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse obtains clarification from the prescriber of [or] the providing pharmacy and documents the clarification in the nursing notes and elsewhere in the medical record as appropriate . On 10/25/23, the administrator stated corrective actions had already been taken in response to R1's insulin error and presented the following plan of correction. The correction plan documented, R1 was administered Insulin Lispro 100 units 10/16/2023 for 0800 [8:00 a.m.] and 1200 [12:00 p.m.] dose. The medication was provided as ordered due to a transcription error. The intended order was Insulin lispro 20 units with meals. R1 was transferred to the hospital where he remains at this time. Correction actions taken in response to the medication error were as follows. -An audit was conducted by the DON of all current residents receiving insulin to ensure proper dosages were ordered with orders verified by the physician/provider. -Order entry template was modified with deletion of insulin template with 100-unit dose. -All residents with orders for short-acting insulin were ordered blood sugar monitoring if not already in place. -Insulin administration competency was conducted with LPN #1 that administered the 100-unit doses to R1. -Education provided to all licensed nursing staff regarding short and long-acting insulin administration, 5-rights of medication administration and need to clarify any questionable orders. -QAPI (quality assurance process improvement) meeting conducted on 10/19/23 for continued actions/follow up on the error. The date of compliance was listed as 10/19/23. Staff education and competency completion were verified by the survey team with document review and staff interviews. The template modification was verified in the electronic health record. Additional blood glucose monitoring orders were entered as needed based upon the audit. Ten current diabetic residents were added to the survey sample with no identified concerns with insulin orders/administration or order clarification. Nurses interviewed from each unit identified no knowledge deficit or problems with the order entry portion of the electronic health record prior to or since the insulin error. After consulting with the state agency supervisory team, immediate jeopardy was identified regarding the inaccurate insulin order for R1 and failure of facility staff to question/clarify the order prior to administration, which indicated a significant medication error. This error resulted in R1 experiencing life-threatening low blood sugar levels and subsequent hospitalization in the intensive care unit for treatment of the insulin overdose. Immediate jeopardy was identified starting on 10/14/23 until 10/19/23. The action plan taken by the facility was verified and deemed acceptable with a correction date of 10/19/23. This deficiency was cited as past non-compliance. The Lippincott Manual of Nursing Practice 11th edition on page 739 describes hypoglycemia as an acute complication of diabetes. This reference documents, .Hypoglycemia (blood glucose [less than or equal to] 70 mg/dL [milligrams per deciliter] occurs because of an imbalance in food, activity, and insulin/oral antidiabetic agent. Blood glucose less than 54 mg/dL is considered serious, clinically important hypoglycemia . This reference lists the normal adult range for fasting blood glucose as 60-99 mg/dL. Page 15 of this reference documents that a common departure from standards of care includes following physician's orders that should have been questioned or not followed, such as orders containing medication dosage errors. (1) The Nursing 2022 Drug Handbook on page 794 describes lispro insulin as a rapid-acting insulin used for the treatment of glycemic control in patients with diabetes. Page 797 of this reference documents, Hypoglycemia is the most common adverse reaction. Severe hypoglycemia can cause seizures, and may be life-threatening or fatal .Mild episodes of hypoglycemia may be treated with oral glucose. More severe episodes of hypoglycemia, such as coma, seizure, or neurologic impairment, may be treated with IM [intramuscular] or subcut [subcutaneous] glucagon or concentrated IV [intravenous] glucose . Page 1588 of this reference documents regarding best practices to avoid common drug errors, .Don't rely on the pharmacy computer system to detect all unsafe orders. Before giving a drug, understand the correct indication, dosage, route, and potential adverse effects. Consult the pharmacist if there is any question . (2) These findings were reviewed with the administrator, DON, regional nurse consultant and regional director of operations during a meeting on 10/25/23 at 4:00 p.m. with no further information presented prior to the end of the survey. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019. (2) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based upon staff interview and clinical record review, the facility staff failed to follow physician orders for one of twelve residents in the survey sample (Resident #1). The findings include: Resident #1's physician order for blood sugar checks before meals and at bedtime were not implemented as ordered for four days. Resident #1 (R1) was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a physician's order with a start date of 10/12/23 for blood sugar checks to be obtained each day before meals and at bedtime. R1's medication administration record (MAR) for October 2023 had no order listed regarding blood sugar checks before meals and at bedtime. Nursing notes documented blood sugar checks on 10/13/23 at 8:00 a.m. and 11:11 a.m., on 10/14/23 at 4:25 p.m., on 10/15/23 at 9:06 a.m., and on 10/16/23 at 9:04 a.m. and 3:29 p.m. There were no other blood sugar checks documented other than those listed in nursing notes and those associated with a change in condition on 10/16/23. On 10/25/23 at 10:30 a.m., the director of nursing (DON) was interviewed about failure to implement R1's routine blood sugar checks as ordered by the physician. The DON stated the order was entered into the electronic health record by a nurse based upon a telephone order from the physician. The DON stated the nurse entering/confirming the order did not mark the order to display on the MAR. The DON stated R1's blood sugar checks were not obtained with the ordered frequency because the order was not displayed on the MAR. This finding was reviewed with the administrator, DON, and regional nurse consultant during a meeting on 10/25/23 at 4:00 p.m.

Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of twelve residents in the survey sample (Resident #1). The findings include: Doses of Resident #1's medications that included IV (intravenous) ampicillin and IV gentamicin were unavailable for administration. Resident #1 (R1) was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented physician orders with start date of 10/12/23 for the following antibiotic medications. Ampicillin sodium intravenous (IV) solution - use 2 grams intravenously every 4 hours for treatment of infection. Gentamicin in saline solution 1-0.9 mg/ml (milligrams/milliliter) - use 40 mg intravenously every 12 hours for 30 days for treatment of infection. R1's medication administration record (MAR) documented the IV ampicillin was not administered as ordered on 10/12/23 at 12:00 a.m., 4:00 a.m. and 8:00 a.m. Nursing notes on 10/12/23 documented the ampicillin was not available to administer and listed the medication as awaiting delivery from pharmacy. R1's MAR documented the IV gentamicin was not administered on 10/13/23 at 9:00 p.m. as ordered because the medication was unavailable. A nursing note dated 10/13/23 documented, Nurse couldn't locate resident Gentamicin to give him is [his] 2100 [9:00 p.m.] dose. Nurse called pharmacy and it was on order. Nurse asked if it could be run stat. Pharmacy stated, 'It would be here in 3 hrs.' . (Sic) On 10/26/23 at 8:00 a.m., the director of nursing (DON) was interviewed about R1's unavailable antibiotic medications. The DON stated the pharmacy was supposed to deliver medications within four hours of order entry, but delivery was not always timely. The DON stated these medications (IV ampicillin and gentamicin) were not part of the emergency/backup medication supply so they had to be delivered from the pharmacy. The DON stated nurses call the pharmacy when these medications are not available, but deliveries were not always timely. This finding was reviewed with the administrator, DON, and regional nurse consultant during a meeting on 10/25/23 at 4:00 p.m. with no other information presented regarding the unavailable medications.

Based on observations, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent potential foodborne illness for 93 out of 94 residents (1 resident was receiving tube feedings). Specifically, the main kitchen freezer was found to have improperly labeled foods in the freezer and three out of four-unit pantry refrigerators were found to be improperly labeled and had expired food items. This failure had the potential to expose residents to expired and/or spoiled food, unknown allergens, and food items that were not in compliance with current dietary orders. Findings include: Review of the undated facility policy titled, Receiving and Storage of Food revealed, Foods shall be received and stored in a manger that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date.) .Food items and snacks kept on the nursing units must be maintained as indicated .a. All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses' station and labeled with a use by date, b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date, c. Refrigerators must have working thermometers and be monitored for temperature, d. Beverages must be dated when opened and discarded after 24 hours, e. Other opened containers must be dated and sealed or covered during storage, f. partially eaten food may not be kept in the refrigerator. Review of the undated facility policy titled Refrigerators and Freezers revealed, The facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation and will observe food expiration guidelines .All food will be appropriately dated to ensure proper rotation by expiration dates .Use by dates may be completed with expiration dates on all prepared food in refrigerator .Expiration dates on unopened food will be observed and use by dates indicated once food is opened .Supervisors/designee will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish dates. A tour of the kitchen on [DATE] at 10:22 AM was conducted with the Food Service Manager (FSM)2. In the main freezer an opened, undated, and unlabeled cake was observed. FSM2 stated that she did not know what the cake was and immediately discarded it. Additionally, an opened, undated, and unlabeled blue plastic bag of unidentified contents was observed. FSM2 stated that they were lima beans and immediately discarded the food item. A tour of the Unit Pantry refrigerators, which was where the residents could store their food from outside and where Food Services provided beverages and small snacks for the residents, was conducted on [DATE] at 8:27 AM, with the corporate Food Service Director (FSD)1 and FSM2. In the refrigerator on the first-floor unit pantry a white plastic bag was observed on the door of the refrigerator. The bag had a resident's name on it (Resident (R) 54) and was dated [DATE]. FSM2 opened the bag which appeared to contain sliced meat and cheese. There was also a bag containing bottled smoothies with R92's name on them and a date of [DATE]. (R92's diet order was nothing by mouth (NPO) at the time of the tour.) The Licensed Practical Nurse (LPN) 1 on the unit stated that the process [when resident's keep food in the refrigerator] is that if family brings in a food item for a resident, it should have a name, date, and room number. On the 2nd floor, observation of the North unit pantry revealed that there was no thermometer in the refrigerator. A Certified Nursing Assistant (CNA) 2 who was near the refrigerator area was immediately interviewed. CNA2 stated, Food that comes in from the residents should be labeled, dated, and have a room number on it. CNA2 stated that it should be three days from when the food item comes in until it is discarded. When questioned, CNA2 did not know where the thermometer was. An observation of the freezer revealed that there was an unlabeled, undated bag of frozen food items in a Walmart bag, with the designation room [ROOM NUMBER] on it. On the 2nd floor South unit pantry, CNA1 stated that when a food item comes in from outside it should be dated and labeled with the resident's room number. CNA1 stated that the 11pm-7am CNA is responsible for doing the temperatures. Observation of the refrigerator revealed the following: 1. an opened, unlabeled, undated 20-ounce container of mayonnaise was observed. CNA1 stated that she didn't know who's that [the mayonnaise] was and that they [the staff] probably just used it if someone [a resident] asked for mayonnaise; 2. an unlabeled, undated 20-ounce container of mustard was observed; 3. an unlabeled, undated 16-ounce container of what looked to be a reddish jar of non-store-bought preserves was observed; 4. an opened, unlabeled, undated 15-ounce bottle of lemon juice was observed; and 6. An unlabeled, undated expired 6-ounce container of yogurt was noted in the door of the refrigerator with a manufacturer's expiration date of [DATE]. Observation of the freezer compartment revealed an unlabeled, undated, one-quart container of ice cream. During the unit pantry tour on [DATE] at 8:43 AM, FSM2 was interviewed. FSM2 revealed that the kitchen was responsible for restocking the soda, pudding, apple sauce, and milk, while the nursing staff was responsible for taking the temperatures in the refrigerator and managing the items that came in from resident family members. FSM2 indicated the sign on the refrigerator that stated Please label resident food items with name and date, place in fridge. Items will be discarded if not labeled and dated. All food items will be discarded after 72 hours.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices regarding hand hygiene during a dressing change for one of twenty-two residents in the survey sample (Resident #25) and on one of two units during the medication pass (unit 2). The findings include: 1. Infection control practices regarding hand hygiene were not followed during a dressing change to Resident #25's foot callous. Resident #25 (R25) was admitted to the facility with diagnoses that included adult failure to thrive, atherosclerotic heart disease, hypertension, chronic kidney disease, dementia, psychotic/mood disturbance, anxiety and thrombocytopenia. The minimum data set (MDS) dated [DATE] assessed R25 with severely impaired cognitive skills. Resident #25's clinical record documented the resident had a callous on the plantar surface of the right foot with a physician's order dated 7/18/23 for Bacitracin and a dry dressing applied to the wound each day shift. On 7/24/23 at 3:25 p.m., registered nurse (RN #3) was observed performing a dressing change to R25's right foot callous. RN #3 washed hands and directly touched the faucet handles when turning off the water and prior to drying her hands with a paper towel. RN #3 then put on clean gloves, removed the soiled dressing from the right foot and discarded it. Without performing hand hygiene or changing gloves, RN #3 applied Bacitracin to the new dressing and applied the clean dressing to the right foot callous. The calloused area was approximately dime sized, flat, intact with pink/red skin surrounding the callous. On 7/24/23 at 3:35 p.m., RN #3 was interviewed about the handwashing and not changing gloves after removing the soiled dressing. RN #3 stated that she forgot and was aware to perform hand hygiene and change gloves after removing an old dressing. 2. RN #3 performed improper hand hygiene during a medication pass observation on unit 2. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89) and Resident #25 (R25). Prior to preparing medications for R89, RN #3 washed her hands and directly touched the faucet handle when turning off water and prior to drying hands with a paper towel. RN #3 then administered medications to R89 and washed hands again, touching the faucet handle prior to drying her hands. RN #3 then prepared and administered medications to R25. RN #3 washed her hands after the medication administration in the same manner, directly touching the faucet handle with a bare hand prior to drying her hands with a paper towel. On 7/25/23 at 8:38 a.m., RN #3 was interviewed about washing hands and then touching the faucet handles. RN #3 stated, Sometimes I forget when I'm rushing. RN #3 stated she was nervous and knew she was noy supposed to touch the faucet handles after washing hands. On 7/26/23 at 8:53 a.m., the licensed practical nurse (LPN #4) responsible for infection prevention programs was interviewed about hand hygiene. LPN #4 stated nurses were not expected to touch faucet handles after washing hands but instead use their elbow or paper towel to turn off the water. LPN #4 stated a glove change and proper hand hygiene were expected after removal of a soiled dressing. LPN #4 stated RN #3 had been educated before about improper hand hygiene. The facility's policy titled Clean Dressing (undated) documented steps for a clean dressing change that included, .Wash and dry your hands thoroughly .Put on clean gloves. Loosen tape and remove soiled dressing .Pull glove over dressing and discard into plastic or biohazard bag .Wash and dry your hands thoroughly .Open, dry, clean dressing .Wash and dry your hands thoroughly .Put on clean gloves .Apply the ordered dressing and secure with tape or bordered dressing per order . The facility's policy titled Hand Hygiene (undated) documented, .This facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene . Procedures for proper handwashing included, .Wet hands and wrist .Apply enough soap to cover all of hand surfaces .Vigorously rub lathered surfaces .for at least 20 seconds .Rinse wrists and hands thoroughly under a stream of running water .Dry hands completely with a clean paper towel .Use dry paper towel to turn faucet off . These findings were reviewed with the administrator and director of nursing during meetings on 7/25/23 at 4:10 a.m. and on 7/26/23 at 12:30 p.m.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed five errors out of forty-one opportunities, resulting in a 12.2% error rate The Findings Include: 1. Resident #2 (R2) was given the wrong dose of Calcium. During a medication pass and pour observation conducted on 7/25/23 at 8:00 AM, license practical nurse (LPN #2) began pulling medications out of the medication cart for R2 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Calcium 600 MG (milligrams) with Vitamin D 5 mcg (micrograms). LPN #1 dispensed the medication into the medication cup and administered to R2. R2's physician's orders were then reviewed to verify accuracy of medications given. There was a physician's order to give Calcium 500 MG/VIT D 400 IU (international units), a combination medication for osteoporosis, which differed from the calcium that had been administered. On 7/25/23 at 11:07 AM, the ADON (assistant director of nursing) discussed the observation findings with this surveyor and verbalized that the wrong dosage of calcium and vitamin D had been given, that the nurse practitioner was made aware, and that the order had been changed to the medication that the pharmacy had delivered. On 7/25/23 at 4:10 PM the above information was presented to the director of nursing (DON) and administrator. No other information was presented prior to exit on 7/12/23. 2. Resident #8 (R #8) was not given Telmisartan 40 MG as ordered (given for hypertension). During a medication pass and pour conducted on 7/25/22 at 8:00 AM, Resident #8 (R #8) was scheduled to receive Telmisartan 40 MG. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #2 then called the pharmacy and relayed the information that the medication would be arriving until later in the day. On 7/25/23 at 10:04 AM, LPN #2 was asked what is the time period for giving a scheduled medication. LPN #2 verbalized a medication can be given an hour before or after the scheduled time. The physician's order for R #8's Telmisartan was reviewed and documented: Telmisartan 40 MG Tablet 10 MG one time a day . dispense 9:00 AM. On 7/25/23 at 10:45 AM, LPN #2 verbalized R #8's medication had arrived. The medication was reviewed for correct medication and dose and was then administered to R #8. On 5/25/23 at 4:10 PM, the above finding was presented to the director of nursing, administrator, and nurse consultant. The DON agreed that medications are to be given within the standard administration range of an hour before or after the scheduled time. No other information was presented prior to exit conference on 7/26/23. 21875 3. Resident #89 (R 89) was given the wrong dose of Paroxetine, Senna instead of Senna with stool softener, and Breo Ellipta was administered but no followed by the mouth rinse. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89). Medications administered to R89 included Paroxetine 20 mg (milligrams), Geri-kot senna 8.6 mg, and Breo Ellipta 200 mcg/25 mcg. R89 did not rinse her mouth after the inhalation of the Breo Ellipta and there was no prompting or request by RN #3 instructing R89 to do so. R89's clinical record documented a physician's order dated 5/11/23 for Paroxetine 30 mg each day for treatment of depression, a physician's order dated 6/8/23 for Senna-Docusate sodium 8.6 mg/50 mg two times per day for constipation, and a physician's order dated 5/15/23 for Breo Ellipta inhalation aerosol powder 200-25 mcg/activation, one puff inhaled orally each day for management of emphysema with instructions to, Rinse mouth after administration to prevent candidiasis [mouth infection]. No physician's order was found for the plain Senna 8.6 mg. On 7/25/23 at 9:11 a.m., RN #3 was interviewed about the medications observed as being administered not as ordered by the physician. RN #3 stated that the Paroxetine was supplied from pharmacy in a 20 mg and 10 tablet to equal the needed 30 mg dose. RN #3 stated that the 10 mg tablet was not available in the medication cart and it was not in the backup supply. RN #3 stated that the senna products were ordered in-house and she was not sure if the senna-docusate sodium product was in the cart. RN #3 stated that she did not think about prompting or instructing the resident to rinse her mouth after the inhaled dose Breo Ellipta powder. The facility's pharmacy information for the medication Breo Ellipta (issue date 7/19/23) documented under instructions for administration, Rinse out mouth after each use. Do not swallow the rinse water. Spit it out . These findings were reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented about the medication errors prior to the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure medication was available for administration for two of four residents during the medication pass and pour observation (Resident #8 and Resident #89). 1. 2. The Findings Include: 1. Resident #8's (R8) Telmisartan 40 milligrams (given for hypertension) was unavailable for administration as ordered by the physician. During a medication pass and pour observation conducted on 7/25/22 at 8:00 AM, Resident #8 (R8) was scheduled to receive Telmisartan 40 MG at 8AM. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #8 then called the pharmacy and relayed that it was stated that the medication would be arriving later in the day. On 7/25/23 at 10:04 AM, LPN #2 was asked when do nurses reorder medications. LPN #2 said that she usually reorders medication when there are 5 pills left to distribute. LPN #2 was then able to look up when the medication was ordered and verbalized that the Telmisartan had been ordered on 7/24/23 (day prior to the medication observation). LPN #2 then reviewed the medication administration record and verbalized that R8 had received the medication on 7/24/23. The physician's order for R8's Telmisartan was reviewed and documented: Telmisartan 40 MG Tablet 10 MG one time a day dispense 9:00 AM. On 5/25/23 at 4:10 PM, the above finding was presented to the director of nursing, administrator, and nurse consultant. A policy titled Ordering and Receiving Non-controlled Medications read in part Reorder medications based on estimated refill date on the pharmacy label, or at least three days in advance, to ensure an adequate supply is on hand. No other information was presented prior to exit conference on 7/26/23. 21875 2. Resident #89's (R 89) Paroxetine 10 milligrams was unavailable for administration as ordered by the physician. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89). Medications administered to R89 included Paroxetine 20 mg (milligrams). RN #3 stated at the time of administration that the 10 mg tablet of Paroxetine was not in the medication cart. Resident #89's clinical record documented a physician's order dated 5/11/23 for Paroxetine 30 mg each day for treatment of depression. On 7/25/23 at 9:11 a.m., RN #3 was interviewed about the unavailable Paroxetine 10 mg for Resident #89. RN #3 stated the Paroxetine was supplied from the pharmacy with a 20 mg and a 10 mg tablet to equal the ordered 30 mg dose. RN #3 stated the Paroxetine 10 mg was not in the medication cart and was not in the backup supply. On 7/25/23 at 9:25 a.m., RN #3 stated that the Paroxetine 10 mg had been reordered on 7/23/23 but had not yet arrived from the pharmacy. RN #3 stated that it typically took two to three days for routine delivery of ordered medications and that Paroxetine was not a medication kept in the backup supply. On 7/25/23 at 1:08 p.m., the director of nursing (DON) was interviewed about the unavailable Paroxetine. The DON stated that nurses were expected to reorder medications three to five days prior to running out in order to maintain a supply. The DON stated that reorders were entered/processed from the computer system. The facility's policy titled Ordering and Receiving Non-Controlled Medications (revised 08/2020) documented, .Medication and related products are received from the pharmacy on a timely basis .Reordering medications is done in accordance with the order and delivery schedule established by the pharmacy provider .Reorder medications based on the estimated refill date ([NAME]) on the pharmacy Rx label, or at least three days in advance, to ensure an adequate supply is on hand . This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented about the unavailable medication prior to the end of the survey.

Based on observation, staff interview, and clinical record review, the facility staff failed to apply a wander prevention device as required in the plan of care for one of twenty-two residents in the survey sample (Resident #25). The findings include: Resident #25 (R25) was admitted to the facility with diagnoses that included adult failure to thrive, atherosclerotic heart disease, hypertension, chronic kidney disease, dementia, psychotic/mood disturbance, anxiety and thrombocytopenia. The minimum data set (MDS) dated [DATE] assessed R25 with severely impaired cognitive skills. R25's comprehensive plan of care (revised 6/20/23) documented that R25 was at risk of wandering/elopement due to disorientation, poor safety awareness, aimless wandering, and a history of attempts to leave the facility. Interventions to maintain safety included, .wander guard on at all times . R25's treatment administration record for July 2023 documented placement of the wander prevention device each shift, and function of the wander prevention device checked daily on the night shift. Resident #25's clinical record documented a physician's order dated 6/14/23 to, Check placement of wander bracelet every shift .Wander bracelet - Check function daily. On 7/25/23 at 8:36 a.m., R25 was observed seated on the bedside. There was no wander prevention device observed on either wrist or ankle. On 7/25/23 at 9:28 a.m., accompanied by certified nurses' aide (CNA) #1, Resident #25 was observed for use of the wandering prevention device. CNA #1, with R25's permission, displayed the resident's wrists and ankles with no wander prevention bracelet observed in use. CNA #1 stated at this time that R25 previously had a Wanderguard device, but she did not know what happened to it. CNA #1 searched R25's walker, wheelchair, beside table, and storage drawers, and then stated that she had not found the device. CNA #1 stated that R25 got up and walked independently with the walker, as well as self-propelling in the wheelchair. On 7/25/23 at 9:34 a.m., the registered nurse (RN #3) caring for R25 was interviewed about the wander prevention device. RN #3 checked R25's clinical record and stated that R25 had a physician's order for a wandering device and that she did not know why the device was not in use. On 7/25/23 at 3:16 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed. LPN #3 stated R25 had a history of exit seeking, increased confusion when he had a urinary tract infection, but had never eloped from the facility. LPN #3 stated that R25 was supposed to have a wander prevention device and at times had attempted to remove the device. LPN #3 stated that prior to today, the wander prevention device had been observed on R25's right wrist. This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no other information presented about the safety device prior to the end of the survey.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty-two residents in the survey sample (Resident #19) The findings include: Resident #19 (R19), assessed with severely impaired vision, had no plan of care regarding blindness/vision impairment. Resident #19 was admitted to the facility with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, hypothyroidism, schizoaffective mood disorder, dysphagia, congestive heart failure, and gastroesophageal reflux disease. The MDS dated [DATE] assessed R19 as cognitively intact and with severely impaired vision. On 7/24/23 at 11:17 a.m., R19 was interviewed about quality of care/life in the facility. R19 stated that she had poor vision and was only able to see shadows. Resident #19 stated that staff assisted her daily with placing items in familiar places and informing her about the location of needed items. Resident #19's MDS dated [DATE] included vision as a triggered concern in the care area assessment summary and was marked that care planning was done regarding visual function. Resident #19's comprehensive plan of care (revised 7/10/23) included no problems, goals and/or interventions regarding the R19's vision impairment. On 7/25/23 at 1:30 p.m., the registered nurse (RN #2) responsible for MDS/care plans was interviewed. RN #2 stated that if a care area triggered on the MDS, the concern should be on the comprehensive plan of care. RN #2 reviewed R19's care plan and stated that there was no plan regarding visual impairment. RN #2 stated, There should be a care plan regarding poor vision. This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented regarding the care plan prior to the end of the survey.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty-two residents in the survey sample (Resident #19). The findings include: Resident 19's annual MDS dated [DATE] failed to accurately assess the resident's dental problems. Resident #19 (R19) was admitted to the facility with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, hypothyroidism, schizoaffective mood disorder, dysphagia, congestive heart failure, and gastroesophageal reflux disease. The MDS dated [DATE] assessed R19 as cognitively intact. On 7/24/23 at 11:12 a.m., R19 was interviewed about quality of care/life in the facility. Resident #19 stated her teeth had been in bad shape for a long time. R19 displayed her teeth, revealing that most of her top teeth were missing and the lower front teeth were broken near the gum line with black/dark discoloration on the teeth surfaces. Several bottom teeth were also missing. Section L0200 of R19's MDS dated [DATE] documented that the resident had no dental problems. This category to indicate obvious or likely cavities or broken natural teeth was not marked. Item Z. was marked indicating R19 had no oral/dental problems. On 7/25/23 at 1:25 p.m., the registered nurse (RN #2) responsible for MDS assessments was interviewed about R19's dental assessment. RN #2 reviewed the 6/23/23 MDS and stated that R19's dental problems were not indicated on the assessment. RN #2 then stated that R19's poor dentition should have been marked/indicated under section L of the MDS. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documents regarding oral/dental assessment, .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m., with no further information presented about the inaccurate MDS prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019.

Based on resident interview, family interview, staff interview, facility policy review and clinical record review, the facility staff failed to offer and/or document pneumococcal immunization status for three of five residents in the survey sample (Residents #3, #4 and #5). The findings include: 1. Resident #4's clinical record documented no evidence that the pneumococcal vaccine was offered, received or refused, as well as no evidence that the resident and/or resident's representative was educated about the benefits and potential side effects of the immunization. Resident #4 was admitted to the facility with diagnoses that included dysphagia, anemia, diabetes, hypertension, schizophrenia, history of COVID-19 and mood disorder. The minimum data set (MDS) dated [DATE] assessed Resident #4 with moderately impaired cognitive skills for daily decision making. Review of Resident #4's clinical record revealed no documentation regarding the resident's pneumococcal immunization status. The pneumococcal vaccination status was not listed under the immunization tab along with the influenza and COVID-19 vaccines. There was no documentation the resident or family had been educated on the benefits and possible side effects of the vaccine. On 2/13/23 at 1:15 p.m., the licensed practical nurse (LPN #1) responsible for tracking vaccinations was interviewed about Resident #4's pneumococcal immunization status. LPN #1 stated that Resident #4's clinical record documented the influenza and COVID-19 vaccinations but not the pneumococcal. LPN #1 stated that the pneumococcal vaccines had been offered to residents, but she had not updated clinical records with the status, education or refusals. On 2/13/23 at 1:25 p.m., Resident #4 was interviewed about her immunization status. Resident #4 stated the facility had previously offered and provided education on all immunizations, but she did not remember when they were discussed. Resident #4 stated, I don't want any of them [vaccines]. On 2/13/23 at 2:10 p.m., the director of nursing (DON) and LPN #1 were interviewed about Resident #4's pneumococcal immunization status. The DON stated she did not know Resident #4's current pneumococcal immunization status. The DON stated that the former assistant director of nursing documented immunizations in a book that was not part of the clinical record, and that she did not know where the book was located. The DON stated immunization status was supposed to be determined upon admission, documented in the clinical record, and updated as needed. LPN #1 stated she had been told to only record influenza and COVID-19 vaccines in the clinical record. This finding was reviewed with the DON and the regional MDS coordinator during a meeting on 2/13/23 at 2:15 p.m. The administrator was out of the facility during the survey. 2. Resident #5's clinical record documented no evidence that the pneumococcal vaccine was offered, received or refused, as well as no evidence that the resident and/or resident's representative was educated about the benefits and potential side effects of the immunization. Resident #5 was admitted to the facility with diagnoses that included gastroenteritis, deep vein thrombosis, vertebral compression fractures, anemia, protein-calorie malnutrition and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed the resident with moderately impaired cognitive skills for daily decision making. Review of Resident #5's clinical record revealed no documentation regarding the resident's pneumococcal immunization status. The pneumococcal vaccination status was not listed under the immunization tab along with the influenza and COVID-19 vaccines. There was no documentation that the resident or family had been educated on the benefits and possible side effects of the vaccine. On 2/13/23 at 1:15 p.m., the licensed practical nurse (LPN #1) responsible for tracking vaccinations was interviewed about Resident #5's pneumococcal immunization status. LPN #1 stated Resident #5's clinical record documented the influenza and COVID-19 vaccinations but not the pneumococcal. LPN #1 stated that the pneumococcal vaccines had been offered to residents, but she had not updated clinical records with the status, education or refusals. On 2/13/23 at 1:20 p.m., Resident #5's family members were interviewed about his pneumococcal immunization status. Resident #5's family members stated the facility had offered and provided an education sheet about immunizations around the time of admission. Resident #5's family members stated the resident refused all the vaccines, as he had experienced a reaction to an influenza vaccine prior to his admission. On 2/13/23 at 2:10 p.m., the director of nursing (DON) and LPN #1 were interviewed about Resident #5's pneumococcal immunization status. The DON stated that she did not know Resident #5's current pneumococcal immunization status. The DON stated that immunization status was supposed to be determined upon admission, documented in the clinical record, and updated as needed. LPN #1 stated that she had been told to only record influenza and COVID-19 vaccines in the clinical record. This finding was reviewed with the DON and the regional MDS coordinator during a meeting on 2/13/23 at 2:15 p.m. The administrator was out of the facility during the survey. 29123 3. Resident #3 was not offered a pneumococcal vaccine at the time of admission to the facility. Resident #3 was admitted to the facility with the following diagnoses, including but not limited to: epilepsy, unsteadiness on feet, muscle weakness, history of falling, dementia, and cerebral infarction. Resident #3's admission MDS (minimum data set) with an ARD (assessment reference date) of 01/17/2023, contained a staff assessment for mental status. Resident #3 was assessed as memory OK for short and long term memory and as modified independence in daily decision making skills. As part of the focused infection control survey process, Resident #3 was added to the survey sample to ascertain his vaccination status. The clinical record was reviewed on 02/13/2023, at approximately 1:00 p.m. A screen labeled Immunizations on the electronic health record (EHR) was reviewed. There were no entries observed. The admission MDS section O Special Treatments, Procedures, and Programs was reviewed. Entry O0300 Pneumococcal Vaccine contained the following: Is the resident's Pneumococcal vaccination up to date? The answer was coded as No. If Pneumococcal vaccination not received, state reason: Not offered. LPN (licensed practical nurse) #1 was interviewed at approximately 1:15 p.m., regarding the process for assessing residents for vaccination status. LPN #1 stated, I get a Virginia vaccine record on all the residents before they are admitted . LPN #1 pulled Resident #3's vaccine record up in the EHR and stated, It doesn't look like he got it . LPN #1was asked if vaccines were offered at admission and where would the documentation be located. LPN #1 pulled up the immunization screen in the (EHR)and stated, It should be here. The screen was blank. The facility policy Pneumococcal Vaccine was reviewed and contained the following: Residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Residents of the long term care facility will be offered the pneumococcal vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control .Before offering pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization .If a resident or resident's representative refuses to have the pneumonia vaccine administered, the attending physician will be notified, and documentation of the refusal and physician notification will be documented in the nursing notes. No documentation of the pneumococcal vaccine being offered, education given, or refusal of the vaccine was observed in the clinical record. The above information was discussed during a meeting with the DON (director of nursing) and LPN #1 on 02/13/2023 at approximately 2:15 p.m. When asked what should have happened when Resident #3 was admitted , LPN #1 responded, We should offer all vaccines on admission, even if they have refused before, and document the information in the clinical record. No further information was obtained prior to the exit conference on 02/13/2023.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to implement policies and procedures to ensure one of five residents, Resident #3, was offered the COVID-19 vaccine. Findings were: Resident #3 was admitted to the facility with diagnoses that included, but not limited to, epilepsy, unsteadiness on feet, muscle weakness, history of falling, dementia, and cerebral infarction. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/17/2023, contained a staff assessment for Resident #3's mental status. Resident #3 was assessed as memory OK for short and long term memory and as modified independence in daily decision making skills. As part of the focused infection control survey process, Resident #3 was added to the survey sample to ascertain his vaccination status. The clinical record was reviewed on 02/13/2023 at approximately 1:00 p.m., but did not contain any documentation regarding a COVID vaccine. LPN (licensed practical nurse) #1 was interviewed at approximately 1:15 p.m., regarding the process for assessing residents for vaccination status. LPN #1 stated, I get a Virginia vaccine record on all the residents before they are admitted . LPN #1 pulled Resident #3's vaccine record up in the EHR and stated, It doesn't look like he got it .I also see that he refused it in the hospital before he came here. LPN #1 was asked if the vaccine had been offered at admission and where would the documentation be located. LPN #1 pulled up the immunization screen in the EHR and stated, It should be here. The screen was blank. The facility COVID-19 vaccination policy was requested. Per the policy COVID-19 Vaccination for Residents: * Prior to admission, the facility will validate COVID-19 vaccination status. * Resident/resident representatives will be educated on: a). risks/benefits of COVID-19 vaccination. The education will be specific to vaccine being offered/administered . * Residents will be encouraged to accept COVID-19 vaccination . * If the resident/resident representative refuses administration of the COVID-19 vaccine, education will be provided to the resident and the resident's refusal will be documented in the resident's medical record No documentation of the vaccine being offered, education given, or refusal of the vaccine was observed. The above information was discussed during a meeting with the DON (director of nursing) and LPN #1 on 02/13/2023 at approximately 2:15 p.m. When asked what should have happened when Resident #3 was admitted , LPN #1 stated, We should offer all vaccines on admission even if they have refused before and document the information in the clinical record. No further information was obtained prior to the exit conference on 02/13/2023.

Based on resident interview, family interview, staff interview, observation, and clinical record review, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to maintain the highest practicable well-being for 11 of 22 residents in the survey sample, residing on three of three floors, Residents #188, #73, #80, #238, #11, #20, #62, #51, #35, #47, and #9. Resident #188 did not receive pain medication as ordered, which was identified as harm. Call bells were not answered in a timely manner as evidenced by resident and family interviews, and as documented in the resident council meeting minutes. Eight residents did not receive skin and/or wound care evaluations, Residents #73, #80, #238, #11, #20, #62, #51, and #35. Two residents who were identified as wandering were not provided supervision, Resident #9 and #47. The facility staff had a med error rate of 81.48% on the second floor due to late medications. On 05/12/2022 at 11:07 a.m. after consultation with the State Agency, the facility staff was notified of the finding of Immediate Jeopardy at a scope and severity Level L-widespread, due to the the lack of sufficient nursing staffing to provide care and services to residents throughout the facility. On 05/19/2022 at 9:21 a.m. the Immediate Jeopardy was abated, reducing the scope and severity of the remaining deficient practice to a Level 3-isolated. The findings include: 1. Resident #188 was admitted to the facility with the following diagnoses, including but not limited to: Displaced bimalleolar fracture of right lower leg, hypo-osmolality and [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], and cerebral infarction. Due to Resident #188's recent admission there was no MDS (minimum data set) assessment completed. The admission nursing note dated 05/06/2022 did not discuss Resident #188's cognitive status. Resident #188 was interviewed during the initial tour of the facility on 05/10/2022 at approximately 11:15 a.m., and was alert, and oriented to her name, place and situation. Resident #188 stated that after her admission to the facility she had asked for pain medication and was told she had missed the cut off for pharmacy delivery. She was given Tylenol, which she stated was not effective. She stated she went over 12 hours without pain relief and described her pain as greater than a 10 and through the roof. Resident #188 stated the next night she had again waited over two hours and twenty minutes for her pain medication. She stated she rang the call bell multiple times and was told, We'll tell her. When the nurse came to the room the nurse told her she had to ask for her pain medication. Resident #188 stated she was told by staff that they would tell her (the nurse). The nurse stated, I am her and no one told me. Resident #188 stated that she had shared her lack of pain management with the nurse practitioner and her pain meds were changed from as needed to scheduled. LPN (licensed practical nurse) #5 was interviewed at approximately 6:45 p.m. on 05/11/2022. She was asked about Resident #188's admission and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .only the facility nurses do. She was asked if there were any facility nurses working that could have accessed the (name of dispensary) and gotten the medication for her. She stated, It takes two facility nurses to pull a narcotic, there weren't two facility nurses here .I was working two floors, I had two admissions, and a resident fell .we (agency staff) have asked for access to the (name of dispensary) and we were told no .That's why the residents can't get their meds if they come in and it's only us here .the meds are in the machine but I can't get to them . She was asked if she had called anyone, such as the DON to let her know that she needed pain medicine for a resident. She stated, They knew I was working two floors, and they knew I had two admissions coming, no I didn't call them . 2. On 5/11/2022 at 10:29 a.m. a group interview was completed with 12 cognitively intact residents. Residents in the group meeting were asked about call bell response time in the facility. Comments in the group included: . It takes 30-40 minutes or longer for them to answer the call bell. We don't have enough staff, they are all quitting. We are short staffed due to the working conditions and the new owners. Staffing is a problem, Sometimes we don't get the help we need . Please get someone to send help . I've been here a long time and we always talk about staffing and nothing has changed. Ringing the bell doesn't help because nobody comes . During the group meeting Resident #12 stated, I've been here almost four years and the call bell response time has been an ongoing issue. We don't have enough help. We talk to the administration about it constantly. Nursing just needs more help. I've had to go down or either call down to the second floor to look for help to come up here to the third floor. Most of the time it is only one nurse on this floor and that just doesn't make sense. This leads to medications not being given on time, treatments not done and lack of supervision. The man next door to me (Resident #9), he wanders and goes in and out of rooms. A couple weeks ago I heard he got through the door and was found wandering in the hospital. If we had more help it would reduce a lot of problems. Resident #33 stated during the group meeting, We ring the bell and it takes 45 minutes to 1 hour before anyone will even come to answer the bell. When they do come it just depends on what is going on whether or not they help us right then or not. You have a nurse or CNA here today and don't see them anymore because they are from an agency. All shifts are bad, but third shift is the worst. We will have one nurse and one CNA on this floor all shift. I stay up late and require help and sometimes I wait for what seems like forever. Also, we don't get our showers as scheduled because of staff problems .sometimes I end up with only one shower a week. The Resident Council meeting minutes for March 2022 through May 2022 were reviewed. March minutes documented, two residents stating .we need more staff. April minutes documented .nursing - needing more staff. May minutes documented, Nursing - needing more staff . Answering of call bells are getting better, but it is worse at night. Showers are not being given twice a week to some residents who have requested showers . A Resident Council Response Request Form for the month of May documented, Showers will be addressed with unit staff. Showers should be given 2x (times)/week. Will address call bells with right staff. The response form was dated and signed by the DON on 05/05/2022 and the facility's administrator on 05/10/2022. There were no response forms for March and April 2022. Additional resident and/or family interviews documented concerns with call bell response time and staffing. Resident #20 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE] assessed Resident #20 as cognitively intact with a score of 15 out of 15. Resident #20 was interviewed on 05/10/2022 during the initial tour. Resident #20 was asked about the quality of care and quality of life since being admitted to the facility. Resident #20 stated, I'm almost totally dependent on staff especially with transfers, bed mobility and toileting. They use the Hoyer lift to transfer me because of my leg issues and sometimes it takes two people. I ring the call bell and it takes them an hour to answer sometimes. Then when they come it just seems like they are rushed to get to the next person because they are short staffed. I've heard the girls talking outside my door about how hard it is for one person to take care of 25-30 people. That's just terrible. Most of us are here because we don't have other options and it's not fair to us or the staff that one person is responsible for some many patients. This is how things get missed because they don't have enough staff to take care of us all . Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE] assessed Resident #18 as severely cognitively impaired with a score of 5 out 15. On 05/10/22 at 12:39 p.m., a family interview was completed with Resident #18's significant other. Resident #18's significant other stated, The staff tell her to ring the bell, but she has dementia and doesn't remember and will try to get out bed. I come three times a day to help her with meals and make sure she is doing okay because I see how short staffed they are. I've had to call down to the second floor to get some help on this floor (third floor). She's been on this floor for about a month now and for the most part everyone is nice, but you can tell they are short staffed. They tell me to call or ring the bell for help even when I'm here but it takes 30 minutes or more for them to respond. I know they are trying to do the best they can, but it's not enough staff here. I can only imagine what happens when I'm not here and for those patients who don't have any family or loved ones who check on them . 3. Resident # 238 was admitted to the facility 5/3/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no MDS (minimum data set) information as the resident was newly admitted less than fourteen days. There also was no nursing admission assessment in the clinical record documenting the resident's cognitive status, or her functional abilities for transferring, walking, and other ADLs (activities of daily living). Resident # 238's baseline care plan had identified the resident as a fall risk on admission. The fall care plan included Focus: Resident is at risk for falls. Date initiated 5/4/22. Goals documented Resident will not have major injury from falls through next review. Date initiated: 5/4/22. Interventions included: Assist with toileting as needed Keep call bell within easy reach .Therapy as ordered. On 5/10/22 at 1:00 p.m. Resident # 238 was interviewed. She was asked about the type of help she needed, if she received help, her most recent fall, and about call bell response. Resident # 238 stated, Well, I wanted to get my brush out of my purse, which was right there in that chair .(pointing to a chair approximately 3 to 4 feet away from the bed), and didn't want to put the call bell on and wait 30 to 40 minutes for someone to come and help me up. I thought 'it's only a few feet, surely I can make it that far' but nope, I found out I can't. My legs are so weak that I do need help to get to the toilet and to the chair; but, when I push the call light, it takes somebody about 30 minutes, or more sometimes, to get to me. I'm trying to prevent them from having to clean up a mess in my bed. When asked about the call bell response, Resident # 238 stated Well, I'm on [MEDICATION(S)] (a fluid pill), and [MEDICATION(S)] (a type of [MEDICATION(S)]), so when I need to go, I need to go .I'm trying not to make a mess in the bed for them to clean up, and I have made it by myself a couple of times without falling to the bathroom since it takes them so long to get to me, so I thought I could make it a few feet today .but, apparently not. On 5/12/22 at 7:50 a.m. registered nurse (RN) # 2 was interviewed about call bells, and informed several residents had identified an issue with call bell response time. RN # 2 stated Yes, that's right, this is a skilled unit, and everyone on this unit needs assistance to toilet, dress, get up to a chair . We just don't have the resources to get to everybody timely. I am the only nurse, and there are usually two CNAs (certified nursing assistants), but if I'm on the med (medication) cart, and they are tied up in other rooms, then no, call bells don't get answered .at least in a timely manner. As a matter of fact, you asked about the nursing admission assessment for (name of Resident # 238). I just finished it yesterday evening. I have been working on it as I have time since her admission 5/3/22 . 4. On 05/11/2022 at 8:45 a.m., LPN #2 who routinely provided care on the third floor was interviewed about missing skin assessments. LPN #2 stated, I've been here since March on this floor and I had another nurse with me when I trained for a couple of days but since then it's been me. We don't have unit managers. So we do the best we can. It's 35 residents on this floor and there is one nurse per shift and 2-3 CNAs if we're lucky on first and second shift, but on third shift there is one nurse and one CNA for this floor. This unit has one of if not the largest med pass in the building. So you an only imagine how some things are missed or put off that never get done. If I have an emergency, an admission or a discharge home or to the hospital, that throws everything behind including meds, treatments, everything. Then I have to look out for the CNAs if they don't come in that just puts extra pressure on me to try to answer more call lights. It's like a [NAME], things just continue to go downhill. Resident #73 was admitted to the facility with a Stage IV pressure ulcer to the sacrum. There was no skin assessment, measurement, or intervention for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #80, #238, #20, #62, and #51, all identified as being at risk for the development of pressure ulcer/skin injury, did not have weekly skin assessments completed. Resident #11 did not have weekly skin assessments completed. Resident #35 did not have accurate and timely skin assessments for pressure ulcer prevention and the facility failed to adequately monitor and provide ongoing assessments of a facility acquired deep tissue injury. On 05/11/2022 at 9:15 a.m., the DON was interviewed regarding the missing skin and wound evaluations. The DON stated, We've identified there is a problem that skin evaluations are not being completed. On 5/11/22 at 3:58 p.m., the director of nursing (DON) was interviewed again about the lack of routine skin assessments. The DON stated weekly skin assessments had been identified as an issue in the facility due to staffing, use of agency staff and a combination of lots of things. On 5/12/22 at 7:50 a.m. RN #2 was interviewed about skin assessments. She stated No, skin assessments aren't done. There's not enough staff, I'm the only nurse and I'm giving medications, doing treatments, and by the time I finish passing medications, it's time to start again, if I don't get an admission. We don't have a unit secretary anymore. The new company has said nursing homes don't have unit secretaries, but this floor is the skilled unit. I am just one nurse .so, in addition to admissions, discharges, medications, treatments, etc., then it's up to me to make sure residents have appointments scheduled and have transportation. When we had a unit secretary, then some of the ancillary work .putting charts together, dealing with appointments .was done by that person and at least we could get our 'nursing work' done. On 05/12/2022 at approximately 2:15 p.m., RN #2 and LPN #1 were interviewed about skin assessments. LPN #1 stated, You have to understand .we are providing direct focus care, that's all we have time for .we make sure the residents get their medications, get fed, and we try to keep them safe .it is like being in a war zone, we have to triage the patients for their main needs .forgive me for saying it, but screw the documentation .we don't have time to do skin assessments .it is the basics. RN #2 stated, That's right. 5. On 05/11/2022 at approximately 9:45 a.m., RN #2 was interviewed regarding Resident #47. RN #2 was asked how the staff provided supervision for Resident #47. She stated, She wanders constantly .supervising her is a 'task'. The DON (director of nursing) was interviewed on 05/11/2022 at approximately 12:23 p.m. Concerns were voiced regarding Resident #47's safety on the unit. She stated, I know, she should be one to one. She was asked why if she felt Resident #47 should have one to one care was it not being provided. She stated, We do not have the staff for that . On 5/12/22 at 9:43 a.m., LPN #3 that cared for Resident #9 was interviewed. LPN #3 stated she was administering medications during the evening shift on 5/8/22 when a therapist and another hospital employee brought Resident #9 back to the unit. LPN#3 stated the hospital staff found the resident wandering on the medical-surgical unit of the hospital which is on the connecting floor to the resident's living unit. LPN #3 stated the incident occurred between 8:00 p.m. and 10:00 p.m. LPN #3 stated she had last seen the resident on his bed around 7:15 p.m. or 7:30 p.m. when she gave him medications. LPN #3 stated, I did not know he (Resident #9) was off the floor. 6. A medication pass and pour observation was conducted on 05/10/2022 with 27 opportunities and 22 errors, which yielded an medication error rate of 81.48 percent. Medications were prepared and administered to two different residents beginning at approximately 11:00 a.m. and ending at approximately 12:20 p.m. After administering the medications RN #2 was asked what time the medications she had administered were scheduled. She stated, (Name of first resident) are due at 8:00 a.m., (Name of second resident) meds are scheduled for the 'AM'. She was asked what that meant. She stated, Anytime between 9:00 and 11:00 a.m. RN #2 was asked if all of the medications that had been observed during the medication pass were late. She stated, Oh yes, and I still have meds to give from this morning. She was asked why the medications were late. She stated, I'm the only nurse up here, I had a resident fall this morning and she went to the ER, she just got back so I need to check on her .there are sixteen residents up here and I am the only nurse, I can't give meds, check on everybody, take care of things that happen like falls, go in and out of isolation rooms, and get everything done on time .we've told them we need two nurses up here nobody is listening . RN #2 was told that directions had been observed on the medication cards for some of the medications she had administered to be given with meals, food or milk. She stated, That's because they are due at breakfast time, hopefully lunch will be up here soon .I'm doing all I can do. On 05/11/2022 at 11:30 a.m., the DON was interviewed regarding the concerns with staffing. The DON stated, We like to have one nurse per floor but because of staffing issues sometimes on third shift we may only have two nurses in the building and they will split the floor that doesn't have a nurse. It's not the ideal situation, but it's what we have to do. The DON was asked for clarification of her statement. The DON stated, We have three floors in this building so on nights we only have two nurses in the building, they will work their assigned floor and then split the floor that doesn't have an assigned nurse. Basically, they decide what time during the shift they check on that unit or as the CNAs notify them of concerns. The DON was asked if the facility had unit managers. The DON stated, No, we don't. The nursing staff is supposed to report to myself and/or the ADON. On 05/11/2022 at 12:43 p.m., the staffing coordinator (OS #2) was interviewed about staffing. OS #2 stated staffing was based off the facility's census. OS #2 stated the facility should be staffed as the following: 1st floor - LTC (long term care) for first and second shifts: 1 nurse and 3 CNAs, third shift: 1 nurse and 3 CNAs 2nd floor- rehab for first and second shifts: 1 nurse and 2 CNAs, third shift 1 nurse and 1 CNA 3rd floor - LTC for first and second shifts: 1 nurse and 3 CNAs, third shift 1 nurse and 2 CNAs OS #2 was asked about the process for call outs and/or to fill available staffing positions. OS #2 stated, I'm the first line of defense and they call me first. They also call the DON and night shift calls the DON. We do like for them to call the unit nurse, but that doesn't happen all the time so they at least call the DON. We use two different staffing agencies and I stay in contact with them for staffing needs. With the new ownership, I no longer have access to the electronic system to post available shifts so I have to make phone calls or send text/group messages. If there are slots that I can't fill, then I notify the administrator and DON. Human Resources has been posting positions online. We're offering 8 hour shifts Monday through Friday and 12 hour shifts on the weekends. Sometimes we have to split shifts and nursing staff will work four hours. We still have open slots. It's just been difficult to get staff. We're doing the best we can with the resources we have. On 05/11/2022 at 5:30 p.m., during a meeting with the Administrator and DON the staffing concerns were discussed. The facility's administrative team was asked about the expectation and/or time frame for call bell response. The administrator stated, I don't have a specific time frame; however, I have discussed with all leadership and staff to look and listen for call bells. I expect them to at least acknowledge the bell and provide assistance if possible, if not, they are to get the appropriate staff member to provide assistance. On 05/12/2022 at 11:07 a.m., the administrator was advised of the multiple findings and concerns related to the lack of staffing at the facility including falls with injuries, the lack of appropriate pain management, wandering residents, physician ordered medications not being completed timely, skin and wound evaluations not being completed timely, and long call bell response time. The administrator stated based on the facility's staffing submission reports, she thought the facility was being staffed correctly based on the census. The administrator was notified at this time that Immediate Jeopardy, Level L - widespread was identified, and advised a plan of removal was needed. On 05/13/2022 at 11:33 a.m., the facility presented a plan of removal of the Immediate Jeopardy with a compliance date of 05/18/2022. The plan included the following interventions: 1. To provide adequate staffing needed to provide essential care and services for resident health and safety. Staffing patterning reviewed for upcoming 14 days and adjusted. 2. Contingent plans for call outs for licensed staff will include licensed staff (Administrator, DON, ADON) set on a call rotation with 2nd backup. 3. Contingent plans for call outs for CNAs included managed certified staff (Admissions, Staffing Coordinator, Medical Records) on call rotation with 2nd backup. 4. Two management offices will be relocated to each clinical floor to assist with supervision. Two additional staff agencies will be contracted for services. 5. The second floor (rehab unit) daily staffing adjustments will be based on the acuity level and total floor census. Acuity levels, affecting staffing patterns will be based on ADL dependency; and will account for infections, feeding assistance, wound care, and significant changes. 6. Staff education will be provided on call out and backup plan. The call schedule will be posted at each nursing station with phone numbers for the Administrator. 7. Monitoring and auditing of the staffing schedules to ensure proper staffing levels with adjustments as needed, daily for 4 weeks and bi-weekly for 8 weeks. 8. Identification of patterns and trends and ongoing education as needed and discussion with the QAPI committee. On 5/18/2022 between the hours of 8:45 p.m. and 10:45 p.m., interviews were conducted with nurses and CNAs on each nursing unit regarding education for the staffing contingency plan for call outs and backup staffing. Interviewed staff stated things were better and they were receiving less complaints from residents about call bell response time. Additionally, it was reported the administrator and DON were now assisting by working the medication cart and/or on the units. On 05/18/2022 at approximately 9:45 p.m. and 10:00 p.m. respectively, the second and third floor nurses were interviewed. Both stated medications times were better and they felt good about the plan now that they had additional staff on the floor. On 05/18/2022 at approximately 10:00 p.m., Resident #12 was interviewed. Resident #12 stated things seem better and Resident #47 was receiving one to one services and not wandering the unit. On 5/18/2022 between the hours of 8:45 p.m. and 10:45 p.m., the DON, Maintenance Manager, Rehab Manager and Activities Manager all were observed onsite. A new agency travel nurse was observed working his first night on the second floor with the second floor charge nurse. The travel nurse stated he had been educated on the staffing contingency call out and back-up plan. The contingency plan and backup plan including contact phone numbers for the administrator and DON was observed posted at each nursing station. On 05/19/2022 at approximately 5:45 a.m., interviews were conducted with nurses and CNAs on each nursing unit regarding education for the staffing contingency plan for call outs and backup staffing. Interviewed staff were all aware of the plan and stated they had plenty of help on the shifts to meet the residents' needs. On 05/19/2022, the day shift sitter (TNA) for Resident #47 was interviewed and stated she was working until 3:00 p.m. and was aware to get coverage for Resident #47 if she needed to leave the room or unit. On 05/19/2022 at 9:21 a.m. the Immediate Jeopardy was abated, reducing the scope and severity of the remaining deficient practice to a Level 3-isolated. No further information was provided prior to exit on 05/19/2022.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide effective pain management for one of 22 residents, Resident #188. Resident #188 reported on two separate occasions, her pain medication was delayed and/or not available for administration resulting in extreme pain greater than ten (on a scale of 1-10) and through the roof. This is harm. The findings were: Resident #188 was admitted to the facility with the following diagnoses, including but not limited to: Displaced bimalleolar fracture of right lower leg, hypo-osmolality and [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], and cerebral infarction. Due to Resident #188's recent admission there was no MDS (minimum data set) assessment completed. The admission nursing note dated 05/06/2022 did not discuss Resident #188's cognitive status. Resident #188 was interviewed during the initial tour of the facility on 05/10/2022 at approximately 11:15 a.m., and was alert, and oriented to her name, place and situation. Resident #188 was asked about care at the facility. She stated, I came in here on Friday evening, that's never a good time to be admitted anywhere. Thankfully I got pain medicine before I left the hospital. It was busy here and my nurse was working more than this floor .by the time she got in here and I told her I needed pain medicine she told me I had missed the cut off to get the pharmacy to deliver it and she gave me Tylenol. Resident #188 was asked if the Tylenol was effective. She stated, No, it wasn't. She was asked on a scale of 1-10 what her pain level was. She stated, It was greater than a ten, it was through the roof .I don't know if you've ever broken a bone or had bone surgery but it is a deep aching pain .I went over twelve hours without relief .the next night I had to wait over two hours and twenty minutes to get my pain medicine. She stated she rang the call bell multiple times and was told, We'll tell her. When the nurse came to the room the nurse told her she had to ask for her pain medication. Resident #188 stated she was told by staff that they would tell her (the nurse). The nurse stated, I am her and no one told me. Resident #188 stated that she had shared her lack of pain management with the nurse practitioner and her pain meds were changed from as needed to scheduled. She was asked how her pain was during the interview. Resident #188 stated, I'm okay right now .I'm not trying to complain .The staff do a good job, but they are spread too thin. I couldn't get my pain medicine the night I came in because there was only one nurse here, then she told me the medicine had to come from North Carolina .I don't know why they don't have something here to give to patients when that happens. The clinical record was then reviewed. An admission note dated 05/06/2022 documented: 5/6/2022 19:38 (7:38 p.m.) Admission Summary: .Patient arrived to facility @ (at) 1850 (6:50 p.m.) via stretcher from (Hospital) Patient admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient alert and oriented x4 . Patient nwb (non weight bearing) to right ankle .Writer called pharmacy to stat pain medications . The admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .moderate pain; [MEDICATION(S)]-Acetaminophen 5-325 mg Give 2 tablets by mouth every 4 hours as needed .for severe pain. Review of the MAR (medication administration record) documented Resident #188 received Acetaminophen 650 mg on 05/06/2022 at 8:55 p.m. for a pain level of 3. On 05/07/2022 at 1:14 a.m, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #188 was did not receive another dose of pain medication until 05/07/2022 at 6:14 p.m. for a pain level of 7. There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This timeframe corresponds to the interview with Resident #188 that she went over twelve hours without pain relief the day after she was admitted to the facility. A note from the nurse practitioner written on 05/09/2022 documented: . history of arthritis .The patient presented to the emergency room at (hospital name) on 05/01/2022 after a syncopal episode at home with subsequent fracture of the right ankle .The patient underwent an open reduction and internal fixation of the right ankle on 05/02/2022. The patient will remain non-weight-bearing status for 8 weeks .On assessment today, the patient is complaining about pain medications not received in a timely fashion as it was ordered on an as-needed basis .Plan: [MEDICATION(S)] APAP 5/325 mg every 4 hours while awake. DC p.r.n. (discontinue/as needed) 1 tablet. [MEDICATION(S)] APAP 5/325 mg q. (every) 8h. p.r.n. for pain scale greater than 5, breakthrough pain. DC p.r.n. Tylenol. Resident #188 was interviewed at approximately 3:00 p.m. on 05/11/2022 regarding the documentation of her pain level of a 3 on the night of her admission. She stated, I don't know what they wrote down, I know what I told her. If my pain had been a three there wouldn't have been a problem. An end of the day meeting was held with the DON and the administrator on 05/11/2022 at approximately 5:30 p.m. The above information was discussed. The DON (director of nursing) stated, Even if the pharmacy cut off for the evening had passed the nurse could have gotten the pain medicine from (Name of the onsite dispensary). LPN (licensed practical nurse) #5 was interviewed at approximately 6:45 p.m. on 05/11/2022. She was asked about Resident #188's admission and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .only the facility nurses do. She was asked if there were any facility nurses working that could have accessed the (name of dispensary) and gotten the medication for her. She stated, It takes two facility nurses to pull a narcotic, there weren't two facility nurses here I was working two floors, I had two admissions, and a resident fell .we (agency staff) have asked for access to the (name of dispensary) and we were told no .that's why the residents can't get their meds if they come in and it's only us here .the meds are in the machine but I can't get to them that's why I wrote the note that I had called the pharmacy and asked they to send her pain medication stat. She was asked if she had called anyone, such as the DON to let her know that she needed pain medicine for a resident. She stated, They knew I was working two floors, and they knew I had two admissions coming, no I didn't call them .I gave the resident Tylenol, that's all I had access to. On 05/12/2022 at approximately 8:15 a.m., the DON was interviewed. The DON stated, The nurse taking care of (Resident #188) was an agency nurse. They don't have access to the (name of dispensary) but there were two facility nurses here who could have gotten it .they also know if there is a situation they can call the ADON. She is the closest and she will come in .We have in-serviced that staff about this . No further information was obtained prior to the exit conference on 05/19/2022.

Based on staff interviews, family interview, clinical record review, and survey findings, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The census in the facility was 73. The facility staff failed to employ sufficient nursing staff which resulted in the identification of Immediate Jeopardy. The findings include: A survey was conducted at from 05/10/2022 through 05/19/2022. During the survey deficient practice was identified in the area of quality of care at F684, F686, F689 and pain management at F697. These identified areas of deficient practice were related to the facility not employing sufficient nursing staff. One of these areas resulted in identified harm for one resident in the survey sample for pain management. Additional deficient practice was identified for failure to follow physician orders, failure to provide services to prevent and/or treat pressure ulcers and failure to provide supervision for residents who were identified as wandering. During the survey interviews were completed with residents, families and staff concerning staffing. The interviews revealed the facility had lengthy call bell response between 30 minutes and 1 hour; physician ordered treatment and services were not being completed in a timely manner because of staffing shortages, the facility did not employ unit managers for oversight and assistance, medications were being administered 3 hours late, and the physician was not being notified of changes in conditions and/or missed medications. On 05/11/2022 at 11:30 a.m., the DON was interviewed regarding the concerns with staffing. The DON stated, We like to have one nurse per floor but because of staffing issues sometimes on third shift we may only have two nurses in the building and they will split the floor that doesn't have a nurse. It's not the ideal situation, but it's what we have to do. The DON was asked for clarification of her statement. The DON stated, We have three floors in this building so on nights we only have two nurses in the building, they will work their assigned floor and then split the floor that doesn't have an assigned nurse. Basically, they decide what time during the shift they check on that unit or as the CNAs notify them of concerns. The DON was asked if the facility had unit managers. The DON stated, No, we don't. The nursing staff is supposed to report to myself and/or the ADON. On 05/11/2022 at 12:43 p.m., the staffing coordinator (OS #2) was interviewed about staffing. OS #2 stated staffing was based off the facility's census. OS #2 stated the facility should be staffed as the following: 1st floor - LTC (long term care) for first and second shifts: 1 nurse and 3 CNAs, third shift: 1 nurse and 3 CNAs 2nd floor- rehab for first and second shifts: 1 nurse and 2 CNAs, third shift 1 nurse and 1 CNA 3rd floor - LTC for first and second shifts: 1 nurse and 3 CNAs, third shift 1 nurse and 2 CNAs OS #2 was asked about the process for call outs and/or to fill available staffing positions. OS #2 stated, I'm the first line of defense and they call me first. They also call the DON and night shift calls the DON. We do like for them to call the unit nurse, but that doesn't happen all the time so they at least call the DON. We use two different staffing agencies and I stay in contact with them for staffing needs. With the new ownership, I no longer have access to the electronic system to post available shifts so I have to make phone calls or send text/group messages. If there are slots that I can't fill, then I notify the administrator and DON. Human Resources has been posting positions online. We're offering 8 hour shifts Monday through Friday and 12 hour shifts on the weekends. Sometimes we have to split shifts and nursing staff will work four hours. We still have open slots. It's just been difficult to get staff. We're doing the best we can with the resources we have. On 05/12/2022 at 11:07 a.m., the survey team identified Immediate Jeopardy in the area of Nursing Services for the lack of sufficient nurse staffing. On 05/12/2022 at 6:26 p.m, during a meeting with the administrator and corporate consultant the administrator stated that the DON had left the facility for the day without notifying the administrator. The administrator was asked about the plan for nursing administration. The administrator stated she had a current nursing license and would provide oversight to the staff as well as the ADON, both who would work the floor and med carts as needed. The administrator stated she was not sure if the DON would return the next day. On 05/19/2022 at 9:21 a.m., the survey team abated the Immediate Jeopardy, which was subsequently lowered to a Level 3 - Isolated. No further information was provided prior to exit on 05/19/2022.

Based on facility document review and staff interview, the facility staff failed to employ a qualified dietitian. There had been no registered dietitian employed since 4/15/22 in the facility with a census of 73. The findings include: On 5/10/22 at 11:27 a.m., the dietary manager (other staff #1) was interviewed about qualified nutrition staff in the facility. The dietary manager stated there was currently no registered dietitian (RD) employed at the facility. The dietary manager stated the previous RD had been gone for approximately two to three weeks. Review of the facility's current personnel list (2022) included no identified RD for the facility. On 5/10/22 at 12:39 p.m., the administrator was interviewed about a RD for the facility. The administrator stated the previous RD quit and she was not sure if a new RD had been hired. On 5/11/22 at 8:22 a.m., the administrator stated the RD left about a week or two weeks ago and there was currently no RD for the facility. The administrator stated they were using the providers for nutritional guidance until a RD was hired. On 5/11/22 at 4:54 p.m., the administrator stated the previous RD's last day worked was 4/15/22 and the facility had been without a RD since then. This finding was reviewed with the administrator and director of nursing during a meeting on 5/12/22 at 8:15 a.m.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure one of 23 residents in the survey sample, (Resident #66), a palliative care resident, was provided effective pain management. The facility staff failed to assess and treat Resident #66 for pain prior to a dressing change, when the resident continually stated she was in pain, resulting in harm. Findings included: Resident #66, a [AGE] year old frail female resident was admitted to the facility on [DATE] originally, with the most current readmission on 12/06/14. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as no ambulation, no locomotion, and as requiring extensive assistance of one person for most all ADLs (activities of daily living). The resident was assessed as having bilateral lower extremity impairment. This MDS also assessed the resident at risk for pressure ulcer with no unhealed pressure areas and assessed the resident as having no venous or arterial ulcers. The MDS did assess the resident as having an infection in the foot to other lesion on the foot. A quarterly MDS dated [DATE] was reviewed for comparison. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for decision making. This MDS assessed the resident the same as above for ADLs. The resident was assessed as having impairment to the lower extremity, on one side. In the skin condition section, the resident was assessed as having no venous or arterial ulcers and as having only skin tears. The resident's annual MDS assessment with CAAS (care area assessment summary) dated 02/05/18 triggered the resident for, but not limited to: cognition, communication, ADLs, and pressure ulcers. On 11/13/18 at approximately 2:20 p.m., Resident #66 was observed in her room, lying supine in bed and covered. The resident was awake. Outside of the resident's room was signage for contact isolation and with information and instructions to don gloves and gown when coming in direct (physical) contact with the resident or objects in the environment in the room. On 11/13/18 at 2:25 PM, CNA (certified nursing assistant) #1 was interviewed about the isolation information. The CNA stated that Resident #66 was on isolation (contact isolation for infection) due to her toe. The CNA did not provide any information regarding the toe. On 11/13/18 at 2:29 PM, Resident #66 was observed and interviewed. The resident was lying in bed on her back. The resident was asked how she was doing and the resident stated, My tail is hurting. The resident was asked if she could grab the side rail and pull herself off of her bottom. The resident stated that she did not think so. The resident was asked if she needed help, the resident stated, yes, I need some help. At approximately 2:33 PM, LPN (Licensed practical Nurse) #1 was informed that the Resident was experiencing pain in her tail and had asked for assistance. The LPN was then asked about the resident's toe. The LPN stated that the resident had infection control precautions in place due to open area on her toe. The nurse stated, It is most likely due to 'pressure from the sheet' laying on her foot. The nurse stated that the resident's skin was very fragile and that it had been a recurring issue. LPN #1 was asked if the resident had dressing changes to this area. The nurse stated yes and that the dressing changes are completed each shift. The nurse stated that the dressing change had not been completed for this shift yet. LPN #1 was asked to observe the dressing change if possible. At approximately 2:40 p.m., LPN #1 stated that she was ready to do the resident's dressing change to her toe. LPN #1 entered the room with the supplies. The resident was whimpering and crying (without tears) and stated, Oh don't touch my toes, don't touch my toes, please don't touch my toes. The resident kept repeating the same thing. The resident was asked if her toes hurt and the resident stated, My toes hurts, oh my toes hurt, don't touch my toes, please don't touch my toes. The resident stated, My toes are sore, don't bother my toes, my toes are sore. The resident was asked if it was one toe or all of her toes. The resident stated that she didn't know. The resident was asked if she could tell if one toe or all the toes hurt and the resident stated that she didn't know. The resident just continued repeating about her toes hurting. LPN #1 prepared the supplies for the dressing change. The resident continued to repeat the above phrase, over and over. LPN #1 asked the resident if she wanted some Tylenol. The resident stated that she didn't know what she wanted and again repeated the phrase, please don't touch my toes, my toes hurts, please don't' touch my toes. The resident continuing to moan and whimper. LPN #1 then asked the resident if she wanted juice, the resident stated in a whimpering voice, some juice? LPN #1 stated, Ok, Let me do this first. LPN #1 removed two blankets and one sheet from the resident's feet. The blankets were lying directly on the resident's feet. The resident continued with the above phrase about her toes. The resident had a large pad dressing that covered several toes. The resident's heels were lying directly on a pillow and were not floated. The resident continued to moan/whimper and cry out (no tears) saying that her toes hurt and were sore. LPN #1 removed the dressing in place, exposing the toes. LPN #1 cleansed the wound on the resident's second toe and applied the ointment to the wound. LPN #1 then applied the dressing over top of several toes. LPN #1 then washed her hands and exited the room. The LPN was asked at this time if the resident was interviewable. LPN #1 stated that she did not think the resident was interviewable, but that she (the resident) could tell you if she was hurting or things like that, but that she (the resident) probably isn't really interviewable. LPN #1 stated that the resident had the place on her toe for about a month and this was the only treatment the resident was receiving. LPN #1 stated that the resident was getting a different treatment when the area was first noticed, but not now. The resident's nursing notes and clinical records were reviewed and documented the following: 10/14/18 at 11:23 AM, a physician's progress note documented, .Date of evaluation 10/14/18 .seen and examined at approximately 11 a.m .She is under palliative care. she is lying in bed .She is stating over and over that her toes are cold and this is a chronic thing that she says. She does not appear to be in any pain or distress. I reviewed with nursing. They have no new concerns at this time .difficult to obtain form her due to dementia .all other review of systems are negative .demented elderly white female .does not appear to be any pain .feet examination, she does have significant [MEDICAL CONDITION]. Both feet are cool, but has capillary refill on both feet. Some ulcerations on the right foot, but no new. There appeared to be more dry gangrene (sic). No foul smell .IMPRESSION: severe [MEDICAL CONDITION] with some dry gangrenous ulcers on right foot .dementia .chronic anxiety .continue palliative care. She is a DNR (do not resuscitate) .as far as her toes feeling cold, we have the blankets over them as so far does not appear to be in any significant pain, no drainage or evidence of infection . 10/15/18 at 11:31 AM, CNA reported that there was a bandaid on resident's second toe on the right foot. Abrasion to second toe noted, unaware of how it happened. Area red and painful to touch .new order to clean with NS (normal saline), apply TAO (triple antibiotic ointment) and cover with [MEDICATION NAME] until resolved. 10/15/18 at 11:56 AM, Resident unable to recall how injury occurred. RP (responsible party) was notified and stated that she notices the blankets are sometimes tucked around feet causing sheet to rub against feet .CNAs have been updated to reflect loosely laying sheet over feet and put blankets over Rsd (resident) ankles. Suggest bar to prevent blankets from covering feet. RP declined, because Rsd (resident) had it once before .Wound care nurse assessed area and noted it as abrasion not pressure .appears to be infected with greenish discharge. Rsd grimace in pain during treatment .in MD (medical doctor) rounding book. 10/16/18 at 6:01 PM, .TX (treatment) applied to right foot 2nd metatarsal. Wound draining small amount of purulent drainage and rsd states much pain and discomfort to the area . 10/18/18 at 4:53 PM, tx (treatment) to 2nd toe metatarsal on the right foot applied, slight amount of purulent drainage observed along with pain to the area during treatment . 10/20/18 6:17 AM .given PRN (as needed) Tylenol d/t (due to) treatment being done to toe . 10/20/18 at 2:42 PM, .[MEDICATION NAME] for infection in wound. Rsds wound to the 2nd metatarsal on right foot applied, continues to have small amount of purulent drainage and pain to the affected area . 10/21/18 at 11:25 AM, .Rsds 2nd metatarsal on the right foot is still draining small amount of purulent drainage and rsd states pain and discomfort to the area during tx change. Rsd refuses to take pain medication at this time . The resident's current physician's orders [REDACTED].Resident may wear socks and keep covers off feet (04/05/16) .Pain assessment three times daily (04/05/16) .Heelz up (04/06/16) .Skin assessments every Wednesday 7-3 shift (08/10/17) .Palliative Care liberate diet as tolerated .do not send to ED except for acute injury .(03/05/18) .leg protectors on BLE's (bilateral lower extremities) as resident tolerates, assess skin each shift (05/31/18). The resident's CCP (comprehensive care plan) was then reviewed and documented, .(name of resident) has difficulty expressing needs/desires and difficulty understanding others; Rd (resident) usually understands others .allow adequate time to express self .short simple questions .if restless assess for pain/discomfort .administer medications as ordered .Adhere to Palliative Care guidelines .staff to support .resident .contact MD for changes in condition .Assess pain every shift using pain scale 1-10 and record, assess location, quality, and intensity of pain .review pain assessment and pain medication effectiveness .explain all treatment and procedures before doing them .assist with decision making . Resident #66's pain assessments were reviewed for the month of (MONTH) (YEAR) and (MONTH) (YEAR) (to present). The resident's pain assessments for the entire month of (MONTH) (YEAR) for all three shifts, everyday were documented that the resident had 0 (zero) pain. The pain assessments for (MONTH) (YEAR) were reviewed for Resident #66. The (MONTH) pain assessments documented that the resident had 0 (zero) pain for the entire month, except for (MONTH) 14th, when the resident was administered Tylenol 650 mg for complaints of a headache on the day shift. The resident's MARs/TARs (medication administration records/treatment administration records) were reviewed for the month of (MONTH) (YEAR) and (MONTH) (YEAR). The resident's MARs for the month of (MONTH) (YEAR) revealed that pain medication had been administered one time to the resident on 10/20/18, but was not administered any other time, even on the days that that it was documented in the nursing notes that the resident was experiencing pain. The (MONTH) MARs revealed that no pain medication had been administered at all, even when the resident was whining and repeatedly stated that her toes were hurting on 11/14/18 during the observed dressing change. The resident was not administered any pain medication in November, except for one time on (MONTH) 14th at 10:05 a.m. for complaints of a headache. On 11/14/18 at approximately 4:00 p.m., the DON (director of nursing) and ADON (assistant director of nursing) were made aware of concerns regarding Resident #66 stating that she was in pain and the nurse failed to administer pain medication and continued on with the treatment to the resident's toe. The DON stated that the resident is palliative care. A policy was requested on palliative care. On 11/15/18 at approximately 8:50 a.m., The DON stated, We are going to get an order to administer pain medication prior to dressing changes. The DON was asked the expectation for a resident stating that they are in pain. The DON stated, The expectation would be to medicate the resident, reassess and then come back for the treatment. The DON was asked for a policy on palliative care. At approximately 9:45 a.m., during an assessment of Resident #66's toe by RN #1, RN #2 stated if she (the resident) is crying or whimpering in pain that she (RN #2) would medicate her and come back to do a dressing change. At 10:53 AM, LPN #1 requested to speak with this surveyor regarding Resident #66. LPN #1 stated she felt like she knew Resident #66 well and that the resident, always gets real shaky and has a whole lot of anxiety, and yes I (LPN #1) did ask her (resident) if she wanted Tylenol and she (resident) didn't know what she wanted, so I offered her juice and I took her juice about 15 minutes later, I can usually calm her down. She (resident) does have anxiety and she does have pain. LPN #1 was asked that given the fact that the resident does have anxiety and pain, would it have been better to give the resident something for pain and/or anxiety. The LPN stated, Yes, it would have been better to give her something, but she is really hard to give medicine too, we have to crush it sometimes. The policy on Palliative Care Services was presented and reviewed and documented, .assist residents and/or resident representative in decisions for serious illness and/or end of life care and support .optimizes quality of life by anticipating, preventing, and treating suffering .involves addressing physical, intellectually, emotional, social, and spiritual needs .all orders and plans of care that address the resident's immediate and ongoing treatment and care . At approximately 12:20 PM, the survey team met with the DON and ADON and informed of the serious concerns regarding Resident # 66. The DON and ADON were made aware of the above observations of Resident #66 and the concerns of the resident not receiving pain medication, when the resident was stating she was in pain. The ADON stated that, when someone is on palliative care the goal is to keep them comfortable-we know they are compromised, we are doing things to keep them comfortable, we did put her (resident) on antibiotics, we really don't care if the wound gets worse, well I shouldn't say we don't care, but we are trying to make them comfortable. The DON and ADON were made aware that the resident was not comfortable, she was whining and was in distress regarding her feet. The DON and ADON were made aware that the resident was not given pain medication and there was no evidence of non-pharmalogical interventions implemented in an attempt to make this resident comfortable. The DON stated, .The careplan is available to look at and edit for all RNs and LPNs, we mangers will do rounds and make sure they (interventions/orders) are in place, we don't have a set structure. No further information and/or documentation was presented prior to the exit conference on 11/15/18, to evidence that the facility staff effectively managed pain for Resident #66.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure safety interventions were in place for the prevention of a fall, which resulted in harm for one of 23 residents in the survey sample, Resident # 10. The facility staff failed to ensure non-skid socks were worn by Resident # 10, as a result Resident #10 fell and sustained a right hip fracture with ORIF (Open Reduction Internal Fixation). Findings include: Resident # 10 was admitted to the facility on [DATE] with the most current readmission on 08/11/15. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE], which assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. This MDS also assessed the resident as requiring extensive assistance for dressing and toileting with at least one staff person physical assistance. The resident was additionally coded as not ambulating at all in room or corridor in the previous look back period. On 06/21/16 through 06/23/16 Resident # 10's clinical record was reviewed. Nursing notes documented that Resident # 10 had a fall on 08/04/15, was sent to the ED (emergency department). The resident was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Nursing notes were reviewed from June 2015 through present and showed a pattern of falls. A nursing note dated 07/10/15 and timed 7:45 a.m. documented: Rsd (resident) found sitting in floor beside bed, rsd only had plain socks on feet. Rsd stated to nurse I didn't fall, I was just trying to get out of bed and I slipped .resident also stated to nurse I turned my bed alarm off during the middle of the night because it makes such a racket . A nursing note dated 07/12/15 and timed 2:00 a.m. documented: Rsd's (resident's) roommate (sic) rang call bell, to report Rsd fell in floor, Rsd was laying on her back beside her bed, btwn (between) the two beds, head at head of bed by the wall feet towards foot of bed. Rsd stated, I need to go to the bathroom appeared disoriented . There was no information or documentation regarding the resident's bed alarm on 07/12/15. A nursing note dated 07/15/15 and timed 7:45 a.m. documented: .resident fell in room stood up from side of bed pants pulled down around feet, rsd (resident) assessed abrasion Left knee .Left elbow .attempt to collect urine for UTI (urinary tract infection) due to incontinent episode and frequent falls . A nursing note dated 07/15/15 and timed 12:45 p.m. documented: Urine sent to lab .result does not indicate UTI .bruising noted on elbow around abrasion, red area on knee cap . A nursing note dated 07/16/15 and timed 11:00 a.m. documented: .Rsd observed walking up hallway this am with clothes in hand, regular socks only on feet .redirected, assisted back to her room, non-skid socks applied to feet . Resident # 10's POS (physician's orders [REDACTED]. The printed POS dated for June 2015 documented: .Bed alarm at bedtime for safety . The printed POS dated for July 2015 documented: .Bed alarm at bedtime for safety (a hand written entry was written in beside of this that documented, 'check placement and function every shift .' The printed POS for August 2015 documented: .Bed alarm at bedtime for safety-check placement and function every shift . The resident's CCP that was in effect just prior to the fall on 08/07/15 was then reviewed. The CCP dated 12/11/14 through 08/20/15 documented: .Fall 07/10/15-non skid strips applied to floor on both sides of bed .Fall 07/12/15-non skid sock (sic) .06/06/15 Fall while ambulating .chair alarm when up in recliner .Self care deficit extensive assistance required with .dressing and grooming .Total assist with dressing and undressing . On 06/22/16 at approximately 2:30 p.m., the above fall investigations were requested for Resident # 10. The DON (director of nursing) presented the investigations, they were reviewed and documented the following: A post fall assessment dated [DATE] documented that the resident was a fall risk, did not have fall mats down, did have alarms in use and in place, but was not sounding due to resident turning off alarm. It was also documented that the resident had on plain socks. Additionally it was documented to add non skid strips to floor as an intervention. A post fall assessment dated [DATE] documented that the resident was a fall risk, did not have fall mats down, did have alarms in use and in place. This assessment documented that the alarm was not sounding and that the resident had on normal socks. Additionally it was documented to add non skid socks, educate on ringing call bell and add grip strips by bed and in bathroom. A post fall assessment dated [DATE] documented that the resident was a fall risk, did not have fall mats down, did have alarms in use and in place. It was also documented that the alarm was not sounding and had a hand written entry that documented, Rsd does not have alarm on after setting up. It was documented that the resident had on slippers, not non skid socks as documented in the resident's CCP. A nursing note dated 08/07/15 and timed 2:00 a.m. documented: Resident has not been asleep so far this shift .stated my husband is in the waiting room .took res (resident) to bathroom then tucked into bed . A nursing note dated 08/07/15 and timed 7:30 a.m. documented: Resident was up in room walking towards bathroom in gown and regular socks when rsd (resident) fell in room hitting her head against the wall, rsd c/o (complained of) right hip pain, unable to sit up or move right leg, right leg externally rotated, protruding out up at hip socket. Rsd has severe complaint of pain when right hip touched .transferred to stretcher. Report called to ED (emergency department) . A long term care flowsheet dated 08/07/15 timed 8:00 a.m. documented: Rsd ambulating in room, regular socks on rsd at the time. Rsd ambulating to BR (bathroom) when rsd lost balance and fell to the floor, hitting her head on wall. Rsd has severe pain .Rsd taken to ED at 7:50 a.m . A post fall assessment dated [DATE] and timed 7:30 a.m. documented that the resident was a fall risk, fall mats were not in place, alarms were in use and in place and sounding. The assessment additionally documented that the resident had on regular socks. On the reverse side of this assessment a nursing note documented: Rsd up ambulating in room, regular socks on at time .ambulating to bathroom unassisted when rsd lost balance and fell to the floor near bathroom, hitting her head on wall near sink . It was documented on 08/07/15 at 10:30 a.m., that the resident was discharged to the hospital. The resident was readmitted to the facility on [DATE] with a (repaired) hip fracture with 36 staples in place. Resident # 10's quarterly MDS assessment dated [DATE] (just prior to the resident's fall with injury) was reviewed for comparison. Resident # 10 was assessed at that time with a cognitive score of 7, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as requiring limited assistance with at least one person physical assist for bed mobility, transfers, ambulating, dressing and toileting. During initial tour of the facility on 06/21/16 at approximately 10:20 a.m., Resident # 10's room was observed. No non skid strips were observed. One fall mat was observed on the resident's right side of the bed. Resident # 10 was observed on 06/21/16 at 4:00 p.m., sitting outside of her room in a w/c (wheelchair), a pad alarm attached and a tab alarm attached; the resident was wearing non skid (slip) socks. Resident # 10 was again observed on 06/22/16 at 7:45 a.m., in the dining area. The resident was again observed in her w/c and again had on non skid socks. On 06/23/16 at approximately 8:15 a.m., the DON (director of nursing), ADON (assistant director of nursing) and corporate consultant were made aware of the above concerns regarding Resident # 10. The facility staff were asked to present any additional documentation or information regarding Resident # 10's fall with injury resulting in harm. The DON presented an employee statement from the CNA (certified nursing assistant) dated 08/07/15, which documented that the resident was trying to go to the bathroom and had been checked on about 10 minutes prior to the fall and that .alarm was not on when she was put in bed the night before . Resident # 10's room was observed again on 06/23/16 at 9:30 a.m., no non skid strips were on the floor. One fall mat was present on the resident's right side of the bed. The resident's current CCP was requested and reviewed (dated 08/27/15 through 06/06/16 and 10/22/15 through present) . The current CCP documented: .Assist with toileting .keep areas free of obstructions .call bell/light within easy reach .respond promptly .footware (sic) will fit properly and have non skid soles .bed alarm .chair alarm .encourage to wear hipsters . In a meeting with the survey team on 06/23/16 at 11:00 a.m., the DON, ADON, and corporate consultant were made aware of concerns regarding actual harm of Resident # 10 and that the resident's non skid socks were repeatedly not applied and as result the resident had multiple falls, one of which occurred on 08/07/15 resulting in the resident sustaining a right hip fracture. No further information or documentation was presented prior to the exit conference on 06/23/16 at 11:30 a.m.

Based on observations, clinical record review, staff interview and complaint investigation, the facility staff failed, for three of 22 residents in the survey sample (Residents # 4, 6 and 21), to ensure the residents were free of accident hazards and received supervision to prevent accidents. For Residents # 4 and 21, the staff failed to provide supervision to prevent the residents from falling and sustaining injuries. For Resident # 6, the staff failed to ensure safety devices were functioning properly. The findings include: 1. Resident # 4, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to an Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/3/11, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired. According to a Quarterly Review MDS, with an ARD of 12/21/11, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired. Under Section G (Functional Status), the resident was assessed on both the Annual MDS and the Quarterly Review MDS as totally dependent with one person physical assist for toileting. Review of the Physician order [REDACTED]." The handwritten entry was carried forward as a printed entry on the Physician order [REDACTED]. Review of the facility's "Post Fall 24 Hour Documentation," contained in the Nurse's Notes section of Resident # 4's clinical record, revealed the following entries: 2/7/12 - 1340 (1:49 p.m.) "This nurse standing with resident while resident using restroom. Nurse reached for gloves. Resident fell off toilet onto floor hitting head on wheelchair. 2 lacerations noted above right eye and side of face - blood present. Pressure placed on areas to stop bleeding ice applied. Resident lying on right side. Resident transferred to stretcher and sent to ER per MD order. Wife present and accompanied to ER." 2/7/12 - 1615 (4:15 p.m.) "Pt (Patient) returned via stretcher from ED. Pt transferred from stretcher to bed via pull sheet. Pt. alert, oriented to name. Pt has a skin tear over R (right) eye which is sutured (and) covered (with) antibiotic oint (ointment). Dry drsg (dressing) over R cheek. Pt has an abrasion on front of R knee 1 x 2 cm. (centimeters). Inner aspect .5 cm x .5 cm. L (left) knee 2 x .5 cm. PERL (Pupils Equal Reactive to Light). R hand contracted. Good grip L hand. Moving lower extremities. 97.2 (temperature), 64 (pulse), 16 (respirations), BP (blood pressure) 106/61." At 11:00 a.m. on 2/22/12, LPN # 2 (Licensed Practical Nurse) was interviewed about the resident's fall on 2/7/12. LPN # 2 confirmed she was the nurse present when the resident fell , and that she had written the post fall documentation entry. Asked about the fall, LPN # 2 said, "I was with him. I had one hand on his shoulder and I reached for some gloves. The box of gloves is usually on the back of the door, but it wasn't. I had to stretch to get them and when I did, he leaned forward and fell ." Asked if someone was with her at the time, LPN # 2 replied, "I was alone." At 10:45 a.m. on 2/23/12, CNA # 1 (Certified Nursing Assistant) was interviewed regarding Resident # 4's fall on 2/7/12. Asked what happened, CNA # 1 said, "I helped put him on the commode. I left to help someone else. Before I could get back, he fell ." At 10:50 a.m. on 2/23/12, LPN # 2 was interviewed again. LPN # 2 confirmed that CNA # 1 had helped put Resident # 4 on the toilet, that CNA # 1 left to help someone else, and that the resident fell before CNA # 1 could get back. 2. Resident #21 fell from her wheelchair after being medicated and left unsupervised in a wheelchair with unlocked brakes. Resident #21 sustained a skin tear on her left lower leg as a result of her fall. Resident #21 was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] assessed Resident #21 as alert, confused and had short and long-term memory problems. This assessment listed Resident #21 was a fall risk and had an unsteady gait. Review of Resident #21's closed clinical record documented the resident was found in the floor in her room on 5/16/11 at 11:45 p.m. and sustained a 3 centimeter (cm) by 3 cm skin tear on her lower left leg as a result of her fall. A nursing note dated 5/16/11 at 11:45 p.m. documented, "During report, called to room by CNA (certified nurses' aide). Resident sitting in floor in front of w/c (wheelchair) - alarms sounding. Assessed resident (with) s/t (skin tear) to left lower leg..." An Occurrence Investigation sheet dated 5/16/11 documented, "Resident found in floor in front of w/c in resident room (with) alarms sounding. 3 cm x 3 cm s/t (skin tear) L (left lower) leg...Resident stated she was going to Lynchburg for a newspaper when asked what happened..." The post fall assessment dated [DATE] documented the resident had been medicated with the antipsychotic medication Seroquel at 9:00 p.m. prior to the fall. The assessment documented the fall was unwitnessed, and at the time of the fall the resident had on shoes and the brakes on the resident's wheelchair were unlocked. Resident #21's closed clinical record documented a history and physical dated 5/15/11 stating, "She (Resident #21) is noted to have a fairly profound dementia but helped rest at night by Seroquel." The resident was admitted on [DATE] with a physician's orders [REDACTED]. Resident #21's medication administration record documented the resident was administered Seroquel on 5/16/11 at 9:00 p.m. Resident #21's interim care plan dated 5/12/11 stated the resident was a safety risk and was at high risk for falls. Interventions for falls included chair/ bed alarms and the use of a gait belt for transfers and ambulation. The clinical record including nursing notes and the accident investigation for the fall on 5/16/11 provided no explanation of why Resident #21 was in her wheelchair and not in bed at 11:45 p.m. on the night of the fall. The fall investigation included no statements from the CNA's and/or nursing staff caring for Resident #21 immediately prior to the fall. On 2/23/12 at 11:40 a.m. the director of senior care services was interviewed about Resident #21's fall on 5/16/11. The director stated concerning information from the investigation, "That's all that's there. We've changed the investigation process since then to include statements." The director stated, "The report (fall investigation) says she was in the wheelchair, had her shoes on and the wheelchair was unlocked. She obviously wasn't in bed." The director had no explanation of why the resident was in her wheelchair at 11:45 p.m. the night of the fall. The Drug Information Handbook for Nursing 13th edition on pages 1015 through 1017 describes Seroquel as an antipsychotic agent used for the treatment of [REDACTED]. This reference states Seroquel is not approved for treatment of [REDACTED]. Use with caution in Parkinson's disease. May induce orthostatic hypotension associated with dizziness, tachycardia, and, in some cases syncope, especially during the initial dose titration period..." (1) These findings were reviewed with the administrator, MDS coordinator and director of senior care services on 2/23/12 at 11:45 a.m. This was a complaint deficiency. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. 3. Resident # 2's safety device (bed alarm) was observed in the "off" position. Resident # 2 was admitted to the facility on [DATE] with the most current readmission on 02/06/12. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a 14 admission assessment, which assessed Resident # 2 as a "15" in cognition, which indicated the resident was cognitively intact. Resident # 2 was assessed as requiring limited assistance with at least one person assist for transfers and was assessed as unsteady for moving from seated to standing position. During Resident # 2's clinical record review, an admission nursing assessment, dated 01/17/12 assessed the resident as having a fall score of "15." According to the admission assessment, a score of 15 indicated that the resident should be identified as a fall risk. On 02/23/12 at approximately 9:00 a.m., Resident # 2 was observed in bed, laying supine, receiving a respiratory treatment. The respiratory therapist was present. The bed was observed with a small boxed device (a bed alarm), the box was hanging from the side-rail of the bed. The bed alarm box was observed; the respirator therapist was asked for assistance in identifying or determining if the device was in the "on" position. The therapist, picked up the box and turned it, and moved a small switch on the side up (to the on position), the therapist was asked if the device was on or off and the therapist stated the device was in the off position and now is "on." The resident's comprehensive care plan (CCP), dated 12/14/11 was observed and documented: "...Has a fall mat in place...Has a bed alarm in place..." Another CCP was observed dated 02/01/12, which documented: "...Bed in low position...call bell in reach...keep environment free of clutter..." On 02/23/12 at 11:40 a.m., the administrator, the corporate nurse consultant and LPN (Licensed Practical Nurse) # 1 were informed in a meeting with the survey team. The nurse consultant stated that the CCP dated 12/14/11 was the "active care plan..." and further stated that it (the CCP dated 12/14/11) was the care plan that staff were using, and was in the black book (notebook for current care plans). The corporate nurse consultant additionally stated, that as far as the bed alarm being in the off position, the expectation would be that staff (all staff) look at the bed alarm before leaving the room (to ensure the device is on), "but would agree should be on at all times." No further information or documentation was provided prior to the exit conference on 02/23/12 at 3:15 p.m.