Every finding on record at Oneida Nursing and Rehab Center

Based on facility policy review, facility job description review, observations, and interviews, the facility failed to identify quality deficiencies related to Enhanced Barrier Precautions (EBP) and put action plans in place to prevent deficient practice. The facility's failure had the potential to affect 37 out of 37 residents. The findings include: Review of the facility's undated policy titled, QAPI [Quality Assurance and Performance Improvement] Plan, revealed .we are committed to focusing on clinical care .committed to using QAPI to improve our performance and practices to assure we meet and exceed regulatory requirements and standards .QAPI program encompasses all areas that impact quality of care .We will utilize available data from state and national organizations .The Administrator and Director of Nursing Services have responsibility for QAPI committee functions . Review of the facility's undated Nursing Home Administrator, job description revealed .lead and direct the overall operations of the facility in accordance with .government regulations .Monitor each department's activities, communicate policies, evaluate performance .Maintain a working knowledge of and confirm compliance with all governmental regulations . Review of the facility's undated Director of Nursing (DON), job description revealed .manage the overall operations of the Nursing Department in accordance with .governmental regulations .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Organize, develop, and direct the administration and resident care of the nursing service department .Perform nursing services and deliver resident care services in compliance with .State and Federal regulations . Review of the facility's undated Assistant Director of Nursing (ADON), job description revealed .Ensures the Nursing Department is in compliance with federal, state, and local regulations .Develop, implement and update departmental policy and procedures when necessary or as directed .Responsible for training and educating staff members .Assure that established infection control and standard precaution practices are maintained at all time .Acting infection control preventionist for the facility . Review of the facility's undated Infection Preventionist (IP) Job Description, revealed .responsible for developing, implementing, monitoring, and evaluating the facility's Infection Prevention and Control Program .works .to reduce the risk of healthcare-associated infections and ensure compliance with federal, state, and local regulations .Essential Job Functions .Monitor communicable diseases and implement appropriate control measures .Review and update infection control policies and procedures in accordance with current CDC [Centers for Disease Control and Prevention], CMS [Centers for Medicare and Medicaid] .and state guidelines .Develop action plans to address infection prevention concerns .Ensure staff competency related to .infection prevention practices .Ensure compliance with CMS .Infection Prevention and Control requirements . During an interview with all surveyors present on 6/16/2026 at 10:18 AM, the DON stated residents with wounds, catheters, and invasive lines required standard precautions. During an interview with all surveyors present on 6/16/2026 at 11:00 AM, the Minimum Data Set (MDS) Coordinator/IP B and the ADON/IP A stated there were no current residents in the facility on EBP. The ADON/IP A stated the facility did not have an EBP policy and the facility used CDC and CMS guidance for policies and procedures. The ADON/IP A stated .I have never heard of Enhanced Barrier until now (6/16/2026) . The MDS Coordinator/IP B stated she was unaware of EBP until today (6/16/2026). The ADON/IP A stated .I have asked the DON and our regional person and they don't know about EBP either . During an interview with all surveyors present on 6/16/2026 at 2:27 PM, Licensed Practical Nurse (LPN) A provided the survey team with the CMS regulations being used in the facility. The regulations LPN A provided to the survey team were titled THE LONG TERM CARE SURVEY .PHASE 3 .September 2022 Edition . During an interview/observation with the Administrator (ADM) on 6/17/2026 at 3:30 PM, in the ADM's office revealed, a discussion of how residents were identified with infections from admission, and while residing in the community of the facility. The ADM stated infections were reviewed during their performance improvement committee meetings, as well as discussion of audits conducted for hand hygiene. The ADM confirmed the facility was not using enhanced barrier precautions until the concern was identified by the survey team. The criteria of enhanced barrier precautions were discussed; at the conclusion of the discussion the ADM voiced the residents who meet the EBP criteria in facility should have had signage and PPE available for staff use at the resident's room. During an interview/observation with the DON, and both Infection Preventionists (IPs) on 6/17/2026 at 3:50 PM, in the DON's office revealed, the discussion arose about tracking and trending infections, both IPs reviewed the tracking data with this surveyor from 1/2026 to present. The data revealed scattered/sparce infections which were color coded by organism on a floor plan map of the facility. The DON voiced the staffing schedules were reviewed for trending of infections. The data did not support the staff spreading organisms. During a telephone interview with the Medical Director (MD) on 6/17/2026 at 4:00 PM, in the DON's office revealed, a discussion regarding the survey team's finding of the non-usage of enhanced barrier precautions protocol within the facility. The lack of knowledge of the term and application of Enhanced Barrier Precautions by facility staff to include administration was discussed. The MD, when asked about EBP, stated she was hesitant to believe the facility staff were unaware of EBP and the protocol used. The MD concluded the discussion with the statement of you must go with your observations. During an interview on 6/17/2026 at 6:11 PM, the Administrator stated the IPs and DON were responsible for keeping up with infection control updates from the CDC and CMS. The Administrator confirmed it was her responsibility to keep up with the newest regulations and confirmed the regulations being used by the facility were from 2022. The Administrator confirmed she was unaware of EBP precautions until 6/16/2026 when surveyors began asking questions. Refer to F880 and F882

Based on facility policy review, Infection Preventionist (IP) Job Description review, Centers for Disease Control and Prevention (CDC) website review, observations, and interviews, the facility failed to ensure the facility staff followed the most used up to date guidance for infection control procedures related to Enhanced Barrier Precautions (EBP). The failure was identified by a sample selected of 3 residents (Resident #21, Resident #5, and Resident #36) to review, the findings had the potential to affect the census population of 37 residents.The findings include: Review of the facility's undated policy titled, Infection Control Plan, revealed .Purpose .To provide overall direction to the facility wide Infection Control Program .Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infection .GOALS .Develop procedures to be applied to certain individual residents, such as isolation .Continually identify and correct problems relating to infection control practices .Monitoring risk of transmission of infection by assuring proper policies and procedures .IMPLEMENTATION OF CONTROL MEASURES .Prevention and spread of infection is accomplished by the use of standard precautions .MANDATORY & CONSULTATIVE SERVICES .Being available to all facility departments for infection control related issues and departmental policy review .Provision of educational services and mandatory annual education .DIVISION OF RESPONSIBILITIES FOR INFECTION CONTROL ACTIVITIES .The Director of Nursing [DON] or designee .performs the following .Supervises preparation of the unit .adherence of the staff to Isolation Precautions .Explains the purpose of isolation and mode of transmission to the resident . Review of the facility's undated policy titled, Foley Catheters, Care of, Infection Control and Insertion Guidelines, revealed .Purpose .To prevent and control Foley catheter associated urinary tract infection .Only persons .who know the correct technique .and maintenance of the catheter will be allowed to handle the catheter . Review of the CDC website, frequently asked questions, dated 6/28/2024, revealed .What are Enhanced Barrier Precautions .an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities (tasks which include direct, physical contact while providing care) that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. Review of the facility's undated Infection Preventionist Job Description, revealed .Reports to Director of Nursing and/or Administrator .The infection preventionist is responsible for developing, implementing, monitoring, and evaluating the facility's Infection Prevention and Control Program .Essential Job Functions .Monitor communicable diseases and implement appropriate control measures .Analyze infection data and identify opportunities for improvement .Maintain accurate infection logs, surveillance records, and reports .Program Management .Review and update infection control policies and procedures in accordance with current CDC (Centers for Disease Control), CMS (Centers for Medicare and Medicaid Services) .and state guidelines .Maintain required documentation and reports for regulatory agencies . Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Peripheral Vascular Disease, Acquired Absence of Left Leg Above the Knee, and Retention of Urine. Review of the physician's order for Resident #21 dated 5/22/2026, revealed .Wash the left lower extremity amputation surgical site with soap and water daily. Rinse. Pat dry. Apply gauze dressing and wrap tightly with an ace bandage for compression daily and as needed for soiling or dislodgement . Review of the comprehensive care plan for Resident #21 dated 5/26/2026, revealed .Wound Management Post-Surgical .Surgical Wound left lower extremity-left above the knee amputation site on 5/12/2026 . Review of the admission 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the physician's order for Resident #21 dated 6/16/2026, revealed .Urinary Catheter Care every shift . Continued review revealed .Remove indwelling Foley catheter .in 7 .days . Review of the medical record for Resident #21 revealed no orders for EBP. Review of the comprehensive care plan for Resident #21 dated 6/16/2026, revealed .resident has indwelling Foley Catheter: urinary retention . During an observation on 6/16/2026 at 9:12 AM, Registered Nurse (RN) A and this surveyor entered Resident #21's room for the 9:00 AM medication pass. Resident #21 had a catheter in a dignity bag on the side of the bed. Upon entering the room, Resident #21 requested to be repositioned in the bed. RN A exited the room and re-entered the room with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) A and repositioned Resident #21 in the bed without wearing gloves or a gown. There was no EBP signage or Personal Protective Equipment (PPE) present in or outside Resident #21's room. During an interview on 6/16/2026 at 9:17 AM, RN A confirmed Resident #21 had a surgical site due to recent left lower extremity amputation and an indwelling urinary catheter for urinary retention that had recently been placed during a hospitalization. RN A stated she was unaware of the facility's protocol for EBP. RN A confirmed she did not wear a gown or gloves to reposition Resident #21 in the bed and was unaware if PPE was required for a resident with a urinary catheter and surgical wounds. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Urinary Tract Infection, Overactive Bladder, and Retention of Urine. Review of the physician's order for Resident #5 dated 8/28/2025, revealed .foley cath care every shift and as needed . Continued review revealed no orders for EBP. Review of the comprehensive care plan for Resident #5 dated 9/30/2025, revealed .FOLEY Catheter: URINARY RETENTION . Review of the physician's order for Resident #5 dated 1/16/2026, revealed .Change18 french foley .cath [catheter] monthly and as needed . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Resident #5 had an indwelling urinary catheter. During an observation on 6/16/2026 at 9:43 AM, with Certified Nursing Assistant (CNA) A and CNA D, in Resident #5's room, revealed both CNAs donned gloves to perform catheter care. The CNAs repositioned Resident #5 in bed. The CNAs explained that they would be providing catheter care and asked for permission for this surveyor to observe catheter care. Resident #5 consented to allow this surveyor to observe catheter care. CNA A provided the catheter care and CNA D stood on the other side of the bed. The CNAs wore gloves during the resident care interaction and no gowns. There was no EBP signage or PPE available in or outside Resident #5's room. During an interview on 6/16/2026 at 9:57 AM, CNA A and CNA D confirmed Resident #5 had a urinary catheter. The CNAs stated gloves were to be worn for catheter care. The CNAs confirmed they had only worn gloves while provided the resident's catheter care. The CNAs stated they were aware of residents in isolation by signage on the door with PPE outside the room. The CNAS were unaware of Enhanced Barrier Precautions. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Anxiety, Retention of Urine, and Palliative Care. Review of the Physician's Orders for Resident #36 dated 12/3/2024, revealed .change 16 fr [French]/10ml [millimeter] foley catheter every month and as needed for blockage/dislodgement . Further review revealed there were no orders for EBP. Review of a quarterly MDS assessment dated [DATE], revealed Resident #36 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further observation revealed Resident #36 had an indwelling urinary catheter. Review of a comprehensive care plan dated 4/3/2026, revealed Resident #36 had a .chronic foley catheter . Review of the physician note for Resident #36 dated 5/19/2026, revealed .chronic urinary retention with indwelling urinary catheter . During an observation on 6/15/2026 at 10:49 AM, revealed Resident #36 had an indwelling catheter attached to side of bed with dignity covering in place. Further observation revealed there was no EBP signage or PPE in or outside Resident #36's room. During an observation on 6/15/2026 at 11:45 AM, in Resident's #36's room, revealed CNA A assisted Resident #36 with repositioning in bed without wearing gloves or a gown. During an observation on 6/16/2026 at 8:40 AM, with CNA B and CNA C, in Resident #36's room, revealed both CNAs donned gloves to perform catheter care. The CNAs repositioned Resident #36 in bed. The CNAs explained that they would be providing catheter care and asked for permission for this surveyor to observe catheter care. Resident #36 consented to allow this surveyor to observe catheter care. CNA C provided the catheter care and CNA B stood on the other side of the bed. The CNAs wore gloves during the resident care interaction and no gowns. There was no EBP signage or PPE available in or outside Resident #36's room. During an interview on 6/16/2026 at 9:00 AM, CNA C stated she does not have any residents on her hall that were on any type of isolation at this time. When asked if she could explain EBP CNA stated she was unaware of EBP. During an interview on 6/16/2026 at 9:00 AM, CNA B stated she does not have any residents on her hall that were on any type of isolation at this time. When asked if she could explain EBP CNA stated she was unaware of EBP. During an interview on 6/16/2026 at 9:15 AM, RN B stated she did not have any residents on her hall that were on any type isolation at this time. During an interview/observation with the Administrator (ADM) on 6/17/2026 at 3:30 PM, in the ADM's office revealed, a discussion of how residents were identified with infections from admission, and while residing in the community of the facility. The ADM stated infections were reviewed during their performance improvement committee meetings, as well as discussion of audits conducted for hand hygiene. The ADM confirmed the facility was not using enhanced barrier precautions until the concern was identified by the survey team. The criteria of enhanced barrier precautions were discussed; at the conclusion of the discussion the ADM voiced the residents who meet the EBP criteria in facility should have had signage and PPE available for staff use at the resident's room. During an interview/observation with the DON, and both Infection Preventionists (IPs) on 6/17/2026 at 3:50 PM, in the DON's office revealed, the discussion arose about tracking and trending infections, both IPs reviewed the tracking data with this surveyor from 1/2026 to present. The data revealed scattered/sparce infections which were color coded by organism on a floor plan map of the facility. The DON voiced the staffing schedules were reviewed for trending of infections. The data did not support the staff spreading organisms. During a telephone interview with the Medical Director (MD) on 6/17/2026 at 4:00 PM, in the DON's office revealed, a discussion regarding the survey team's finding of the non-usage of enhanced barrier precautions protocol within the facility. The lack of knowledge of the term and application of Enhanced Barrier Precautions by facility staff to include administration was discussed. The MD, when asked about EBP, stated she was hesitant to believe the facility staff were unaware of EBP and the protocol used. The MD concluded the discussion with the statement of you must go with your observations. During an interview on 6/17/2026 at 6:11 PM, the Administrator stated the IPs and DON were responsible for keeping up with infection control updates from the CDC and CMS. The Administrator confirmed it was her responsibility to keep up with the newest regulations and confirmed the regulations being used by the facility were from 2022. The Administrator confirmed she was unaware of EBP precautions until 6/16/2026 when surveyors began asking questions.

Based on facility policy review, Infection Preventionist (IP) job description review, Centers for Disease Control and Prevention (CDC) website review, observation, and interview, the facility failed to ensure the IPs practiced using the most current guidance for infection control procedures related to Enhanced Barrier Precautions (EBP). The failure had the potential to affect 37 of 37 residents in the facility. The findings include: Review of the facility policy titled, Infection Control Plan, undated, revealed .Purpose .To provide overall direction to the facility wide Infection Control Program .Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infection . Review of the Infection Preventionist Job Description, undated revealed .Reports to Director of Nursing and/or Administrator .The infection preventionist is responsible for developing, implementing, monitoring, and evaluating the facility's Infection Prevention and Control Program .Essential Job Functions .Monitor communicable diseases and implement appropriate control measures .Analyze infection data and identify opportunities for improvement .Maintain accurate infection logs, surveillance records, and reports .Program Management .Review and update infection control policies and procedures in accordance with current CDC, CMS (Centers for Medicare and Medicaid Services) .and state [agency regulatory] guidelines .Maintain required documentation and reports for regulatory agencies . Review of the CDC website, frequently asked questions, dated, June 28, 2024, revealed .What are Enhanced Barrier Precautions .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. Review of the publication titled, September edition of AHCA's Long-Term Care Survey released 6/29/2022, revealed the documentation the facility was using was not the most current version for information released by CMS as it applies to Enhanced Barrier Precautions (EBP). During interviews conducted with both Ips over the course of the survey on 6/15/2026 through 6/18/2026, revealed both IPs had been in their position for less than a year. Both IPs have completed the online training for Infection Preventionist provided by the CDC. Continued interview revealed the IPs had stated they were unfamiliar with the use of Enhanced Barrier Precautions (EBP) protocol, the facility used standard precautions (hand hygiene and gloving). Further interview revealed the discussion which arose from observations made by the survey team who had identified EBP signage was not present in the facility. An interview and observation were conducted on 6/17/2026 at 4:00 PM, with the Administrator (ADM) and DON, both had confirmed the facility had not used the EPB isolation protocol. The Adm and DON stated the facility was using standard precaution (the use gloves and hand hygiene during patient care) protocol instead of the EBP protocol. The DON stated each month, infections, tracking and trending were discussed, and strategies were formulated for the infection control program. Performance improvement documentation was provided for review of the topics presented in their performance improvement minutes. During an interview on 6/17/2026 at 6:11 PM, the Administrator stated the IPs and DON were responsible for keeping up with infection control updates from the CDC and CMS.

Based on medical record review and interviews, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) was provided to 1 resident (Resident #44) of 3 residents reviewed for beneficiary notices. The findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Congestive Heart Failure, Cellulitis of Right and Left Lower Limb, Unspecified Lack of Coordination, Muscle Weakness, Difficulty in Walking, and Presence of Wound of Right Foot. Review of the PT (Physical Therapy) Discharge Summary for Resident #44 dated 4/29/2026, revealed .4/23/2026 - 4/29/2026 .Discharge Disposition: Skilled Services No Longer Justified .Planned Discharge Destination: SNF .continues to have compromised skin integrity at left ankle with complaints of pain in left foot, thus decreased tolerance to weight bearing mobility and unable to participate in ambulation at this time . Review of the OT (Occupational Therapy) Discharge Summary for Resident #44 dated 4/30/2026, revealed .4/24/2026 - 4/29/2026 .Discharge Disposition: Skilled Services No Longer Justified .Planned Discharge Destination: SNF [Skilled Nursing Facility] .Patient progressed initially but was limited due to increased discomfort in LE [lower extremities] and unable to progress further .dc'd [discontinued] from OT due to achieving max potential at this time . Review of the SNF Beneficiary Protection Notification Review for Resident #44 revealed .Medicare Part A Skilled Services Episode Start Date: 3/26/2026 .Last covered day of Part A Service: 4/29/2026 .How was the Medicare Part A Service Termination/Discharge determined .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Continued review revealed .Was an SNF ABN, Form CMS-10055 provided to the reisdent? .Yes .Was a NOMNC (CMS 10123) provided to the resident .No .Facility unaware 10123 was required in addition to 10055 . During an interview on 6/17/2026 at 3:15 PM, the Social Service Director (SSD) stated she was responsible for the Beneficiary Notices. The SSD confirmed Resident #44 was receiving therapy services and was discharged due to meeting her maximum potential. Resident #44 is a long term care resident and remained in the facility after discharge from therapy. The SSD confirmed the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was issued to Resident #44 on 4/23/2026. The SSD confirmed a NOMNC was not issued to Resident #44. During an interview on 6/17/2026 at 4:55 PM, Physical Therapy Assistant (PTA) A stated Resident #44 was discharged from therapy services due to having met her maximum rehab potential. PTA A confirmed Resident #44's discharge from therapy was a facility initiated discharge because the resident had a plateau in progress due to a wound on her foot. During an interview on 6/17/2026 at 5:39 PM, the Administrator stated there was no facility policy related to Notice of Medicare Non-Coverage. The Administrator confirmed it was her expectation that federal and state regulations were followed.

Based on facility policy review, facility professional standards documentation, medical record review, and interviews the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #5) of 5 residents reviewed for Unnecessary Medications.The findings include: Review of the facility's policy titled, Medication Administration, revised on 3/16/2015, revealed .The nurse is responsible to read and follow precautionary or instructions on prescription labels .the physician's orders are checked for the correct dosage schedule . Review of the facility's policy titled, Physician Orders, revised 6/1/2016, revealed .Physician orders are obtained to provide a clear direction in the care of the resident . Review of an untitled and undated facility document revealed .According to nursing guidelines, including the widely used Lippincott NursingCenter resources, the rights are .Right Patient .Right Medication .Right Dose .Verify the dosage is accurate and appropriate for the patient .Right Route .Right Time . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Congestive Heart Failure and Hypertension. Review of the physician's order dated 8/1/2024, revealed .Metoprolol Succinate [medication use to treat high blood pressure] .ER [Extended Release] .Give 25 mg [milligrams] by mouth one time a day .HOLD AND NOTIFY MD IF BP LESS THAN 90/60 OR PULSE BELOW 60 . Continued review revealed an order for .Sacubitril-Valsartan [medication used to treat chronic heart failure] .24-26 MG .Give 1 tablet by mouth two times a day .HOLD AND NOTIFY MD IF BP LESS THAN 90/60 OR PULSE BELOW 60 . Review of the comprehensive care plan dated 9/13/2024, revealed .The resident has Congestive Heart Failure and HTN [Hypertension] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #5's active diagnoses included Hypertension and Heart Failure. Review of the Medication Administration Record (MAR) dated 5/1/2026 - 5/31/2026, revealed Resident #5 received Metoprolol Succinate ER 25 mg on 5/12/2026 with a blood pressure of 113/53, 5/25/2026 with a blood pressure of 118/52, 5/26/2026 with a blood pressure of 126/50 and pulse of 58, and 5/31/2026 with a blood pressure of 116/58. Continued review revealed Resident #5 received Sacubitril-Valsartan 24-26 mg on 5/1/2026 with a blood pressure of 127/54, 5/8/2026 with a blood pressure of 117/59, 5/12/2026 with a blood pressure of 113/53, 5/18/2026 with a blood pressure of 132/53, 5/25/2026 with a blood pressure of 118/52, 5/26/2026 with a blood pressure of 126/56, 5/29/2026 with a blood pressure of 111/54, 5/30/2026 with a blood pressure of 118/58, and 5/31/2026 with a blood pressure of 116/58. Review of the MAR dated 6/1/2026 - 6/17/2026, revealed Resident #5 received Metoprolol Succinate ER 25 mg on 6/4/2026 with a blood pressure of 124/53, 6/6/2026 with a blood pressure of 116/59, 6/7/2026 with a blood pressure of 112/54, 6/8/2026 with a blood pressure of 106/58, 6/15/2026 with a blood pressure of 137/56, and 6/17/2026 with a blood pressure of 118/51. Continued review revealed Resident #5 received Sacubitril-Valsartan 24-26 mg on 6/2/2026 with a blood pressure of 103/47, 6/4/2026 with a blood pressure of 124/53, 6/6/2026 with a blood pressure of 116/59, 6/7/2026 with a blood pressure of 112/54, 6/8/2026 with a blood pressure of 106/58, 6/9/2026 with a blood pressure of 135/58, 6/13/2026 with a blood pressure of 102/55, twice on 6/15/2026 with blood pressures of 137/56 and 137/59, and 6/17/2026 with a blood pressure of 118/51. During an interview on 6/17/2026 at 2:21 PM, Registered Nurse (RN) A stated medications not administered would be indicated on the MAR with a reason why the medication was not administered. RN A confirmed Resident #5 had an order for Metoprolol 25 mg by mouth daily with parameters to notify the physician and hold for blood pressure less than 90/60 or pulse less than 60. RN A confirmed she administered Resident #5's Metoprolol on 5/31/2026 with a blood pressure of 116/58, 6/15/2026 with a blood pressure of 137/56, and 6/17/2025 with a blood pressure of 118/51. RN A confirmed Resident #5 also had an order for Sacubitril-Valsartan 24-26 mg 1 tablet by mouth twice daily with parameters to hold and notify the physician for blood pressure less than 90/60 or pulse less than 60. RN A confirmed she administered the medication on 5/31/2026 with a blood pressure of 116/58, 6/15/2026 with blood pressure of 137/56, and 6/17/2026 with blood pressure of 118/51. RN A confirmed she had not notified the physician and the medication should have been held according to physician orders. During a telephone interview on 6/17/2026 3:18 PM, the Medical Director confirmed it was her expectation that physician's orders were followed. The Medical Director confirmed Resident #5's Metoprolol and Sacubitril-Valsartan were to be held and the physician notified for systolic blood pressure less than 90, diastolic blood pressure less than 60, or pulse less than 60. It was the Medical Director's expectation that she be notified and the decision would be made whether the medication was to be given or not. The Medical Director stated she was unaware the medication was being given with diastolic blood pressures less than 60. The Medical Director stated it would be unlikely that she would have ordered the medication to be held for diastolic blood pressure less than 60 and it was more likely she would have discontinued the diastolic blood pressure parameter if she had been notified. The MD stated it was unlikely administration of either medication with a diastolic blood pressure less than 60 would cause any harm and was unaware of any negative outcomes to the resident as a result During an interview on 6/17/2026 at 5:41 PM, the Director of Nursing (DON) stated the facility followed [NAME] professional standards of practice for medication administration. Resident #5 had an order for Metoprolol 25 mg by mouth daily with parameters to hold and notify the physician if blood pressure less than 90/60 or pulse less than 60. The DON confirmed nurses were to verify the physician's order to ensure the medication was administered according to physician's orders. The DON confirmed Resident #5 received the Metoprolol on 5/12/2026, 5/25/2026, 5/26/2026, 5/31/2026, 6/4/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/15/2026, and 6/17/2026 in error according to Resident #5's diastolic blood pressure below 60. The DON confirmed Resident #5 had an order for Sacubitril-Valsartan 24-26 mg po twice daily with parameters to hold and notify the physician if blood pressure was less than 90/60 or pulse less than 60. The DON confirmed Resident #5 received the Sacubitril-Valsartan on 5/1/2026, 5/8/2026, 5/12/2026, 5/18/2026, 5/25/2026, 5/26/2026, 5/29/2026, 5/30/2026, 5/31/2026, 6/2/2026, 6/4/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/9/2026, 6/13/2026, 6/15/2026, and 6/17/2026 in error according to Resident #5's diastolic blood pressure less than 60. The DON confirmed Resident #5's medication rights for right dose were not followed and the dose should have been held according to the parameters. The DON confirmed there was no evidence that the physician had been notified.

Based on facility policy review, professional standards review, medical record review, observation and interview, the facility failed to provide services which met professional standards of practice when a Registered Nurse (RN) #1 failed to administer essential medications, including anti-hypertensives, cardiac medications, and insulin, as ordered by the resident's physician, and failed to notify the physician when the essential medications had been withheld for 3 residents (Resident #3, #13, and #22) of 7 residents reviewed for medication administration. The facility's failure had the potential to create negative adverse outcomes to Residents #3, #13 and #22 and had the potential to affect all residents of the facility. The facility's failure created an immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment, or death to a resident). The Immediate Jeopardy (IJ) of F658 was cited at a scope and severity of K and was effective 8/12/2023-9/21/2023. The Administrator was informed of the Immediate Jeopardy on 9/21/2023 at 11:27 AM. An Acceptable Allegation of Compliance was received on 9/21/2023 and verified on site on 9/22/2023. F658 remains at a scope and severity of E, and the facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/2014, showed .A medication error is defined as the preparation or administration of drugs and biological which is not in accordance with physician's orders .or accepted professional standards . Review of the accepted standard used by the facility titled, Medication Administration: NCLEX [National Council Licensure Examination]-RN, dated 9/2023, showed .Nurses are legally and ethically responsible and accountable for accurate and complete .documentation .All medications that are .held or refused by the patient must be documented in .medication record in addition to other data like vital signs .as indicated by .the doctor's order . Resident #3 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Unspecified Dementia, Chronic Pain Syndrome, Impulse Disorder, Heart Failure, Mood Disorder, Insomnia, Personal History of Transient Ischemic Attack (TIA), Psychosis, and Paroxysmal Atrial Fibrillation (an irregular heartbeat). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had severe cognitive impairment and required limited assistance of 1 staff member for eating. On the 7-day look back, antipsychotic medications, anticoagulant medications and antidepressant medications were given on 7 days, and the resident had no swallowing disorders. Review of Resident #3's physician's orders with dates showed the following: Depakote (a medication used to treat mood disorder) Extended Release (ER) 500 milligram (mg, a unit of measure), daily at bedtime (HS), dated 2/11/2022, Mirtazapine (a medication used to treat Depression) 7.5 mg, give 1 tablet HS, dated 3/14/2022, Seroquel (a medication used to treat Psychosis and Depression) 200 mg, give 1 tablet HS, dated 4/14/2022, Carvedilol (a medication used to treat Heart Failure) 3.125 mg, give 1 tablet twice daily (BID), hold and notify physician if blood pressure (BP) is less than 90/60 or pulse is less than 60, dated 12/22/2021, Acetaminophen (a medication used to treat pain) 500 mg, give 2 tablets to equal 1000 mg BID, dated 4/4/2022. Docusate Sodium (a medication used to treat occasional constipation) 100 mg, give 1 tablet BID, dated 12/8/2022 and Eliquis (a medication that thins the blood) 2.5 mg, give 1 tablet BID, dated 4/23/2022. Review of a psychiatry follow up note, for Resident #3, dated 8/4/2023 showed, .Follow up regarding mood disorder, insomnia .Staff deny any recnet [recent] psychosis .Cognition remains at baseline .Staff report mood remains stable .Sleep remains stable with Mirtazapine 7.5mg .[Resident #3] appeared to be calm and not in distress . Also, the current medications of Depakote 500 mg HS, Mirtazapine 7.5 mg HS, Seroquel 200 mg HS were reviewed by the psychiatric provider. Gradual dose reduction (GDR) comments stated, .Continued use of current psychotropic medication(s) is in accordance with the current standards of practice. It is my assessment that a GDR is contraindicated at this time as target symptoms are unstable . this [resident] is at high risk for decompensation if a GDR were attempted . Review of Resident #3's Medication Administration Record (MAR) dated 8/2023 showed the medication of Depakote ER 500 mg BID, Mirtazapine 7.5 mg HS, Seroquel 200 mg HS, Docusate Sodium 100 mg BID, Carvedilol 3.125 mg BID, Acetaminophen 500 mg BID and Eliquis 2.5 mg BID had not been administered as ordered by the physician on 8/12/2023 at 9:00 PM by RN #1. The vital signs documented for 8/12/2023 were a BP of 124/64, Pulse 80 and was within the parameters for the administration for the anti-hypertensives. It was documented that Resident #3 had no pain at 7:00 AM, 3:00 PM and 11:00PM. On 8/13/2023, the vital signs documented were BP 127/70, Pulse 76 and no pain at 7:00 AM, 3:00 PM and 11:00PM which showed no adverse changes in the vital signs related to the omission of the medications. There was no rationale documented on the omission of the ordered medications by RN #1or that RN #1 had notified the physician after the medications had been withheld. During a telephone interview on 9/19/2023 at 4:36 PM, RN #1 confirmed he had worked on 8/12/2023 and had not administered the 9:00 PM doses of Depakote ER 500 mg, Mirtazapine 7.5 mg, Seroquel 200 mg, Docusate Sodium 100 mg, Carvedilol 3.125 mg, Acetaminophen 500 mg and Eliquis 2.5 mg on 8/12/2023 to Resident #3 according to the physician's orders and had failed to notify the physician when the medications had been withheld. Continued interview revealed RN #1 had not documented a rationale as to why the medications had not been administered and was unable to provide an explanation during the interview. Resident #13 was admitted to the facility 8/25/2023 with diagnoses including End Stage Renal Disease, Acute on Chronic Diastolic Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Dementia, Pulmonary Edema, Hyperlipidemia, Asthma, Anxiety, Hypertension, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], showed Resident #13 had moderate cognitive impairment. Resident #13 received insulin injections on 3 of the 7 days of the look back period and the resident received dialysis services. Review of Resident #13's physician's orders with dates showed the following: Lisinopril (a medication used to treat high blood pressure) 40 mg by mouth daily. It was noted .CHECK BP AND PULSE BEFORE ADMIN [administration]., IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD [medical doctor] . dated 8/27/2023. Carvedilol 25 mg by mouth twice daily. It was noted .CHECK BP AND PULSE BEFORE ADMIN., IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023. Clonidine (a medication used to treat high blood pressure) 0.2 mg by mouth three times daily for Hypertension. It was noted .CHECK BP AND PULSE BEFORE ADMIN, IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023. Amlodipine Besylate (a medication used to treat high blood pressure) 10 mg by mouth daily, with note .CHECK BP AND PULSE BEFORE ADMIN., IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD . dated 8/27/2023. Hydralazine (a medication used to treat high blood pressure) 50 mg was noted to give 2 tablets by mouth three times daily, and it was noted .PRIOR TO ADMIN CHECK BP AND PULSE IF BP IS LESS THAN 90/60 OR PULSE IS LESS THAN 60 HOLD AND NOTIFY MD . dated 8/28/2023. Insulin Lispro (a medication that lowers the level of sugar in the blood) 100 units/milliliter (ml) showed, .Give sliding scale subcutaneously as follows per sliding scale: [for a measured blood glucose of the following values, give the dictated amount of insulin] 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 10 units, 351-400 = 12 units. If 400 and above give 14 units and notify md . dated 8/28/2023 and discontinued on 9/7/2023, and .Notify MD of blood glucose less than or equal to 60 or greater than 400, follow MD orders. Hold all insulin if blood glucose less than 100 . dated 8/28/2023. Glimepiride (a medication used to treat Diabetes) 1 mg by mouth twice daily, showed .HOLD FOR BLOOD GLUCOSE LESS THAN 70 . dated 9/1/2023 and discontinued on 9/8/2023. Lantus Solostar (a medication used to treat Diabetes) 100 unit/ml was noted to give 8 units subcutaneously every night and hold if the resident's blood glucose was less than 100 dated 9/8/2023. During observation and interview on 9/19/2023 at 3:35 PM, of Resident #13's MAR dated 9/2023 with RN #1, showed the following: 9/1/2023 a BP of 124/72 and Pulse of 76. 9/3/2023 a BP of 122/70 and Pulse of 76. 9/4/2023 a BP of 119/68 and Pulse of 67. 9/5/2023 a BP and Pulse had not been documented. 9/9/2023 a BP of 116/72 and Pulse of 74. Continued review showed Lisinopril 40 mg- 1 tablet by mouth had not been administered on 9/1/2023, 9/3/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM dose of Carvedilol 25 mg had not been administered on 9/1/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM dose of Clonidine 0.2 mg had not been administered on 9/1/2023, 9/5/2023, and 9/9/2023 and the 9:00 PM dose of Hydralazine 50 mg had not been administered on 9/1/2023, 9/4/2023, and 9/9/2023. The MAR showed the documented BP's and pulses were within the parameters noted in the physician's orders for the administration of the anti-hypertensive and cardiac medications. Glimepiride 1 mg had not been administered on 9/1/2023 (blood glucose 112), 9/2/2023 (blood glucose 106), 9/3/2023 (blood glucose 167), 9/4/2023 (blood glucose 84), and 9/5/2023 (blood glucose 110). The Insulin Lispro 100 unit/ml pen, 4:30 PM dose had not been administered on 9/3/2023 (blood glucose 167), and the resident should have received 2 units; the 9:00 PM dose had not been administered on 9/5/2023 (blood glucose 246), and the resident should have received 4 units; the 4:30 PM dose had not been administered on 9/6/2023 (blood sugar 315), and the resident should have received 10 units; the 9:00 PM dose had not been administered on 9/6/2023 (blood glucose 173), and the resident should have received 2 units. The Lantus Solostar 100 units/ml. Give 8 units subcutaneously every night, had not been administered on 9/9/2023 (blood glucose 340), 9/13/2023 (blood glucose 198), and 9/14/2023 (blood glucose 187). RN #1 confirmed the medication had not been administered as ordered by the physician and had failed to notify the physician when the medications had been withheld. Resident #22 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including End Stage Renal Disease, Anemia, Heart Failure, and Hypertension. Review of a quarterly MDS assessment dated [DATE] showed Resident #22 was cognitively intact, required supervision with eating and had received 7 days of injections of insulin, 7 days of antianxiety medications, 7 days of antidepressant medications and 6 days of opioids during the 7-day look back period. Continued review showed the resident received dialysis services. Review of Resident #22's physician's orders and dates showed the following: Metoprolol Tartrate (a medication used to treat high blood pressure and Atrial Fibrillation) 50 mg tablet give 1 tablet by mouth twice daily. Hold if BP less than 90/60 or Pulse below 60 and notify Medial Doctor (MD) dated 5/25/2023. Hydralazine 25 mg tablet give 1 tablet by mouth twice daily. Hold if BP is less than or equal to 90/60 or Pulse is less than 60 dated 7/13/2023. Review of Resident #22's MAR dated 9/2023 showed the following: 9/4/2023 at 6:00 PM, a BP of 118/69 and Pulse of 72 9/6/2023 at 6:00 PM, a BP of 122/71 and Pulse of 65. 9/9/2023 at 6:00 PM, a BP of 133/62 and Pulse of 62. 9/10/2023 at 6:00 PM, a BP of 158/76 and Pulse of 68. The 6:00 PM dose of Metoprolol Tartrate 50 mg had not been administered on 9/4/2023, 9/6/2023, 9/9/2023, and 9/10/2023. The 6:00 PM dose of Hydralazine 25 mg had not been administered on 9/4/2023, 9/6/2023, and 9/10/2023. The MAR showed N (not given) in the initial box with RN #1's initials for those days. Continued review showed no documented rationale as to why the medications had been withheld. During an interview on 9/19/2023 at 2:29 PM, RN #1 confirmed the medications for Residents #3, #13 and #22 had not been administered as ordered by the physician. RN #1 further confirmed he was aware the physician's orders, and the BP, pulse, and blood glucose were within the designated parameters for the medications to be administered. The RN stated he had not administered the BP medications or the insulin because he was afraid the resident's blood pressure and blood sugar would drop to low. RN #1 stated he was aware of the procedure to document a rationale when a medication was not administered and to notify the physician. RN #1 also confirmed he had failed to notify the physician when he withheld the essential medications for Residents #3, #13, and #22. RN #1 also confirmed he had failed to document a rationale for the omission of the medications. During an interview on 9/20/2023 at 4:37 PM, the Administrator and DON stated it was their expectation that the physician was notified when a medication was not administered and that medications were administered according to the physician's orders. The DON confirmed RN #1 had failed to administer essential medications as ordered for Residents #3, #13 and #22, failed to document the rationale for the omitted medications, and had failed to notify the physician when the medications had been withheld. Continued interview with the DON confirmed RN #1 had not followed the facility's policy on medication administration and had not met the professional standards of practice for medication administration. During a telephone interview on 9/20/2023 at 8:51 AM, the Medical Director revealed it was her expectation the prescribed orders were to be followed as written with the parameters set for BP, pulse, and blood glucose levels and to be notified when the medications had not been administered. The Medical Director further stated it was her expectation when a medication was withheld a rationale was to be documented in the residents' medical records. On 9/19/2023, the Medical Director stated she had not been made aware the medications for Residents #3, #13, and #22 had not been administered as ordered until after it had been identified by the State Agency. The Medical Director stated Resident #13's long term glycemic control was maintained with the insulin and Glimepiride, and no immediate harm was noted. However, not maintaining the blood glucose undermines the glycemic control. She stated Residents #3, #13 and #22 had not suffered any complications or had required medical interventions after the medications had been withheld. On 9/22/2023, Surveyors reviewed the education sign in sheets and new audit forms implemented which validated the corrective action plans onsite. Surveyors reviewed the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheet and interviewed QAPI members regarding the ad-hoc meeting that occurred on 9/19/2023 which discussed the implementation of the medication pass audit and the Medication Administration Record (MAR) audit. Attendees of the ad-hoc QAPI meeting included Minimum Data Set (MDS) Coordinator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Operations, and the Administrator. Surveyors verified onsite the implementation of the medication pass audit and Medication Administration Record (MAR) audits. Surveyors reviewed medication pass audits, interviewed staff, and reviewed education sign in sheets for education provided that included medication error and medication hold procedure. Surveyors verified that 100% of facility nurses had received the education by reviewing education sign in sheets and interviewing staff present in the facility. Surveyors reviewed the MAR audits for all in house residents and the daily audit form of non-administered medications to be completed 5 days per week by the DON, ADON, or MDS Coordinator. Registered Nurse (RN) #1 was suspended by the facility on 9/19/2023 and terminated on 9/21/2023.

Based on facility policy review, medical record review, and interview the facility failed to ensure essential medications were administered as ordered by the physician and failed to notify the physician when the medications had been withheld, which had the potential to alter therapeutic drug levels and create negative adverse outcomes for 3 residents (Resident #3, #13, and #22) of 7 residents sampled for medication administration. The facility's failure placed Resident #3, Resident #13, Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment, or death to a resident) and had the potential to affect all residents of the facility. The Immediate Jeopardy (IJ) of F684 was cited at a scope and severity of K and was effective 8/12/2023-9/21/2023. The Administrator was informed of the Immediate Jeopardy on 9/21/2023 at 11:27 AM. An Acceptable Allegation of Compliance was received on 9/21/2023 and verified on site on 9/22/2023. F684 remains at a scope and severity of E and the facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/2014, .A medication error is defined as the preparation or administration of drugs and biological which is not in accordance with physician's orders .or accepted professional standards .Examples of medication errors include: omission-a drug is ordered but not administered .The attending physician is notified of any medication error . Resident #3 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Unspecified Dementia, Chronic Pain Syndrome, Impulse Disorder, Heart Failure, Mood Disorder, Insomnia, Personal History of Transient Ischemic Attack (TIA), Psychosis, and Paroxysmal Atrial Fibrillation (an irregular heartbeat which returns to normal within 7 days). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had severe cognitive impairment and required limited assistance with eating. Received 7 days of antipsychotic, anticoagulant, and antidepressant medications for the 7-day look back period. Review of Resident #3's physician's orders with dates showed the following: Depakote (a medication used to treat mood disorder) Extended Release (ER) 500 milligram (mg) at bedtime (HS), dated 2/11/2022. Mirtazapine (a medication used to treat Depression) 7.5 mg at HS, dated 3/14/2022, Seroquel (a medication used to treat bipolar disorder, psychosis and depression) 200 mg at HS, dated 4/14/2022, Carvedilol (a medication used to treat Heart Failure) 3.125 mg, give 1 tablet twice daily (BID), hold and notify physician if blood pressure (BP) is less than 90/60 or Pulse is less than 60, dated 12/22/2021, Acetaminophen (a medication used to treat pain) 500 mg, give 2 tablets to equal 1000 mg BID, dated 4/4/2022, Docusate Sodium (a medication used to treat occasional constipation) 100 mg, give 1 tablet BID, dated 12/8/2022, and Eliquis (a medication used to treat Atrial Fibrillation) 2.5 mg, give 1 tablet BID, dated 4/23/2022. Review of a Medication Administration Record (MAR) dated 8/2023, showed the medications for Resident #3 for Depakote ER 500 mg, BID, Mirtazapine 7.5 mg HS, Seroquel 200 mg HS, Docusate Sodium 100 mg BID, Carvedilol 3.125 mg BID, Acetaminophen 500 mg BID and Eliquis 2.5 mg BID had not been administered as ordered on 8/12/2023 at 9 PM by RN #1. The vital signs documented for 8/12/2023 were a BP of 124/64, Pulse 80 and no pain at 7:00 AM, 3:00 PM and 11:00 PM. On 8/13/2023, the documented vital signs were BP 127/70, Pulse 76 and no pain at 7:00 AM, 3:00 PM and 11:00PM. There was no documentation stating why the medications were held or that the RN had notified the physician. Resident #13 was admitted to the facility 8/25/2023 with diagnoses including End Stage Renal Disease, Acute on Chronic Diastolic Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Dementia, Pulmonary Edema, Hyperlipidemia, Asthma, Anxiety, Hypertension, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], showed Resident #13 had moderate cognitive impairment. Resident #13 received insulin injections on 3 of the 7 days of the look back period. Continued review showed the resident received dialysis services. Review of Resident #13's physician's orders with dates showed the following: Lisinopril (a medication used to treat high blood pressure) 40 mg by mouth daily. It was noted .CHECK BP AND PULSE BEFORE ADMIN [administration] .IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD [medical doctor] . dated 8/27/2023. Carvedilol 25 mg by mouth twice daily.CHECK BP AND PULSE BEFORE ADMIN., IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023, Clonidine (a medication used to treat high blood pressure) 0.2 mg by mouth three times daily .CHECK BP AND PULSE BEFORE ADMIN, IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023, Amlodipine Besylate (a medication used to treat high blood pressure) 10 mg by mouth daily .CHECK BP AND PULSE BEFORE ADMIN., IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD . dated 8/27/2023, Hydralazine (a medication used to treat high blood pressure) 50 mg give 2 tablets by mouth three times daily, .PRIOR TO ADMIN CHECK BP AND PULSE IF BP IS LESS THAN 90/60 OR PULSE IS LESS THAN 60 HOLD AND NOTIFY MD . dated 8/28/2023, Insulin Lispro (a medication used to treat Diabetes) 100 units/milliliter (ml) showed, .Give sliding scale subcutaneously as follows per sliding scale: [for a measured blood glucose of the following values, give the dictated amount of insulin] 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 10 units, 351-400 = 12 units. If 400 and above give 14 units and notify md . dated 8/28/2023 and was discontinued on 9/7/2023, .Notify MD of blood glucose less than or equal to 60 or greater than 400, follow MD orders. Hold all insulin if blood glucose less than 100 . dated 8/28/2023, Glimepiride (a medication used to treat Diabetes) 1 mg by mouth twice daily, showed .HOLD FOR BLOOD GLUCOSE LESS THAN 70 . dated 9/1/2023 and was discontinued on 9/8/2023, and for the Lantus Solostar (a medication to treat Diabetes) 100 unit/ml give 8 units subcutaneously every night and hold if the resident's blood glucose if less than 100 dated 9/8/2023. During an observation of Resident #13's MAR dated 9/2023 and interview with RN #1 on 9/19/2023 at 3:35 PM, showed the following: 9/1/2023 a BP of 124/72 and Pulse of 76 9/3/2023 a BP of 122/70 and Pulse of 76 9/4/2023 a BP of 119/68 and Pulse of 67 9/5/2023 a BP or Pulse was not documented 9/9/2023 a BP of 116/72 and Pulse of 74 Lisinopril 40 mg- 1 tablet by mouth had not been administered on 9/1/2023, 9/3/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM dose of Carvedilol 25 mg had not been administered on 9/1/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM doses of Clonidine 0.2 mg had not been administered on 9/1/2023, 9/5/2023, and 9/9/2023 The 9:00 PM dose of Hydralazine 50 milligrams had not been administered on 9/1/2023, 9/4/2023, and 9/9/2023. The MAR showed the documented BP's and pulses were within the designated parameters for the medication administration as ordered by the physician. Glimepiride 1 mg had not been administered on 9/1/2023 (blood glucose 112), 9/2/2023 (blood glucose 106), 9/3/2023 (blood glucose 167), 9/4/2023 (blood glucose 84), and 9/5/2023 (blood glucose 110). Insulin Lispro 100 unit/ml pen, 4:30 PM dose had not been administered on 9/3/2023 (blood glucose 167), and the resident should have received 2 units; the 9:00 PM dose had not been administered on 9/5/2023 (blood glucose 246), and the resident should have received 4 units; the 4:30 PM dose had not been administered on 9/6/2023 (blood sugar 315), and the resident should have received 10 units; the 9:00 PM dose had not been administered on 9/6/2023 (blood glucose 173), and the resident should have received 2 units. The Lantus Solostar 100 units/ml. Give 8 units subcutaneously every night and had not been administered on 9/9/2023 (blood glucose 340), 9/13/2023 (blood glucose 198), and 9/14/2023 (blood glucose 187). RN #1 confirmed the medications had not been administered as ordered. Resident #22 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including End Stage Renal Disease, Anemia, Heart Failure, and Hypertension. Review of a quarterly MDS assessment dated [DATE] showed Resident #22 was cognitively intact, required supervision with eating, and had received 7 days of injections of insulin, antianxiety and antidepressant medications, and 6 days of opioid medications during the 7- day look back period. Continued review showed the resident received dialysis services. Review of Resident #22's physician's orders with dates showed the following: Metoprolol Tartrate (a medication used to treat high Blood Pressure and Atrial Fibrillation) 50 mg tablet give 1 tablet by mouth twice daily. Hold if BP less than 90/60 or Pulse below 60 and notify MD dated 5/25/2023, Hydralazine 25 mg tablet give 1 tablet by mouth twice daily. Hold if BP is less than or equal to 90/60 or Pulse is less than 60 dated 7/13/2023. Review of Resident #22's MAR dated 9/2023 showed the following: 9/4/2023 at 6:00 PM a BP of 118/69 and Pulse of 72 9/6/2023 at 6:00 PM a BP of 122/71 and Pulse of 65 9/9/2023 at 6:00 PM a BP of 133/62 and Pulse of 62 9/10/2023 a BP of 158/76 and a Pulse of 68 The 6:00 Pm dose of Metoprolol Tartrate 50 mg not been administered on 9/4/2023, 9/6/2023, 9/9/2023, and 9/10/2023. Hydralazine 25 mg had not been administered on 9/4/2023, 9/6/2023, and on 9/10/2023. The documentation showed an N (not given) in the initial box with RN #1's initials. Continued review showed a rationale had not been documented when the medications had been withheld. During an interview on 9/19/2023 at 2:29 PM, RN #1 stated he was aware of the facility's policy to document a rationale when medications were not administered and to notify the physician if the ordered medications had been withheld. RN #1 confirmed the physician was not notified of the omitted medications, and the essential medications had not been administered to Residents #3, #13, and #22 as ordered by the physician on the listed dates. During an interview on 9/20/2023 at 4:37 PM, the Administrator and the DON stated it was their expectation that the physician was notified when a medication was not administered and that medications were administered as ordered by the physician. The DON confirmed the following medications had not been administered according to the physician's orders for the following residents and dates: Resident #3's Depakote, Mirtazapine, Seroquel, Docusate Sodium, Eliquis, Carvedilol and Acetaminophen on 8/12/2023. Resident #13's Lisinopril on 9/1/2023, 9/3/2023, 9/4/2023, 9/5/2023, and 9/9/2023, 9:00 PM dose of Carvedilol on 9/1/2023, 9/4/2023, 9/5/2023, and 9/9/2023, 9:00 PM dose of Clonidine on 9/1/2023, 9/5/2023, and 9/9/2023, 9:00 PM dose of Hydralazine on 9/1/2023, 9/4/2023, and 9/9/2023, 5:00 PM dose of Glimepiride on 9/1/2023, 9/2/2023, 9/3/2023, 9/4/2023, and 9/5/2023, 4:30 PM dose of sliding scale Lispro insulin on 9/3/2023 and 9/6/2023, 9:00 PM dose of sliding scale Lispro insulin on 9/5/2023 and 9/6/2023, 9:00 PM dose of Lantus insulin on 9/9/2023, 9/13/2023, and 9/14/2023. Resident #22's Metoprolol Tartrate on 9/4/2023, 9/6/2023, 9/9/2023 and 9/10/2023, and Hydralazine on 9/4/2023, 9/6/2023, and 9/10/2023. The DON confirmed RN #1 had not followed the facility's policy or professional standards of practice for medication administration and had not notified the physician of the medication omissions. However, the residents were placed at risk for harm by the omission of essential life sustaining medications. The DON and Administrator confirmed they had not been made aware of the medication omissions and did not have an effective auditing system to monitor for medication omissions. The DON and Administrator had not been made aware of any concerns related to medication administration until it was brought to their attention by the survey team on 9/19/2023. During a telephone interview on 9/20/2023 at 8:51 AM, the Medical Director revealed she expected for the prescribed orders to be followed with the parameters set for the B/P, Pulse, and blood glucose. The Medical Director stated if medications were not administered as ordered, it was expected a rationale be documented for not administering the medication in the residents' medical records and she was to be notified of the omitted medications. The Medical Director stated before 9/19/2023, she had not been made aware the medications had not been administered as ordered for Residents #3, #13, and #22. The Medical Director further stated Resident #13's long term glycemic control was maintained with the use of insulin and Glimepiride medications. She also stated no immediate harm or serious adverse outcome was noted to Resident #13, but letting Blood Sugars go untreated undermined the glycemic control. The Medical Director stated she had not been made aware of any residents suffering any complications, and the residents had not required any new orders or medical interventions since the medications were omitted. On 9/22/2023, Surveyors reviewed the education sign in sheets and new audit forms implemented which validated the corrective action plans onsite. Surveyors reviewed the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheet and interviewed QAPI members regarding the ad-hoc meeting that occurred on 9/19/2023 which discussed the implementation of the medication pass audit and the Medication Administration Record (MAR) audit. Attendees of the ad-hoc QAPI meeting included Minimum Data Set (MDS) Coordinator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Operations, and the Administrator. Surveyors verified onsite the implementation of the medication pass audit and Medication Administration Record (MAR) audits. Surveyors reviewed medication pass audits, interviewed staff, and reviewed education sign in sheets for education provided that included medication error and medication hold procedure. Surveyors verified that 100% of facility nurses had received the education by reviewing education sign in sheets and interviewing staff present in the facility. Surveyors reviewed the MAR audits for all in house residents and the daily audit form of non-administered medications to be completed 5 days per week by the DON, ADON, or MDS Coordinator. Registered Nurse (RN) #1 was suspended by the facility on 9/19/2023 and terminated on 9/21/2023.

Based on facility policy review, medical record review, and interview, the facility failed to ensure 3 residents (Residents #3, #13, and #22) of 7 residents reviewed for Medication Administration were free of any significant medication errors when a Registered Nurse (RN) #1 failed to administer anti-hypertensives, cardiac medications, and insulin to the residents and failed to notify the physician after the essential medications had been omitted. The RN's failure to administer essential medications as ordered by the physician placed Residents #13 and #22 in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment, or death to a resident) and had the potential to affect all residents in the facility. The Immediate Jeopardy (IJ) of F760 was cited at a scope and severity of K and was effective 8/12/2023-9/21/2023. The Administrator was informed of the Immediate Jeopardy on 9/21/2023 at 11:27 AM. An Acceptable Allegation of Compliance was received on 9/21/2023 and verified on site on 9/22/2023. F760 remains at a scope and severity of E and the facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/2014, showed .A medication error is defined as the preparation or administration of drugs and biological which is not in accordance with physician's order .or accepted professional standards .Examples of medication errors include: omission-a drug is ordered but not administered .In the event of a significant medication-related error .immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: requiring medication discontinuation or dose modification (A current list of medications that should not be abruptly discontinued should be consulted before discontinuing a medication) .The attending physician is notified promptly of any significant error . Resident #3 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Unspecified Dementia, Chronic Pain Syndrome, Impulse Disorder, Heart Failure, Mood Disorder, Insomnia, Personal History of Transient Ischemic Attack (TIA), Psychosis, and Paroxysmal Atrial Fibrillation (an irregular heartbeat). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had severe cognitive impairment and required limited assistance of 1 staff member for eating. On the 7-day look back, antipsychotic medications, anticoagulant medications and antidepressant medications were given on 7 days, and the resident had no swallowing disorders. Review of Resident #3's physician's orders with dates showed the following: Depakote (a medication used to treat mood disorder) Extended Release (ER) 500 milligram (mg, a unit of measure), daily at bedtime (HS), dated 2/11/2022, Mirtazapine (a medication used to treat Depression) 7.5 mg, give 1 tablet HS, dated 3/14/2022, Seroquel (a medication used to treat Psychosis and Depression) 200 mg, give 1 tablet HS, dated 4/14/2022, Carvedilol (a medication used to treat Heart Failure) 3.125 mg, give 1 tablet twice daily (BID), hold and notify physician if blood pressure (BP) is less than 90/60 or pulse is less than 60, dated 12/22/2021, Acetaminophen (a medication used to treat pain) 500 mg, give 2 tablets to equal 1000 mg BID, dated 4/4/2022. Docusate Sodium (a medication used to treat occasional constipation) 100 mg, give 1 tablet BID, dated 12/8/2022 and Eliquis (a medication that thins the blood) 2.5 mg, give 1 tablet BID, dated 4/23/2022. Review of Resident #3's Medication Administration Record (MAR) dated 8/2023 showed the medication of Depakote ER 500 mg BID, Mirtazapine 7.5 mg HS, Seroquel 200 mg HS, Docusate Sodium 100 mg BID, Carvedilol 3.125 mg BID, Acetaminophen 500 mg BID and Eliquis 2.5 mg BID had not been administered by RN #1 as ordered by the physician on 8/12/2023 at 9:00 PM. The vital signs documented for 8/12/2023 were a BP of 124/64, Pulse 80 and was within the parameters for the administration for the anti-hypertensives. It was documented that Resident #3 had no pain at 7:00 AM, 3:00 PM and 11:00PM. On 8/13/2023, the vital signs documented were BP 127/70, Pulse 76 and no pain at 7:00 AM, 3:00 PM and 11:00PM which showed no adverse changes in the vital signs related to the omission of the medications. There was no rationale documented on the omission of the ordered medications by RN #1or that RN #1 had notified the physician after the medications had been withheld. Resident #13 was admitted to the facility 8/25/2023 with diagnoses including End Stage Renal Disease, Acute on Chronic Diastolic Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Dementia, Pulmonary Edema, Hyperlipidemia, Asthma, Anxiety, Hypertension, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #13 had moderate cognitive impairment. Resident #13 received insulin injections on 3 of the 7 days of the look back period. The resident received dialysis services. Review of Resident #13's Physician's Orders with dates showed the following: Lisinopril (a medication used to treat high blood pressure) 40 milligram (mg) by mouth daily .CHECK BP AND PULSE BEFORE ADMIN [administration] .IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD [medical doctor] . dated 8/27/2023, Carvedilol (a medication used to treat high blood pressure) 25 mg by mouth twice daily .CHECK BP AND PULSE BEFORE ADMIN .IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023, Clonidine (a medication used to treat high blood pressure) 0.2 mg by mouth three times daily for hypertension .CHECK BP AND PULSE BEFORE ADMIN, IF BP BELOW 90/60 OR PULSE BELOW 60 HOLD AND NOTIFY MD . dated 8/27/2023, Amlodipine Besylate (a medication used to treat high blood pressure) 10 mg by mouth daily .CHECK BP AND PULSE BEFORE ADMIN .IF BP BELOW 90/60 OR PULSE BELOW 60, HOLD AND NOTIFY MD . dated 8/27/2023, Hydralazine (a medication used to treat high blood pressure) 50 mg give 2 tablets by mouth three times daily, .PRIOR TO ADMIN CHECK BP AND PULSE IF BP IS LESS THAN 90/60 OR PULSE IS LESS THAN 60 HOLD AND NOTIFY MD . dated 8/28/2023, Insulin Lispro (a medication that lowers the level of sugar in the blood) 100 units/milliliter (ml) showed, .Give sliding scale subcutaneously as follows per sliding scale: [for a measured blood glucose of the following values, give the dictated amount of insulin] 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 10 units, 351-400 = 12 units. If 400 and above give 14 units and notify md . dated 8/28/2023 and discontinued on 9/7/2023 .Notify MD of blood glucose less than or equal to 60 or greater than 400, follow MD orders. Hold all insulin if blood glucose less than 100 . dated 8/28/2023, Glimepiride (a medication used to treat Diabetes) 1 mg by mouth twice daily, showed .HOLD FOR BLOOD GLUCOSE LESS THAN 70 . dated 9/1/2023 and discontinued on 9/8/2023, Lantus Solostar (a medication used to treat Diabetes) 100 unit/ml was noted to give 8 units subcutaneously (an injection under the skin) every night and hold if the resident's blood glucose was less than 100 dated 9/8/2023. During an observation and interview on 9/19/2023 at 3:35 PM, with RN #1 of Resident #13's MAR dated 9/2023, showed the following: 9/1/2023 a BP of 124/72 and Pulse of 76 9/3/2023 a BP of 122/70 and Pulse of 76 9/4/2023 a BP of 119/68 and Pulse of 67 9/5/2023 a BP and Pulse was not documented 9/9/2023 a BP of 116/72 and Pulse of 74 Lisinopril 40 mg- 1 tablet by mouth had not been administered on 9/1/2023, 9/3/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM dose of Carvedilol 25 mg had not been administered on 9/1/2023, 9/4/2023, 9/5/2023 and 9/9/2023. The 9:00 PM doses of Clonidine 0.2 mg had not been administered on 9/1/2023, 9/5/2023, and 9/9/2023 The 9:00 PM dose of Hydralazine 50 milligrams had not been administered on 9/1/2023, 9/4/2023, and 9/9/2023. The MAR showed the documented BP and pulse were within the parameters noted in the physician's orders. The Glimepiride 1 mg had not been administered on 9/1/2023 (blood glucose 112), 9/2/2023 (blood glucose 106), 9/3/2023 (blood glucose 167), 9/4/2023 (blood glucose 84), and 9/5/2023 (blood glucose 110). The Insulin Lispro 100 unit/ml pen, 4:30 PM dose had not been administered on 9/3/2023 (blood glucose 167), and the resident should have received 2 units; the 9:00 PM dose had not been administered on 9/5/2023 (blood glucose 246), and the resident should have received 4 units; the 4:30 PM dose had not been administered on 9/6/2023 (blood sugar 315), and the resident should have received 10 units; the 9:00 PM dose had not been administered on 9/6/2023 (blood glucose 173), and the resident should have received 2 units. Lantus Solostar 100 units/ml, give 8 units subcutaneously every night, and had not been administered on 9/9/2023 (blood glucose 340), 9/13/2023 (blood glucose 198), and 9/14/2023 (blood glucose 187). The RN confirmed the medications had not been administered as ordered by the physician. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Eng Stage Renal Disease, Anemia, Heart Failure, and Hypertension. Review of Resident #22's quarterly MDS assessment dated [DATE] showed resident was cognitively intact, required supervision with eating, and had received 7 days of insulin injections, 7 days of antianxiety medications, 7 days of antidepressant medications and 6 days of opioid medications during the 7 day look back period. Continued review showed the resident received dialysis services. Review of Resident #22's physician's orders with dates showed the following: Metoprolol Tartrate (a medication used to treat high blood pressure and Atrial Fibrillation) 50 mg tablet give 1 tablet by mouth twice daily. Hold if BP less than 90/60 or Pulse below 60 and notify MD dated 5/25/2023, Hydralazine 25 mg tablet give 1 tablet by mouth twice daily. Hold if BP is less than or equal to 90/60 or Pulse is less than 60 dated 7/13/2023. Review of Resident #22's MAR dated 9/2023 showed the following: 9/4/2023 at 6:00 PM a BP of 118/69 and a Pulse of 72. 9/6/2023 at 6:00 PM a BP of 122/71 and a Pulse of 65. 9/9/2023 at 6:00 PM a BP of 133/62 and a Pulse of 62. 9/10/2023 at 6:00 PM showed a BP of 158/76 and a Pulse of 68 The 6:00 PM dose of Metoprolol Tartrate 50 mg had not been administered on 9/4/2023, on 9/6/2023, on 9/9/2023 and on 9/10/2023. Hydralazine 25 mg tablet had not been administered on 9/4/2023, on 9/6/2023, and on 9/10/2023. The documentation showed N (not given) in the initial box with RN #1's initials. Continued review showed a rationale had not been documented after the medications had been omitted. During an interview on 9/19/2023 at 2:29 PM, RN #1 confirmed the essential medications for Residents #13 and #22 had not been administered as ordered by the physician as follows: Resident #13's Lisinopril, Clonidine, Hydralazine, Insulin Lispro, Glimepiride, and Lantus Solostar had not been administered as ordered on 9/1/2023, 9/2/2023, 9/3/2023, 9/4/2023, 9/5/2023, 9/6/2023, 9/9/2023, 9/13/2023 and 9/14/2023. Resident #22's Metoprolol and Hydralazine had not been administered as ordered on 9/4/2023, 9/6/2023, 9/9/2023 and 9/10/2023. RN #1 stated he was aware of the facility's policy to document a rationale when medications were not administered and to notify the physician if the ordered medications were withheld. RN #1 confirmed the physician was not notified of the omitted medications, and the essential medications had not been administered as ordered on the listed dates which resulted in significant medication errors. During an interview on 9/20/2023 at 4:37 PM, the Administrator and the DON stated it was their expectation that the physician was notified when a medication was not administered and that medications be administered as ordered by the physician. The DON confirmed Resident #13's 4:30 dose sliding scale Lispro insulin on 9/3/2023 and 9/6/2023, the 9:00 PM dose of sliding scale Lispro insulin had not been administered according to the physician's order on 9/5/2023 and 9/6/2023, and the 9:00 PM dose of Lantus insulin had not been administered according to the physician's order on 9/9/2023, 9/13/2023, and 9/14/2023. Resident #22's Metoprolol Tartrate had not been administered on 9/4/2023, 9/6/2023, 9/9/2023, and 9/10/2023. The Administrator confirmed the omission of certain cardiac medications and insulin would be considered a significant medication error. The DON confirmed the physician had not been notified of the significant medication errors. During a telephone interview on 9/20/23 08:51 AM, the Medical Director revealed she expected for the orders she prescribed to be followed with the parameters set for BP and pulse, and if medications were not administered, she expected a documented reason and to be notified. The Medical Director stated before 9/19/2023, she had not been made aware of the omitted medications. The Medical Director also stated Resident #13's long term glycemic control was maintained with the use of insulin and the Glimepiride medications, and no immediate harm or serious adverse outcome was done to Resident #13, but letting Blood Sugar go untreated undermined the glycemic control. The Medical Director stated she had not been made aware of any residents suffering any complications and the residents had not required any new orders or medical interventions since medications had been omitted. On 9/22/2023, Surveyors reviewed the education sign in sheets and new audit forms implemented which validated the corrective action plans onsite. Surveyors reviewed the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheet and interviewed QAPI members regarding the ad-hoc meeting that occurred on 9/19/2023 which discussed the implementation of the medication pass audit and the Medication Administration Record (MAR) audit. Attendees of the ad-hoc QAPI meeting included Minimum Data Set (MDS) Coordinator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Operations, and the Administrator. Surveyors verified onsite the implementation of the medication pass audit and Medication Administration Record (MAR) audits. Surveyors reviewed medication pass audits, interviewed staff, and reviewed education sign in sheets for education provided that included medication error and medication hold procedure. Surveyors verified that 100% of facility nurses had received the education by reviewing education sign in sheets and interviewing staff present in the facility. Surveyors reviewed the MAR audits for all in house residents and the daily audit form of non-administered medications to be completed 5 days per week by the DON, ADON, or MDS Coordinator. Registered Nurse (RN) #1 was suspended by the facility on 9/19/2023 and terminated on 9/21/2023.

Based on facility policy review, observation, and interview the facility failed to ensure food items were properly stored in 2 of 3 freezers, failed to ensure expired food items were not available for resident use on 1 of 1 bread cart, failed to properly store food items in 1 of 2 refrigerators, and failed to ensure pots and pans were stored appropriately in 1 of 1 pot and pan storage area, which had the potential to effect 34 of 35 residents. The findings include: Review of the facility's policy titled, Food Storage, dated [DATE], showed .Food is stored and prepared in a clean safe sanitary manner .All food not in original containers will be labeled, dated, and stored .in approved containers . Review of the facility's policy titled, Pots & [and] Pans, dated [DATE], showed .Remove all food debris/grease before placing pots & pans in the sink .Wash, rinse, and sanitize pots & pans .Allow pots & pans to air dry . Review of the facility's policy titled, Cold Storage Areas, dated [DATE], showed .Cold food(s) will be stored under safe and sanitary conditions .Refrigerators and freezers are designed to keep food cold enough to prevent or slow the growth of bacteria as well as preserve the freshness and quality of foods .Date, label, and properly secure all products removed from original containers with all items labeled stating the contents inside, the date opened, and the appropriate use-by date .When labeling and dating open food items, the label should include the food item, date opened, and use-by date . Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated [DATE], showed .Food will be stored properly and used within the appropriate time period to ensure safe and high-quality food is served .Expiration date: This is the last day the product should be used for the best quality . An observation and interview on [DATE] at 10:07 AM, with the Certified Dietary Manager (CDM) in the Vegetable Freezer, showed an unsealed, unlabeled, and undated 2-gallon bag of crinkle cut French fries and an unopened, unlabeled, and undated large clear plastic bag of food item identified by the CDM as .hush puppies . The CDM stated it was her expectation that items in the freezer were sealed to maintain freshness and labeled with the contents and dated. The CDM confirmed the bag of crinkle cut French fries was not sealed, labeled, or dated, and the bag of hush puppies was not labeled or dated. The CDM confirmed the food items were not properly stored and were available for resident use. An observation and interview on [DATE] at 10:09 AM, with the CDM in the Meat and Ice Cream Freezer, showed 2 large resealable bags of frozen food identified by the CDM as chicken breasts . The 2 bags had been opened and were not labeled or dated. The CDM confirmed the 2 bags of chicken breasts were not labeled with contents or dated and were available for resident use. During an observation and interview on [DATE] at 10:12 AM, with the CDM, the bread cart stored ,d+[DATE] loaf of white sandwich bread with an expiration date of [DATE]. The CDM stated it was her expectation that expired food items were discarded. The CDM confirmed the bread was expired and available for resident use. During an observation and interview on [DATE] at 10:19 AM, with the CDM, the drink refrigerator stored 37 plastic containers of an off-white, thick substance covered with saran wrap that were unlabeled and undated. The CDM identified the plastic containers as .pudding . and confirmed that the items were unlabeled, undated, and available for resident use. During an observation and interview on [DATE] at 10:26 AM, with the CDM, the pot and pan storage area showed 2 medium sized metal pans stacked together wet, 2 large sized metal pans stacked together wet, and 1 full size metal pan that was stored wet. The CDM confirmed the pans were stored wet and stated it was her expectation that they were air dried prior to storage.

Based on medical record review and interview, the facility failed to refer 1 resident (Resident #3) of 4 residents reviewed for Pre-Admission Screening and Resident Review (PASRR), to the state-designated authority for a Level II PASRR after the resident was identified with possible serious mental disorder diagnosis. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Anxiety Disorder, Unspecified Dementia and Atherosclerotic Heart Disease. A diagnosis of Psychosis was added on 4/14/2022. Review of a Level I PASRR dated 12/17/2021 showed diagnoses of Dementia, Anxiety and Depression, and a Level II PASRR was not required. Record review showed a diagnosis of Psychotic Disorder was identified on 4/14/2022 and added to the resident's list of diagnoses. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had severely impaired cognitive skills. The resident had verbal behaviors directed towards others on 1-3 days of the 7 day look back period. During an interview on 9/18/2023 at 2:14 PM, Social Services Coordinator #1 stated the PASRR Level I dated 12/17/2021 was the only PASRR on Resident #3's chart. She stated if a new mental health diagnosis was added, a new PASRR should be submitted to the state designated authority. She confirmed a new PASRR for a level II evaluation had not been submitted after a new mental health diagnosis of Psychosis was added on 4/14/2023.

45837 Based on facility policy review, record review, observation, and interview, the facility failed to develop a comprehensive care plan to meet the person-centered dementia care needs for 2 residents (Resident #3 and #29), and activities of daily living (ADL) care needs for 1 resident (Resident #33) of 16 residents reviewed for care plans. The findings include: Review of the facility's undated policy titled, Care Plans-Comprehensive, showed .individualized comprehensive care plan that includes .objectives .to meet the resident's .needs is developed for each resident .Care plans are revised as changes .dictate .Residents, their families .are invited to attend .care planning conferences .Changes .must be reported to the MDS Coordinator .care plan can be made . Resident #3 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Anxiety Disorder, Unspecified Dementia and Atherosclerotic Heart Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had severe cognitive impairment and required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident had verbal behaviors directed towards others on 1-3 days of the 7 day look back period, and there was no rejection of care behaviors noted. During an interview on 9/17/2023 at 11:29 AM, Licensed Practical Nurse (LPN) #1 stated the staff reviewed the resident's care plan to obtain individualized care information for each resident. Record review showed an individualized care plan for Resident #3 had not been developed or implemented related to the resident's Dementia care needs. Resident #29 was admitted to the facility on [DATE] with diagnoses including Dementia, Type II Diabetes and Hyperlipemia. Review of a quarterly MDS assessment dated [DATE] showed Resident #29 had severe cognitive impairment. Record review showed an individualized care plan for Resident #3 had not been developed or implemented related to the resident's Dementia care needs. Resident #33 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Pneumonia and Hyperkalemia. Review of a quarterly MDS assessment dated [DATE] showed Resident #33 had severe cognitive impairment and required total dependence of 2 staff for bed mobility, toilet use and personal hygiene. An observation on 9/18/2023 at 9:58 AM, in Resident #33's room, showed the resident's beard was unkempt. During an interview on 9/18/2023 at 3:20 PM, Certified Nursing Assistant (CNA) #1 stated Resident #33's daughter did not want staff to shave him. During a telephone interview on 9/19/2023 at 12:10 PM, the MDS Coordinator confirmed with Resident #33's daughter that she did not wish for staff to shave his beard. The MDS Coordinator stated nursing staff had not reported the specific ADL preference to her. During an interview on 9/19/2023 at 12:14 PM, the MDS Coordinator stated Resident #3 had a diagnosis of Dementia with Behavioral Disturbance and Dementia with Agitation, and Resident #29 had a diagnosis of Dementia. She stated she would expect the residents to have care plans for dementia and the ADLs would be updated on the care plan to reflect the family's wishes. The MDS Coordinator confirmed Residents #3 and #29 had no care plan for dementia, and Resident #33 had no personalized care plan for ADLs regarding his beard.

45837 Based on facility policy review, medical record review, observation and interview, the facility failed to implement appropriate infection control practices by improperly storing a Continuous Positive Air Pressure (CPAP) mask and tubing and improperly securing a catheter bag for 2 residents (Residents #15 and #33) of 35 residents reviewed for infection prevention. The findings include: Review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised on 11/2011, showed .Infection Control Considerations Related to .CPAP .Store the circuit in plastic bag, marked with date and resident's name, between uses . Review of the facility's undated policy titled, [Indwelling urinary] Catheters, Care of, Infection Control and Insertion Guidelines, showed, .Secure indwelling catheters after insertion .A sterile continuously closed drainage system should be maintained . Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Sleep Apnea, Wheezing, and Acquired Absence of Lung. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #15 was cognitively intact. The resident had shortness of breath with exertion and while lying flat and received oxygen therapy. Review of a physician's order dated 8/16/2023, showed an order for Resident #15 for CPAP (a machine to help you breathe while you are sleeping) at night. During an observation on 9/17/2023 at 11:03 AM, in Resident #15's room, the resident's CPAP mask was lying on the table next to the bed uncovered and open to air. An observation and interview on 9/17/2023 at 3:04 PM, in Resident #15's room, showed the resident's CPAP mask lying on the table next to the bed uncovered and open to air. During an interview, Resident #15 stated an unknown staff member removed it from the resident's face this morning and laid it on the table. During an observation and interview on 9/17/2023 at 3:15 PM, in the resident's room, the Director of Nursing (DON) stated Resident #15's CPAP mask was lying on the table next to the bed uncovered and open to air. The DON stated CPAP masks were to be stored in a bag when not in use to reduce the risk of infection. The DON confirmed Resident #15's CPAP mask had not been stored appropriately to prevent the risk of infection. Resident #33 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Pneumonia and Hyperkalemia. Review of a care plan dated 6/17/2023, showed Resident #33 preferred not to wear catheter tubing secured to the thigh to prevent pulling. Review of a quarterly MDS assessment dated [DATE] showed Resident #33 was severely cognitively impaired and required total dependence on 2 staff for bed mobility, toilet use and personal hygiene. The resident had an indwelling urinary catheter. During an observation on 9/17/2023 at 10:03 AM, Resident #33 was in bed, and an indwelling urinary catheter collection bag was attached to the tubing inside the resident and was lying on the floor on the left side of the resident's bed. During an observation and interview on 9/17/2023 at 10:11 AM, in Resident #33's room, the DON confirmed the urinary catheter collection bag was lying on the floor. The DON confirmed the collection bag was not secured off the floor to prevent the risk of infection.

Based on facility policy review, medical record review, and interview the facility failed to provide an evaluation and rationale for continued use of a PRN (as needed) antianxiety drug beyond 14 days for 2 residents (#3 and #22) of 6 residents reviewed for unnecessary medications of 20 sampled residents. The findings include: Review of facility policy [MEDICAL CONDITION] Medication Management developed 8/3/17 General Guidelines revealed . 5) PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation Order dated 10/30/18 for the month of (MONTH) (YEAR), revealed the medication order initiated 8/16/18 .[MEDICATION NAME] . (an anti-anxiety drug) 0.5 mg( milligram) tablet. Give one half tablet to equal 0.25 mg by mouth once daily as needed for anxiety . with no stop date. A subsequent order for .[MEDICATION NAME] 0.25 mg 1 PO (by mouth) daily PRN per telephone order r/t (related to) resident behavioral symptoms r/t anxiety-per MD( Medical Doctor) medication needed in an ongoing basis . with no stop date. Medical record review of a Physician's Progress Notes from 4/30/18 through 11/26/18 revealed the physician failed to provide an evaluation and rationale for the continued use of the medication beyond 14 days. Medical record review of a PRN (medication) Administration Record for the month of (MONTH) (YEAR) revealed the PRN [MEDICATION NAME] was given on the following days: 11/4/18 and 11/18/18. Interview with the Assistant Director of Nursing (ADON) on 11/27/18 3:44 PM with ADON in ADON's office confirmed the PRN [MEDICATION NAME] was prescribed for over 14 days and confirmed the facility failed to document rationale for the continued use of the PRN antianxiety medication beyond the 14 days. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's progress note dated 9/6/18 revealed no documentation to include the evaluation and rationale for the continued use of the PRN (as needed) [MEDICATION NAME] (anti-anxiety medication) beyond 14 days. Medical record review of the Pharmacist Consultation Report revealed .has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date .Please discontinue .if the medication cannot be discontinued .document the indication for use, the intended duration of therapy, and the rationale for the extended time period . Continued review revealed on 9/12/18 the physician declined with the pharmacist recommendation and failed to provide an evaluation and rationale for the continued use of the PRN [MEDICATION NAME] beyond the 14 days. Medical record review of a physician's orders [REDACTED].Continue [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg (milligram) .QAM (every morning) PRN x (for) 60 days . Medical record review of the physician's recapitulation orders dated 11/2/18 revealed [MEDICATION NAME] 0.5 mg give one half tablet to equal 0.25 mg dose every morning as needed for 60 days. Interview with the Director of Nursing and the ADON on 11/27/18 at 3:20 PM, in the social services office confirmed the PRN [MEDICATION NAME] was prescribed for over 14 days and the facility failed to provide appropriate rationale for the continued use of the PRN medication.

Based on review of facility policies, observation and interview, the facility failed to store food items in a sanitary manner in 3 of 4 refrigerators observed and failed to date 1 container of food in 1 of 4 refrigerators observed affecting 54 residents. The findings included: Review of the facility policy Food Storage dated 1/12/16 revealed .Foods .should be stored in airtight containers . Review of the facility policy Trayline Refrigerated Leftover Storage dated 1/1/14 revealed .Date container with use by date . Observation and tour of the kitchen with the Certified Dietary Manager (CDM) on 10/30/17 from 9:30 AM-10:30 AM revealed 1 unsealed plastic storage bag with bologna, 1 unsealed plastic storage bag with cheese, and 1 unsealed plastic storage bag with whipped topping in the stand-up refrigerator. Interview with the CDM on 10/30/17 at 10:00 AM, in the kitchen confirmed the food items were not stored in a sanitary manner. Observation of the nourishment refrigerator for the 400 and 500 Hall with the Minimum Data Set (MDS) Coordinator on 10/31/17 at 2:30 PM, revealed 1 unsealed plastic storage bag with bologna and sliced cheese. Interview with the MDS Coordinator on 10/31/17 at 2:30 PM, in the 400 and 500 Hall nourishment room confirmed the food items were not in a sealed container and were not stored in a sanitary manner. Observation of the nourishment refrigerator for the 700 hall with the Assistant Director of Nursing (ADON) on 10/31/17 at 2:45 PM, revealed 1 unsealed plastic storage bag of sliced cheese. Continued observation revealed 1 plastic container of greens undated in the refrigerator. Interview with the ADON on 10/31/17 at 2:45 PM, in the 700 Hall nourishment room confirmed the food items were not stored in a sealed container and were not stored in a sanitary manner. Continued interview confirmed the container of food was not dated.

Based on medical record review, review of manufacturer's instructions, observation, and interview, the facility staff failed to properly administer medications in 2 of 31 opportunities resulting in a 6.45 percent medication error rate. The findings included: Medical record review of Resident #36's November 2016 physician's recapitulation orders revealed .[MEDICATION NAME] (medication to help prevent low levels of calcium in the body) 800 mg (milligram) tablet. Give one tab (tablet) by mouth three times daily, must be given one hour before other meds (medications) . Observation on 11/8/16 at 8:20 AM revealed Licensed Practical Nurse (LPN) #1 administered the following medications by mouth to Resident #36 [MEDICATION NAME] 800 mg, [MEDICATION NAME] LA (medication to treat overactive bladder) 4 mg, [MEDICATION NAME] (antidepressant) 10 mg, Senna (laxative) 8.6 mg 2 tablets, [MEDICATION NAME] 100 mg 2 tablets, and HCTZ (diuretic) 12.5 mg. Medical record review of Resident #43's November 2016 physician's recapitulation orders revealed .[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) .inhaler administer 2 inhalations twice a day . Review of the manufacturer's instructions for [MEDICATION NAME] revealed .What are the possible side effects of [MEDICATION NAME]? [MEDICATION NAME] Can cause serious side effects, including .Thrush in the mouth and throat. You may develop a yeast infection ([MEDICAL CONDITION][MEDICATION NAME]) in your mouth or throat. Rinse your mouth with water after using [MEDICATION NAME] to help prevent an infection in your mouth or throat . Observation on 11/8/16 at 8:30 AM revealed LPN #1 administered 2 inhalations of [MEDICATION NAME] to Resident #43. Continued observation revealed LPN #1 did not instruct or assist the resident to rinse the mouth after the administration of [MEDICATION NAME]. Interview with LPN #1 on 11/8/16 at 12:35 PM, in the training room, confirmed the [MEDICATION NAME] was not administered to Resident #36 one hour prior to the administration of other medications. Continued interview confirmed Resident #43 was not instructed or assisted to rinse the mouth after the administration of [MEDICATION NAME].

Based on review of the Quality Assurance Performance Improvement (QAPI) attendance records and interview, the facility failed to ensure the Medical Director attended the QAPI meetings for 12 of 12 months reviewed. The findings included: Review of the QAPI meeting attendance records for the past 12 months, November 2014-September 2015, revealed the Medical Director had not attended any the monthly QAPI meetings. Interview with the facility Administrator on 11/4/15 at 1:45 PM, in the Administrator's office, confirmed the facility failed to ensure the Medical Director attended the QAPI meetings at least quarterly.

Medical record review revealed the resident was readmitted to the facility on [DATE], with diagoses including Hemplegia Dominant Side, Heart Failure, and Dementia. Medical record review of a physician's orders [REDACTED]. Continued review revealed the resident was sometimes able to express (resident's) needs and responded adequately to simple direct communication only, was free of behavioral problems, and totally dependent on staff for activities of daily living. Continued review revealed the resident had no history of falls since readmission or the prior MDS assessment. Medical record review of a Fall Risk assessment dated [DATE], revealed a score of 16 and a score of 10 or greater was high risk. Medical record review of a care plan revised June 16, 2011, revealed, "Potential for falls...eval (evaluate) cause of prev (previous) falls and implement appro (appropriate) interventions..." Medical record review of a nurse's note dated July 13, 2011, at 1:59 p.m., revealed, "...found in floor...Bedside table beside (resident) with bright red blood noted to the floor. Large hematoma noted to right brow..." Continued review revealed the resident was transported to an emergency room . Medical record review of a nurse's note dated July 13, 2011, at 8:09 a.m., revealed the resident returned to the facility. Review of facility investigation documentation dated July 13, 2011, revealed the resident's fall was unwitnessed and included, "Incident Type Fall/no head injury...res states reaching for bottom drawer of bedside table and rolled OOB (out of bed)...possible cause...res was reaching for bottom drawer of bedside table and lost balance...Implement: Remove bedside table Fall mat in place..." Continued review revealed, "...Alert and oriented to person only..." Continued review revealed, "I walked into room and seen (resident) wasn't in bed. I went on over and seen...in the floor..." Continued review revealed no documentation regarding staff member responsible for the resident's care at the time of the fall, when/where the resident was last seen and/or the activity the resident was engaged in prior to the fall, other staff/residents' interviews, or the position of the bed. Observation on August 17, 2011, at 1:12 p.m., revealed the resident seated in a wheelchair in the resident's room, next to the resident's low bed and a floor mat on end placed against the front of the resident's bed. Continued observation revealed no visible bruises. Interview with the resident on August 17, 2011, at 1:12 p.m., revealed the resident was not oriented to time or situation. Interview with the Assistant Director of Nursing (ADON) on August 13, 2011, at 2:35 p.m., in an office by the dining room, revealed the ADON completed the investigation documentation dated July 13, 2011, and the type of incident was in error. Continued interview confirmed the facility failed to thoroughly investigate an injury of unknown origin for Resident #2 on July 13, 2011. C/O: #

Based on medical record review, observation, and interview, the facility failed to timely notify the attending physician and responsible party of a fall for one resident (#5) of sixteen residents reviewed. The findings included: Resident #5 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility investigative report and nurses notes revealed the resident experienced a fall without injury on September 10, 2010, at 4:20 p.m.; continued review revealed the resident's physician and responsible party was not notified of the fall until September 13, 2010. Observation on December 5, 2010, at 12:40 p.m., in the dining room, revealed the resident sitting in a wheelchair eating lunch and talking with another resident at the table. Interview with the Assistant Director of Nursing (ADON), and Director of Nursing (DON) in the DON's Office on December 7, 2010, at 8:50 a.m., confirmed the facility failed to notify the attending physician and responsible party of the resident's fall occurring on September 10, 2010, until September 13, 2010, (three days later).

Based on medical record review, observation, and interview the facility failed to maintain an accurate and complete medical record for one resident (#4) of sixteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of dental records dated April 26, 2010, revealed "extract prn(as needed) #10 (upper front lateral)." Medical record review of the facility's quarterly dental assessments dated July 15, 2010, and October 8, 2010, revealed the resident to have three missing upper teeth (#1, #2, #16). Continued review of a Dental assessment dated [DATE], revealed the assessment of the upper teeth section to be blank. Observation of the resident's upper front teeth on December 5, 2010, at 2:00 p.m., in the resident's room, revealed tooth #10 (upper front lateral incisor) was broken at the gum line. Interview with the Licensed Practical Nurse (LPN) #1 on December 5, 2010, at 2:50 p.m., in the Director of Nursing's (DONs) office confirmed LPN #1 failed to complete the October 1, 2010, quarterly dental assessment of the resident's upper teeth. Interview with the Minimum Data Set (MDS) Coordinator on December 5, 2010, at 3:10 p.m., in the Director of Nursing's (DONs) office confirmed the MDS Coordinator completed the quarterly dental assessments dated July 15, 2010, and October 8, 2010, and did not recall a missing lateral incisor (#10 - upper front lateral). Telephone interview with the resident's dentist on December 6, 2010, at 10:00 a.m., confirmed the resident's lateral incisor - tooth #10 (upper front lateral) was broken at the gum line upon the initial visit with the resident on April 26, 2010. Continued interview with the dentist confirmed the tooth did not need extracting, "...unless the tooth was symptomatic (causing pain) it did not need to be extracted; tooth extraction in geriatric residents can have adverse side effects or be detrimental to the resident..."