Every finding on record at Palmetto Subacute Care Center

Based on observations, records reviewed and interviews, the facility failed to provide oxygen therapy at the rate ordered for one (Resident #104) out of one resident reviewed for respiratory therapy as evidenced by Resident #104 was receiving oxygen at a flow rate of 3.5 liters per minute instead of the physician-ordered 2 liters per minute as needed. This deficient practice has the potential for increased significant health risks including oxygen toxicity and pulmonary damage. The findings include. Observation on 02/02/2026 at 7:38 AM revealed Resident #104 in bed with eyes closed and nasal canula in place with oxygen being administered at a flow rate of 3.5 Liters Per Minute (LPM). Observations of Resident #104 on 02/03/2026 at 11:13 AM and 02/04/2026 at 10:13 AM revealed the resident was seated in a wheelchair with no oxygen in use. Review of Resident #104's clinical record revealed the resident was admitted on [DATE]. Clinical diagnoses included Pneumonitis due to inhalation of food and vomit, with additional respiratory conditions requiring monitoring and treatment. Record review of physician orders dated 01/26/2026 revealed an order for Oxygen at 2 LPM via nasal cannula as needed for shortness of breath or oxygen saturation less than 92%. Review of the admission Minimum Data Set (MDS) dated [DATE], Section O (Special Treatments, Procedures, and Programs), revealed the resident was receiving oxygen therapy. Review of the care plan initiated on 01/24/2026, with a next review date of 04/24/2026, identified the resident as having altered respiratory status/difficulty breathing related to anxiety and pulmonary edema. Interventions included administering oxygen and respiratory treatments as ordered, monitoring oxygen saturation, positioning the resident to promote effective breathing, and monitoring for signs and symptoms of respiratory distress. Interview with Staff F Registered Nurse, on 02/04/2026 at 9:57 AM, revealed the resident orders for PRN (as needed) oxygen at 2 liters via nasal cannula if oxygen saturation is less than 92%, along with prescribed nebulizer treatments. The protocol includes checking vital signs and oxygen saturation before and after respiratory treatments and administering oxygen based on the physician's orders. Interview with Staff G, Registered Nurse Supervisor, on 02/04/2026 at 10:24 AM, revealed nursing staff are expected to review physician orders prior to administering respiratory treatments, complete a respiratory assessment, and administer oxygen and nebulizer treatments strictly according to the physician's prescription. Review of the facility's undated Policy and Procedures titled Oxygen Administration documented:PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observations, record review and interviews, the facility failed to provide safe and secure storage of medications and biologicals for five Residents (Resident #6, Resident #9, Resident #31, Resident #32 and Resident #102) out of 18 residents sampled. There were 88 residents residing in the facility at the time of the survey. The findings include. During the initial resident and room screenings and subsequent screenings on the 2nd floor North/South Unit of the facility, the following were observed: Resident #6Observation n 02/02/2026 at 7:56 AM revealed Resident #6 in bed awake, a tube of ointment was noted on the overbed table.Observation on 02/02/2026 at 10:36 AM revealed Resident #6 was out of the facility on an appointment and ointment was noted on the overbed table in the resident's room. Review of the medical records revealed Resident #6 was admitted on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to embolism of left middle cerebral artery. The admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 13 on a 0-15 scale, indicating Resident #6 is cognitively intact. Section GG for functional status documented supervision required for personal hygiene and Activities of Daily Living, impairment on both sides of the lower extremities. Resident #9Observation on 02/02/2026 at 6:42 AM revealed Resident #9 in bed awake, there were several lotions and creams on the bedside table. Observation on 02/03/2026 at 9:19 AM revealed Resident #9 in bed awake watching television. Several lotions and creams noted on the bedside table in a wooden crate.Review of the medical records revealed Resident #9 was initially admitted on [DATE] and readmitted [DATE]. Clinical diagnoses included but not limited to Polyneuropathy, unspecified, Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 13 on a 0-15 scale, indicating Resident #9 is cognitively intact. Section GG for functional status documented dependent for personal hygiene and Activities of Daily Living, impairment on one side of the lower extremities. Resident #31Observation on 02/02/2026 at 6:32 AM, Resident #31 was in bed with eyes closed. A tube of ointment was on the bedside tableReview of the medical records revealed Resident #31 was admitted on [DATE]. Clinical diagnoses included but not limited to Fracture of right patella, subsequent encounter for closed fracture with routine healing. The admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 15 on a 0-15 scale, indicating Resident #31 is cognitively intact. Section GG for functional status documented dependent for personal hygiene and Activities of Daily Living, impairment on one side of the lower extremities. Resident #32Observation on 02/02/2026 at 6:35 AM revealed Resident #32 in bed with eyes closed. A tube of ointment was noted on the overbed table Review of the medical records revealed Resident # 32 was initially admitted on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Diverticulosis of large intestine without perforation or abscess with bleeding. The Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 14 on a 0-15 scale, indicating Resident #32 is cognitively intact. Section GG for functional status documented maximal assistance required for personal hygiene and Activities of Daily Living, impairment on both upper and lower extremities. Resident # 102Observation on 02/02/2026 at 6:46 AM revealed Resident #102 in bed with eyes closed; a tube of ointment and a bingo pack of white round pills were observed at the bedside.Review of the medical records revealed Resident # 102 was admitted on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to unspecified occlusion or stenosis of right posterior cerebral artery. The admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 15 on a 0-15 scale, indicating Resident #102 is cognitively intact.Review of the medical records revealed Resident # 102 was admitted on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to unspecified occlusion or stenosis of right posterior cerebral artery. admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive patterns documented Brief Interview of Mental Status score is 15 on a 0-15 scale, indicating Resident #102 is cognitively intact. Interview on 02/03/2026 at 9:48 AM Registered Nurse (Staff A) South Two Unit stated: I do rounds with my residents prior to giving medications (at least 3 times per day) and I am constantly checking on the residents at other times during the day. The residents are long-term residents, several residents are not as alert, and require more frequent check-ins. If the resident has their own lotions, creams and shampoo, they are stored in a [resealable plastic bag] with the room number and are kept in the nightstand drawer. If they have prescribed creams, ointments and lotion, they are kept on the medication cart. Interview on 02/03/2026 at 9:58 AM, Certified Nursing Assistant (Staff B) South One Unit via Spanish Translator revealed the residents' creams and lotions have to be stored in their bedside drawer. Alert residents are allowed to have their own creams and lotions stored in [brand resealable plastic] bags in their bedside drawers. On 02/03/2026 at10:03 AM Registered Nurse (Staff C) South One station, revealed residents' prescribed ointments and creams have to be stored on the medication cart, residents' personal lotions and creams are stored in [resealable plastic bags] in their personal bedside drawer. We have these protocols in place for the safety of the resident. On 02/03/2026 at 10:12 AM, Certified Nursing Assistant (Staff D) North Two Unit via Spanish Translators reported creams, lotions and ointments cannot be stored in the residents' room, if any of those items are found in a resident's room, they have we have been instructed to give the items to the nurse or store in a [resealable plastic bags] in the residents' bedside drawer. On 02/03/2026 at10:23 AM, after Registered Nurse Supervisor (Staff E) was shown the photographs of the surveyor findings in the resident's room; Staff E, Registered Nurse Supervisor revealed Residents' personal creams and lotions are supposed to be stored in a [brand resealable plastic bags] with the room number in the residents' personal drawer. Prescribed cream and ointments are stored on the medication cart. Review of the undated facility policy titled Medication storage states: Medication will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F761-Label/Store Drugs and Biologicals. As evidenced by: F761 was cited during a Recertification Survey with exit dated 12/19/24 because the facility failed to ensure drugs and biologicals used in the facility were stored and labeled properly. The findings include.Record review of the facility's survey history revealed, during the Recertification Survey conducted on December 16, 2024, through December 19, 2024, F761 was cited as the facility failed to ensure drugs and biologicals used in the facility were stored and labeled properly. Review of the facility policy and procedure titled Quality Assurance and Performance Improvement Plan revision date 09/2025 states: Purpose: Quality is defined as meeting or exceeding the needs, expectations, and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. Quality Assurance Performance Improvement (QAPI) principles will drive decision making within our facility. The purpose of our QAPI plan is to guide our overall quality improvement program. Decisions will be made to promote excellence in promoting quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in our facility. Revisions to the QAPI Plan will be communicated as they occur to residents, families, and staff through meetings, newsletters, etc. With QAPI as our guiding principle, our facility has a Performance Improvement Program which systematically monitors, analyzes, and improves its performance to improve resident/patient outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care and services and cost. Key issues will be addressed on an ongoing basis to improve overall outcomes. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 11/19/2025, 12/17/2025, and 01/21/2026 documented the facility had QAA Committee meetings monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON)Infection Control Preventionist, Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, Director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator. Interview on 02/04/2026 at 11:39 AM, the Director of Nursing (DON) reported the QAA Committee meets every month, the last meeting was held on 01/21/2026. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to identify any potential issues or any concerns, ideally looking at systems and policies that can be improved and continuously evaluating interventions to make sure they are effective. In monthly meetings data from the previous month is reviewed, each department head reports their assigned tasks and any new issues. Data is entered into the QAPI log in the system to be more efficient on topics to be discussed with their recommended interventions for review by the QAPI team.

Based on observation, interview and record review, the facility failed to ensure appropriate storage of personal cleaning supplies for one Resident (#101) out of 18 sampled residents. As evidenced by dishwashing liquid soap and disinfectant spray stored in the resident's room on a shelf above the handwashing sink. There were 88 residents residing I the facility at the time of the survey. The findings include. On 02/02/2026 starting at 06:30 AM, during the initial resident and room screenings on the 2nd floor North/South Unit of the facility, the following were observed: On 02/22/2026 at 6:38 AM revealed Resident #101 in bed with eyes closed. Cleaning supplies (dishwashing liquid soap, disinfectant spray) were stored in the resident's room on a shelf above the handwashing sink. On 02/03/2026 at 9:20 AM Resident #101 was out of facility on an appointment, the cleaning supplies- (dishwashing liquid soap, disinfectant spray), remained stored in the resident's room on a shelf above the handwashing sink. The Housekeeper was in the resident's room mopping the floor. Review of Resident #101 clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included Aftercare Following Joint Replacement Surgery and Unilateral Primary Osteoarthritis, Left Knee. The admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact. Interview on 02/03/2026 at 9:48 AM with Registered Nurse (Staff A) South Two Unit regarding the cleaning supplies like dishwashing soap and disinfectant sprays being stored in the resident's room. Registered Nurse (Staff A) stated: if I encounter them in the resident's room, I will contact the nursing supervisor to see what to do with the products. While waiting for instructions from the nursing supervisor, I would store the items in a bag on the medication cart.These are long-term residents, several residents are not as alert, and require more frequent check-ins. On 02/03/2026 at 9:58 AM Certified Nursing Assistant (Staff B) South One station, via Spanish Translator revealed cleaning supplies such as dishwashing soap and disinfectant sprays found in the resident's room should be given to the nurse for safe keeping. On 02/03/2026 at 10:03 AM Registered Nurse (Staff C) South 1 station, stated: Any cleaning supplies such as dishwashing soap and disinfectant sprays I find in the residents' room during my rounds are taken out of the room, stored in a bag and the floor supervisor is notified for instructions for storage of the items. The residents are not allowed to have any cleaning supplies in their room. We have these protocols in place for the safety of the resident. On 02/03/2026 at 10:12 AM Certified Nursing assistant (Staff D) North Two Unit via Spanish Translators revealed cleaning supplies such as dishwashing soap and disinfectant sprays found in residents' room should be given to the nurse for safety reasons. On 02/03/2026 at 10:23 AM, after being shown the photographic evidence of the identified concerns; Registered Nurse Supervisor (Staff E) stated: Cleaning supplies are not allowed to be stored in the residents' room. We put all these processes in place to ensure the safety of the residents in our facility. Review of the policy and procedure titled Storage Areas Environmental dated 10/09/25 states: Housekeeping and laundry department storage areas shall be maintained in a clean and safe manner. Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on labels such as products.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one (Resident #1) out of three residents sampled for elopement. to ensure Resident #1's safety as evidenced by On 03/03/2025 Resident #1 a vulnerable resident left the facility undetected through the first floor's exit door and walked seven to eight blocks to his home. There were 93 residents residing in the facility at the time of the survey. The findings included: Review of the facility policy titled wandering Elopements dated 01/28/25 indicate: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the facility policy and procedure titled accidents and Incidents-Investigating and Reporting dated 01/28/25 states: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Record review of the Abuse/Neglect Log from January 2025 to May 2025 documented the incident occurred on 03/03/25 at 07:54 PM. Record review of the Incident note on 03/03/25 timestamped 20:30 (8:30 PM) documented: At approximately 7:50 PM, assigned Licensed Practical Nurse (Staff A) received a phone call from the resident's wife who informed him that the resident just called her and stated he wants to go home and does not want to remain at facility. Staff A informed wife that he saw the resident five (5) minutes ago but would go immediately to check on him. Staff A went to the resident's room and the resident was not there. Staff on the unit informed Staff A that they saw the resident ambulating towards the North Unit. Staff A went to the North Unit, checked all areas but did not locate the resident. Staff A notified Staff B, Registered Nurse (RN), Supervisor and Code Silver was initiated immediately. The resident's wife, Physician (MD), Administrator (NHA), and Director of Nursing (DON) were notified. Facility was checked inside and surrounding property; staff drove cars around surrounding streets. The resident was not located, RN Supervisor (Staff B) notified the local police department. A few minutes later, the resident's daughter arrived at the facility and stated that wife informed her resident walked home (8 blocks from facility). Stated he was fine but wanted to be home. Daughter wanted to collect his belongings and have him discharged . MD stated he may be discharged Against Medical Advice (AMA). The resident's daughter signed the resident out AMA. The local Police were canceled. RN supervisor (Staff B) informed daughter to contact facility in the morning to speak with Social Worker for referrals for home care and/or for prescriptions. Daughter stated that the family was aware of caring for him at home with a [indwelling urinary catheter] and they did not require anything from the facility, but if they did, the wife would call the next day. Daughter signed the resident out AMA. All belongings were sent with the resident's daughter. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Elevated white blood cell count, Retention of urine, Benign Prostatic Hyperplasia with lower urinary tract symptoms, Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Major Depressive Disorder, Unspecified Psychosis not due to a substance or known physiological condition. Resident #1 was discharged from the facility AMA on 03/03/25. Review of Resident #1's Physician's Orders Sheet for March 2025 orders included but not limited to: Resident discharged AMA 03/03/25 at 8:30 PM. Trazodone oral tablet 50 milligram (mg) tablet by mouth at bedtime for insomnia; Quetiapine Fumarate Tablet 25 mg tablet by mouth at bedtime for Psychosis; Donepezil Oral Tablet 10 tablet by mouth at bedtime for Alzheimer's and Buspirone Oral Tablet 5 mg mouth two times a day for anxiety. Record review of Resident #1 's Admission and Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE], 03/03/25 revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score-unable to determine. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional Abilities documented partial assistance to Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Section H for Bowel and Bladder documented Indwelling catheter, always continent of bowel. Section J for Health Conditions documented no falls, no shortness of breath. Section N for Medications documented the resident was receiving antipsychotic, antidepressant, antianxiety, antibiotic and Antiplatelet medications. Record review of Resident #1's Care Plans Reference Date 03/03/25 revealed: Resident displays or report the following: Feeling down, depressed, hopeless easily annoyed and/or short-tempered Fidgety or restless, tired, sleep disturbance Diagnosis of anxiety, diagnosis of depression, on psychoactive medications. Date Initiated: 03/03/2025 Revision on: 03/03/2025. Resident will demonstrate improved mood through the next review date. Interventions include-Administer psychotropic meds as ordered, encourage family involvement, Provide support and reassurance, Psychological Consult. Interview on 05/28/25 at 7:28 AM, the Director of Nursing (DON) stated [Resident #1] was alert and oriented x 3 to person, place and situation, I met with the resident on 03/03/25 in the morning, he was a new admission from the weekend and that is our protocol. In addition, I interviewed the resident about his [indwelling urinary catheter], I wanted to get information pertaining to how long he had the [indwelling catheter] his care needs. The resident stated he had the [indwelling urinary catheter] since October of last year, the [indwelling urinary catheter] came out at home, and he had to go to the hospital to have it re-inserted. The resident was admitted to the facility on antibiotics. The resident and I had a lengthy discussion, he requested the facility reach out to his neurologist to find out about the timeline of him having to use the [indwelling urinary catheter]. Based on his records I reviewed before meeting with the resident he had some neurological and psychiatric diagnosis and was on a very small dose of psychotic medication. On 3/3/25 around dinner time, the resident's wife called the facility and spoke with Staff A, Licensed Practical Nurse (LPN). The resident's wife stated her husband wanted to go home and she was going to send her daughter to sign the resident out Against Medical Advice (AMA). LPN (Staff A) after speaking with the resident's wife, went to look for the resident, the resident could not be located on the unit, all the rooms on the unit were checked, a Code Silver Alert was initiated. The staff present at the facility at the time completed a head count of all the residents and started looking for [Resident #1] in the building and outside of the building in the neighborhood .Approximately 20 minutes later the resident's daughter showed up to the facility and stated The resident was at home, he walked home, the resident's house is 7-8 blocks from the facility. The daughter signed the resident out AMA and collected his personal belongings. The local police department, AHCA (Agency for Health Care Administration) and DCF (Department of Children and Families) were contacted. We have a video of the resident exiting the building with some other visitors that were leaving the facility. The resident's room was on the south unit on the second floor [Room number] it is a private room. The resident walked north to the elevator, got on, went to the ground floor and exited to the parking lot with a group of visitors that were leaving. There was a receptionist at the front desk helping other guests at the time. Visitors must be let in and out via the electronic door opener system. The resident was ambulatory, had the [indwelling urinary catheter] hanging from his waist when he exited the facility. We completed an elopement risk assessment for all the residents; we have an elopement book at all the nurses' station and at the reception desk. The elopement book contains the list of residents at risk for elopement, location of their [Wander Alert System], a photo, and resident identification information. Education was completed for all staff on elopement risk, code silver alert, and leave of absence. The residents that are identified as at risk for elopement [Wander Alert System] are checked for placement and functionality every shift by the nursing staff. The [Wander Alert System] is checked weekly to ensure it is working correctly. The system is checked by placing a close to all the exits doors to ensure the alarm is working and the actual [Wander Alert System] is checked for functionality also. Elopement drills were conducted on 03/10/25 and 03/11/25 two times per day with all staff. A resident was hidden, a code silver alert was called, and the staff had to follow the elopement risk procedure to find the resident. The resident council president volunteered to be the hidden/lost resident. Interview via telephone on 05/29/25 at 9:10 AM, Staff A, LPN stated: I was assigned to the resident in the evening of 03/03/25, when I started my shift the resident expressed that he wanted to go home, I called and spoke to the resident's wife, and told her the resident was really agitated and wanted to go home, she stated she was going to send her daughter to pick him up, after speaking with the resident's wife I went to go look for the resident, I could not find him. I called the RN supervisor (Staff B) on duty and told her I could not find the resident, [Staff B] called a code silver alert, and we started looking for the resident everywhere in all the rooms in the facility,outside of the facility and in the neighborhood; 20 minutes later the resident's daughter called the facility, spoke with [Staff B] and stated,my dad is home. A a few minutes later the daughter came to the facility and collected his belongings and signed the resident out AMA. The resident and his family live close to the facility in the neighborhood. I then wrote up my notes of what happened. Interview on 05/29/25 at 9:23 AM, RN Supervisor (Staff B) stated: On 03/03/25 around 8:00 PM the LPN (Staff A) came to me in the office and reported that [Resident #1] was missing, the wife called him and stated the resident called her and stated he wanted to leave the facility because he did not want to stay and did not think he belonged at the facility. After [Staff A] spoke to the resident's wife he went to look for the resident and could not find him on the unit. I immediately called Code Silver through the entire building, all the staff started looking for [Resident #1]. During the search, I called the resident's wife to let her know [Resident #1] was missing, the wife stated she already called her daughter to come pick the resident up. I notified the DON and the police department. When I was on the phone with the police department, the daughter arrived at the facility and stated her father was at home. The daughter arrived at the facility approximately 20 minutes after we started looking for the resident. The daughter stated she was at the facility to pick up the resident's belongings and sign the AMA paperwork. I spoke with the resident's daughter about arranging home health and rehabilitation services, she stated we can talk in the morning about that. The next day I called the resident's wife to see how the resident was doing and discuss the services that he would need, she did not answer the phone. Interview on 05/29/25 at 9:53 AM via telephone with Spanish translator, Certified Nursing Assistant CNA (Staff C) stated: I was the CNA assigned to [Resident # 1] on 03/03/25 in the evening, I gave the resident a bath then left him in the room, I went to take care of another resident, later as I was walking by the room, the resident was standing in the room on the phone, I heard him saying he did not want to be at the facility, later I went back to the resident's room he was still standing talking on the phone and I ask him to please sit down in his chair. Later during my shift, I saw the LPN (Staff A) coming out of the resident's room and he asked me if I had seen the resident, I stated no and started to help look for the resident all over the building. As we were looking for the resident, after 20 minutes the resident's daughter came to the facility and stated, the resident was home, and she is here to pick up his stuff. We were all relieved that the resident was safe. Interview on 05/29/25 at 10:20 AM, the Administrator (NHA) stated: On 03/03/25 I was informed about a missing resident at the facility, I was at home on medical leave, I checked the facility's camera and was able to establish a timeline of the resident leaving the facility. The camera showed the resident's room door was closed at 17:52:29 (5:52:29 PM), at 19:30 (7:30 PM ) resident's exits his room, closed the door, wearing white T-shirt and [NAME] shorts, [indwelling urinary catheter] clipped to shorts at the right side of waist, wearing sneakers, holding phone in left hand, walks to north unit on second floor, stops in the middle of hallway, turns around and goes to the other direction while talking on the phone, goes back and forth north to south unit, 19:55 (7:55 PM) arrives at elevator lobby, walks into elevator with visitor, walks out of the elevator on the first floor with the visitor talking to the phone and the visitor. Visitor waves at the receptionist to open door, resident walks out of the front door with the visitor, at the time other visitors were checking in at the receptionist's desk. At 19:58:25 (7:58:25 PM) on 03/03/25, [Staff A] hangs up the phone at 2nd floor south station, at 19:58:32 (7:58:32 PM) [Staff A] knocks on resident's closed door, enters the room, 19:58:43 (7:58:43 PM) [Staff A] leaves resident's room, goes to north unit on 2nd floor, then center stairwell, other staff starts looking for the resident. 19:55 (7:55 PM) wife called to let us know the resident wanted to leave, the resident walked out of the facility 30 seconds before the call. The resident walked home; he lives a few blocks from the facility in the neighborhood. He lives on 19 Street and the facility is located on 8th Street. We received a report from the family that the resident was home safe. We now make visitors check in and out on the camera system. The resident was assessed for elopement risk upon admission, he was not exit seeking, there was no way for us to know that he was going to leave. The nursing staff checked on residents at least every two hours. This facility is not a lockdown facility; we do have a [wander alert system] for residents that are at risk for elopement.

Based on observations, interviews and record review the facility failed to implement infection control protocols for the disinfectant wipes on two out of three floors in the facility, as evidenced by one container of expired disinfectant wipes observed on the second floor and two containers of expired disinfectant wipes on the third floor, and two containers of disinfectant wipes with expiration dates that were illegible. There were 85 residents residing in the facility at the time of survey. On [DATE] at 9:55 AM, during a facility tour, disinfectant wipes were observed secured to the walls. Further observations revealed one container of disinfectant wipes on the second floor and two containers of disinfectant wipes on the third floor had an expiration date of [DATE] and two other disinfectant wipes containers expiration date was not legible (photographic evidence). On [DATE] at 10:03 AM, a visual tour to look at the disinfectant wipes was conducted with the Minimum Data Set (MDS) Coordinator on the second and third floors. The MDS Coordinator stated: According to the dates on the containers these wipes are expired, and I will notify the Housekeeping director to change them. During an interview on [DATE] at 10:43 AM, the Housekeeping/Maintenance Director stated: I am responsible for replacing the disinfectant wipes when they run out. I check the wipes containers weekly on each floor. If the container is expired, I throw it away. The reason some of the containers have an expiration date of [DATE] is because I placed new wipes from a new container into the old containers and I change the bottle when it breaks. I don't know how staff will be able to know it is not expired. On [DATE] at 1:47 PM, The Certified Nursing Assistants (CNAs) on the second floor were asked how and when the disinfectant wipes were used. Staff G, CNA replied, I use the disinfectant wipes to clean equipment, and I check the expiration date and tell maintenance if its expired. Staff H, CNA replied: We use the disinfectant wipes to clean equipment. We check the expiration date of the wipes and if its expired we tell the nurse and the maintenance. We don't use the wipes that are expired. Staff I, Certified Nursing assistant (CNA) replied, I use the disinfectant wipes to clean equipment. I check the expiration date of the wipes and if its expired I don't use them and tell the nurse and the maintenance. We don't use the wipes that are expired. Staff J, CNA stated: We use the disinfectant wipes to clean equipment. We check the expiration date of the wipes and if its expired we tell the nurse and the maintenance. We don't use the wipes that are expired. On [DATE] at 1:21 PM, the Nursing supervisor stated: Staff should check expiration dates before using the wipes. If they notice the wipes are expired it should be communicated to maintenance. Interview on [DATE] at 12:55 PM, with the Facility's Infection Preventionist and Director of Nursing. Both revealed the Environmental Services personnel replace expired or finished Personal Protective Equipment (PPE). Staff should not be using any expired PPE or disinfectant wipes. Record review of a Policy titled, Infection Prevention and Control Program Revised [DATE]. Policy Statement: 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Policy Interpretation and Implementation 1. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).

Based on observations record reviews and interviews, the facility's failure to ensure drugs and biologicals used in the facility are stored and labeled properly, failed to ensure expired medical supplies are discarded and failed to ensure controlled medication are reconciled in accordance with professional standards; as evidence by an antibiotic eye ointment observed with no open and or expiration date for Resident #75, two normal saline bottles on Resident# 54's night stand and an unreconciled controlled substance for Resident #76. The findings included: 1) On [DATE] at 9:07 AM, review of the second floor North Medication Cart#2 with Staff B, Registered Nurse (RN). revealed one antibiotic eye ointment for Resident#75. without an open date or expiration date prescribed for Resident# 75, the label read dispense date [DATE] (photo). The Medication Administration Record revealed it was last administered on [DATE] at 1:00 PM to Resident#75. When asked what was the open or expiration date Staff B, RN reported it was opened on a previous shift and would refer to the supervisor. 2) On [DATE] at 9:20 AM a check of the suction machine on the third-floor emergency cart was completed with Staff D, RN. The short tubing that connects the suction machine to canister had an expiration date of 2018 (photo) Staff D, RN acknowledged the expired date and stated That tubing was in the bag with the suction machine and would have been the first tubing used upon emergency. The supervisor checks the emergency cart every day. On [DATE] at 1:21 PM The Nursing supervisor stated: All eye drops and ointments should be labeled with an open date and an expiration date. If it isn't labeled staff should reorder not write the date it was found open and the suction machine on the emergency cart should be checked daily on the night shift. 3) On [DATE] at 9:13 AM, during a medication administration observation for Resident#54 with Staff E, RN on the second floor's South Medication cart#2 revealed two bottles of saline observed on Resident# 54's bedside. After the medication administration Staff E, RN was asked if saline solutions are permitted at the resident' bedside. Staff E stated:: No. and returned to Resident#54's bedside and discarded the two bottles of normal saline in the trash bin in the room Staff E, RN revealed: [Resident#54] has a colostomy, and we use the saline to clean it. I did round this morning and did not notice it was there. 4) On [DATE] 09:05 AM Resident #76 was in bed and complained of knee pain to the surveyor. Staff N, Licensed Practical Nurse (LPN) was asked about Resident#76 pain management. Staff N revealed Resident#76 received Tramadol 50 mg(milligram) tablet by mouth 8:00 AM and had been reassessed at 8:30 AM and she reported an improvement. Review of the Medication Administration Record (MAR) for Resident #76's Tramadol revealed Staff N, LPN signed at 8:06 AM for a Tramadol administration and record review of the controlled substance log sheet revealed the last signature for the administration of Tramadol 50 mg tablet to Resident#76 was on [DATE] at 3:00 AM by another staff member (photo). Staff N, LPN stated, I administered the medication at 8:06 AM and usually sign at the time of administration but I didn't because I was with [Resident#76] at that time Staff. Staff N, LPN reassessed Resident #76 with the surveyor and resident reported a relief of pain. Record review of a demographic sheet for Resident#76 revealed an admitted : [DATE] with Diagnosis that included: GOUT and record review of Resident#76's [DATE] physician's order sheet revealed orders dated [DATE]: Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* directions: give one tablet by mouth every six hours as needed for Moderate Pain for 10 Days and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give one tablet by mouth one time a day for Pain Management (prior to Rehab) for 10 Days. On [DATE] at 2:41 PM The Director of Nursing was asked the protocol for signing out controlled substances and replied, Narcotics should be signed out at the time of administration. Record review of a Policy entitled, Medication Labeling Storage Published: [DATE]. Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation. Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or brand); d. expiration date, when applicable. 4. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications. Record review of a Policy titled, Controlled Substances effective date ,d+[DATE] revised ,d+[DATE] revealed Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations. Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe controlled substances. IV. Documentation of a Controlled Substance Prescription: 1. Each controlled substance prescription is documented in the resident's medical record with the date and time of receipt and the signature of the person receiving the prescription. The prescription is recorded on the physician order sheet or telephone order sheet or posted elsewhere in the record and recorded on the MAR.

Based on interviews and record reviews the facility failed to notify the hospice provider of a significant change in condition for one resident (Resident #239) out of two sampled hospice residents as evidenced by no documentation indicating the hospice provider was notified of Resident #239's transfer to the hospital via emergency services. The findings included: Record review of Resident #239's demographic face sheet revealed an initial admitted d 8/23/21 a readmitted [DATE] and a discharged date of 7/4/24 with diagnosis that include Alzheimer's disease with late onset. Review of Resident # 239's physician's order sheet indicated an order dated 9/1/22 for: Routine Hospice Care for diagnosis of End stage Alzheimer's. Record review of Care plan initiated on 9/2/22 and revised on 8/15/24 revealed Resident #239 was at end of life with a of terminal illness and has chosen a palliative approach to care, comfort Care and is under hospice services with a goal that Resident #239 will receive comfort/palliative care according to individual wishes and facility policy through the review date. Interventions included: Assess and treat pain, administer medications per orders, assess emotional and spiritual needs of resident/family/caregiver and meet same when possible. Review of a hospice visit report revealed the last evaluation provided by the hospice nurse was on a note dated 7/2/24. Further record review revealed a progress note dated 7/8/24 indicating Resident #239's family members met with the Director of Nursing (DON) on 7/8/24 and reported they did not inform the facility of their new phone number; and had not received the voice mail until Saturday 7/7/24 when the phone data was transferred to the new phone. Record review of progress note revealed Resident#239 was transferred to the hospital and a voicemail was left for the family. There was no documentation found to indicate that hospice was notified. On 12/18/24 at 11:45 AM The Nursing supervisor revealed when a resident is receiving hospice care and is sent to the hospital the doctor, family and hospice nurse are notified immediately, and it is documented in the progress notes. On 12/19/24 at 9:12 AM Staff A, Registered Nurse for Hospice (RN) stated, I remember visiting [Resident #239] while he was residing in the facility however I don't recall if I was notified when he was discharged to the hospital. During an interview on 12/19/24 at 9:39 AM the DON was asked who was notified when Resident #239 was discharged to the hospital; the DON stated: The family came to facility to retrieve the belongings and told me the hospice nurse called them to see how the resident was doing in the hospital. They also mentioned they didn't know he had been transferred and I told them a voicemail was left on the phone number we had. It was revealed through the conversation that the family's phone information was being transferred to a new phone and the information was received once it was transferred. The nurse on the floor was supposed to notify hospice but there is no documentation that hospice was notified however it is the standard. Record review of a hospice contract dated 8/29/13 titled Nursing Facility Services Agreement: Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient. This includes, without limitation, a significant change in a Hospice Patient's physical, mental, social or emotional status, clinical complications that suggest a need to alter the Plan of Care, a need to transfer the Hospice Patient to another facility, or the death of a Hospice Patient. Record review of a policy titled Hospice Program published 10/3/24 documented: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. 10. In general, It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative .The responsibilities include the b. Twenty-four-hour room and board care; C. hospice and delineated in the hospice plan of care; Notifying the hospice about the following: emotional status. A significant change in the resident's physical, mental, social, or care. Clinical complications that suggest a need to alter the plan of (3) A need to transfer the resident from the facility for any condition. The resident's death. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.

Based on record reviews and interview, the facility failed to demonstrate effective plan of actions to correct identified quality deficiency in the problem area related to repeated deficient practice for F761-Label/Store Drugs and Biologicals. As evidenced by nurse not signing narcotic log at time of medication administration and not labeling antibiotic eye ointment with expiration and opened date. Review of the facility's survey history revealed; during the recertification survey with an exit dated 08/24/2023 the facility was cited F761 for failure to secure a controlled medication. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan revision dated 09/2024 states: Our QAPI plan includes the policies and procedures used to identify and use data to monitor our performance and establish goals, thresholds for improvement measures, and data at the facility, state, and national levels. Such data and performance measures will be used to: i. Identify and monitor our performance ii. Establish goals and thresholds for our performance measurement. iii. Utilize resident, staff, and family input. iv. Identify and prioritize problems and opportunities for improvement. v. Systematically analyze underlying causes of systemic problems and adverse events. vi. Develop corrective action or performance improvement activities. During an interview on 12/19/2024 at 2:16 PM, the Director of Nursing (DON) revealed the Quality Assurance and Performance Improvement (QAPI) committee meet on the third Wednesday of each month. The committee includes the Medical Director, Corporate Medical Director, Administrator, DON, Infection Prevention, Dietitian, Food Service Director, Environmental Services, Human Resources, Social Worker, Activities Director, Business Office, Rehab Director, Educator, and MDS. The Pharmacy Consultant come quarterly, and the pharmacy representative comes monthly. Every department need to be presenting for their own department. They should all have an area of performance improvement for their specific department and reports are submit for corporate on any projects they are working on. For the previously cited deficiencies, audits were done weekly for approximately 3 months. Monitoring and surveillance are done by observations, competencies, and cameras. I have a huge screen TV in my office, and I watch the staff; for example, when they are passing meds

Based on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment as evidenced by not providing housekeeping and maintenance services necessary to maintain an orderly, and comfortable interior for resident rooms #203, #207A, #210, #213, #215A, #217, #219, #225B, #229, #235, #236A. The findings included: Review of the facility's policy and procedure noted the following: Homelike Environment dated 03/08/2023. Policy Statement: Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to extent possible. Policy Interpretation and implementation: 1. Staff provides person-centered care that emphasizes the resident's comfort, independence and personal need and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a) Clean, sanitary and orderly environment. b) Personalized furniture and room arrangements. c) Clean bed and bath linens that are in good condition. During the Environmental Tour conducted on 8/21/23 08:50 AM the following was observed: Room# 203 - The exterior of the nightstand had exposed/sharp edges (X2). Room# 207A - The bed foot board was peeled. Room# 210 - The exterior of the nightstand had exposed/sharp edges (X2). Room# 213 - The exterior of the nightstand had exposed/sharp edges (X2) and the bathroom's mirror with desilverization(removal of silver). Room# 215A - The exterior of the nightstand had exposed/sharp edges and the bathroom's mirror with desilverization. Room# 217 - The exterior of the nightstand had exposed/sharp edges (X3) and the bathroom's mirror with desilverization. Room# 219 - The exterior of the nightstand had sharp edges. Room# 225B - The exterior of the nightstand had sharp edges. Room# 229 - The exterior of the nightstand had exposed/sharp edges (X2). Room# 235 - The bed was in disrepair (headboard is peeling (X2). Room# 236A - The bed was in disrepair, a peeling surface. During an interview on 08/24/23 at 07:24 AM, with the Maintenance Director, it was revealed the room maintenance is monthly, the Maintenance Director reported, when there is a new admission, we check everything. On a monthly basis we check, touch up paint on the walls and bathrooms. The Maintenance Director reported, at the moment, I am in charge of checking night tables and beds, and I am changing some on a monthly basis. I started that project two months ago. He reported, for the night tables I have changed only three, and for the beds I have changed eleven. At the moment we are ordering 6 beds at month, and we haven't put a specific plan in place for the night tables.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for two residents (Resident # 67, and Resident # 81) out of two residents MDS reviewed for accuracy. Resident # 67 was not coded for hospice care, and Resident # 81 was inaccurately coded for discharge to the hospital and the resident was discharged home. The findings included: 1. Record review of the clinical records for Resident # 67 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Other Specified Degenerative Diseases of Nervous System; Dysphagia Following Other Cerebrovascular Disease; Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety; Unspecified Psychosis Not Due to a Substance or Known Physiological condition; Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, Unspecified. Record review of the Physician Orders dated 08/26/2022 revealed, the resident had a Do Not Resuscitate Order. Record review of the Physician Orders dated 10/11/2022 revealed, Routine Hospice Care with a Hospice Company. Record review of the Physician Orders dated 10/12/202 revealed, the resident was admitted under Hospice Care with a diagnosis of Cerebrovascular Disease. Record review of the Quarterly Minimum Data Set (MDS) Section C Cognitive Status dated 07/22/2023 revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 03 out of 15, indicating severe cognitive impairment; Section O Special Treatments, Procedures and Programs revealed the resident was not coded for the resident being the under hospice care. Record review of Hospice Care Plan initiated on 7/22/2022 with the next review date 11/9/2023 revealed, the resident is at the end of life/diagnosis of terminal illness - Cerebrovascular Disease. Goal: Resident will receive comfort/palliative care according to individual wishes and facility policy through the review date. Interventions: Administer medications per physician orders. Assess and treat Pain. Assess emotional and spiritual needs of resident/family/caregiver and meet same when possible. Position for comfort. Provide comfort measures and honor preferences when possible. Refer to hospice program physician orders. Refer to Social Services for emotional support and assistance with advanced directives if necessary. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Interview with Staff B, the MDS coordinator on 08/24/2023 at 11:32 AM revelaed, he started to work as the MDS Coordinator recently. He stated resident # 67 is under hospice care. He stated the resident should be coded as a hospice resident. Review of the facility's Policies and Procedures for Comprehensive Assessments dated 03/08/2023 revealed, that Policy Statement: Comprehensive Assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation: 8-A significant error is an error in an assessment where: a) the resident overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and b) the error has not been corrected via submission of a more recent assessment. 2. Record review of Resident #81's Minimum Data Set (MDS) Discharge Return Not Anticipated/End of Prospective Payment System (PPS) Part A Stay dated 6/20/2023, admitted [DATE] revealed, Section A-Identification Information revealed Entry/discharge reporting: Discharge - return not anticipated, Type of Discharge-Planned, discharge date : 06/20/2023, Discharge Status: Acute hospital. Section I - Active Diagnoses included: Diabetes Mellitus (DM). Review of the Nursing Progress Note dated 6/20/2023 revealed, Patient is on the way home in family's car via wheel chair. Skin without impairment. Able to ambulate with assisting device. Prescriptions, clothing, and valuables were received by patient. Discharge instructions and follow up appointment with Primary Care Physician (PCP) in two weeks given. Patient verbalized understanding. Review of the Physician Visit Note dated 6/20/2023 revealed, Chief complaint-Discharge Summary, Plan: discharge home, home health evaluation and treatment. Record review of the document titled, Nursing Home Transfer And Discharge Notice with date notice is given as 6/16/23.The effective date was 6/19/23. Location to which resident is transferred or discharged (required): Name: Home. Reasons: Your health has improved sufficiently so that you no longer need the services provided by this facility. Brief explanation: discharged (D/C) home signed and dated 6/19/23. Reviewed Post Discharge Plan of Care signed and dated 6/19/23 with Discharge Destination: Home and Family. During an interview with Staff B, the (MDS) Coordinator on 08/24/23 at 11:28 AM, when asked about the MDS for Resident #81 and upon revision of Resident #81's MDS list there was a correction dated 08/24/2023. The MDS Coordinator was asked whether the MDS correction was done today? The MDS Coordinator stated, yes, a correction was done today, she came from an acute hospital and she was discharged to the community. 47182

Based on observations, interviews, and record reviews, the facility failed to follow the physician's orders and policy for a midline intravenous (IV) dressing change for one (Resident #25) out of five residents who were receiving intravenous therapy at the facility. As evidenced by the midline dressing being dated as changed on 7/20/2023. The midline dressing was not changed for one month. The findings include: In an observation on 08/21/23 at 02:45 PM, Resident #25 was awake and sitting in a wheelchair. A midline intravenous catheter to the right arm was observed. The midline dressing was dated 7/20/23. (See photo evidence) In an observation on 08/22/23 at 11:07 AM, Resident #25 was awake in bed, and it was observed that the dressing to the midline was changed and dated 8/21/23. (See photo evidence) In an interview on 08/23/23 at 02:46 PM with the Director of Nursing (DON). When asked, What is your facility's policy for midline dressings changes for residents? The DON stated It is the night shift nurse's responsibility to change the midline dressings two times a week. Our protocol is to change the midline dressings on Mondays and Thursdays. The night shift (7 PM to 7 AM) Registered Nurse / Licensed Practical Nurse responsibilities are posted on the bulletin board in the nursing station. Record review of Resident #25 medical record revealed, an admission on 7/5/23. The residents medical diagnoses included but were not limited to cellulitis of the right lower limb and right artificial knee joint and aftercare following joint replacement surgery. Record review of Resident #25 physician's orders revealed, an order start date of 7/10/2023 at 7:00 PM, intravenous midline catheter to measure external catheter length on admission, with each dressing change, and as needed. On every night shift on Mondays and Thursdays. An antibiotic order, Meropenem 2 grams two times a day by intravenous solution for right knee septic joint for six weeks. The antibiotic was started on 07/07/2023 at 9:00 AM and completed on 8/17/23 at 9:00 PM. Record review of Resident #25 medical record revealed, in the admission minimum data set (MDS) dated [DATE]. In Section C: Cognitive patterns, a brief interview of mental status (BIMS) was a fifteen (indicating cognitively intact). In section G: Functional status is bed mobility was extensive assistance with a one-person physical assist. In section I Active diagnosis, hip and knee replacement, aftercare following joint replacement. In section K: Swallowing/ Nutritional status, no swallowing disorders. In section J: health conditions, partial or total knee replacement. In section N: Medication, 4 days on antibiotics in the past 7 days. In section O: special treatments were resident on intravenous medication while as a resident. A record review of the care plans for Resident #25 revealed, on an intravenous antibiotic related to a right lower limb abscess with cellulitis. Initiated on 07/14/2023. The goal was the resident would be free from complications related to infection through the review date. Interventions were to administer antibiotics as per medical doctor orders and maintain universal precautions when providing resident care. Record review of the document titled 7P- 7A RN/LPN responsibilities revealed, on Mondays and Thursdays to perform IV dressing changes.

Based on observation, interview, and record review, the facility failed to follow physician's orders for oxygen administration for one out of four sampled residents (Resident #334). The findings included: Observation on 08/21/23 at 10:32 AM revealed, Resident #334 was lying in bed sleeping. Further observation showed the resident was receiving oxygen therapy; the oxygen concentration level was at 3.5 LPM (liters per minute). (photo evidence obtained) Review of the physicians order dated 08/18/2023 revealed, an order for Oxygen (O2) via nasal cannula at 2L/min as needed for O2 sat <92% as needed for SOB (shortness of breath). Review of Resident #334's medical diagnoses dated 08/17/2023 revealed, Gout unspecified (primary), essential (primary) hypertension, myocardial infarction, chronic kidney disease, and polyneuropathies. Review of Resident #334's progress notes dated 08/21/2023 (e-medication administration notes) revealed, an Oxygen via nasal cannula at 2L/min as needed for O2 sat <92% as needed for SOB was administered. Further review revealed, on 08/22/2023 an Oxygen via nasal cannula at 2L/min as needed for O2 sat <92% as needed for SOB was administered. During an interview with Staff C, a Registered Nurse (RN), on 08/23/23 at 12:39 PM, Staff C stated that they provide supervision for Resident #334 only when she needs it. Staff C then stated, She's receiving oxygen as PRN (as needed) when her saturation is low at 92. If there is a problem with her oxygen administration, I will call the pulmonary doctor. I monitor the oxygen level in the morning, in the afternoon. I check all the vital signs, if there is a problem, I call the doctor. On 08/23/2023 at 12:56 PM Staff D, a RN, stated that he takes the vital signs for all the residents in the morning, and that's how he monitors the residents' oxygen saturation. When he comes in the morning, he checks the oxygen level. He stated that the oxygen saturation has to be less than 92% for the resident to receive oxygen. He then stated that Resident #334 is only receiving oxygen as PRN. He stated he only worked with Resident #334 the day before, and the resident's oxygen saturation level was below 92%, so the resident was receiving oxygen. Review of the Oxygen Administration policy and procedures dated 05/19/2023 revealed: Level III Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal cannula, and/or nasal catheter. a. The oxygen mask is a device that fits over the resident's nose and mouth . Steps in in the procedures: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minutes. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 14. Periodically re-check water level in humidifying jar.

Based on record review, observation, and interviews, the facility failed to properly secure a controlled medication for one out of three medication carts observed. The findings include: On 08/21/23 at 09:38 AM, during a medication cart observation with Staff A, Registered Nurse (RN) on Two - South - cart one. The Surveyor observed the narcotic count binder was placed on top of the treatment cart next to Staff A's medication cart. Staff A, RN and the Surveyor performed a narcotic count, and it was correct, but the Surveyor observed a bingo card containing one remaining Lorazepam 0.5 mg(milligram) tab at the end of the narcotic count sheets with its narcotic count record sheet. On 08/21/23 at 09:45 AM, in an interview with Staff A, RN, when asked, How are controlled substances to be stored and reason the Ativan was placed in the back of the binder? Staff A, RN stated, these medications are always to be stored in a locked box. The nurse from the previous shift did this. Review of the narcotic count sheet revealed, Lorazepam 0.5 mg tab was signed out on 8/21/23 a 4:45 PM with one tablet remaining. (See photo evidence) Record review for resident #42 revealed, a medical diagnosis of anxiety disorder. A physician order for Lorazepam 0.5 milligrams was to be discontinued on 8/21/2023 at 11:59 PM and a new order for Lorazepam 0.5 milligrams was to be discontinued on 9/5/2023 at 10:29 AM. On 08/23/23 at 02:52 PM, during an interview with the Director of Nursing. When asked, What is your facility procedure for storing controlled medications? The Director of Nursing stated, This medication was discontinued at midnight. Normally, the nurse would give me the medication in the morning, and it needed to be reordered for the resident. I collect all narcotics and place them in a locked box in my office. It shouldn't have been in the binder. It should be in the locked box on the cart. Review of facility policy titled, Storage of Controlled Substances. Revised on August 2020. The policy statement was medications classified by the Drug Enforcement Administration as controlled substances are subject to special handling, storage, disposal, and record-keeping in the facility in accordance with federal, state, and other applicable laws and applicable laws and regulations. In the section, titled Procedures, 2. Schedule two through five medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double-locked compartment separate from all other medication or in accordance with state regulations. 10. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations.

Based on record review and interview the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission to determine if a Level II PASRR screening was required for one (Resident # 21) of three residents reviewed for PASRR. This has the potential to affect eighty-six residents residing in the facility at the time of the survey. The findings included: Review of the facility's policy titled PASRR dated 4/11/22 revealed: It is the facility policy that all residents have the required pre- admission screen prior to admission to the facility, and any time there is a significant change that has bearing on the resident specialized service needs. Guidance: 3. The PASRR process requires that all applicants to Medicaid certified Nursing facilities be given a preliminary assessment to determine whether they might have SMI (serious mental illness) or ID (intellectual disability) and/or related disorders. This is called a: Level I Screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR Screen. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. Record review revealed Resident #21 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 21's Level I PASRR dated 5/31/22 under Section I: PASRR Screen Decision Making: A: MI (Mental Illness) or suspected MI (check all that apply), no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings were based on documented history. Under Section II Other indicators for PASRR screening Decision-Making: All areas were checked No. Does individual have validating documentation to support dementia or related Neurocognitive disorder checked No. Section III indicated Resident #21 was not a provisional admission. Section IV the PASRR indicated no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Level II PASRR evaluation was not required. The PASRR Level I was completed by a Registered Nurse at the hospital on 5/31/22. Review of Resident # 21's Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 Is resident currently considered by the State level II PASRR process to have a SMI or ID or a related condition No. Section C for cognitive pattern revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15 which indicated severely impaired cognitive status. Section D revealed mood indicators included feeling down, depressed, feeling tired or having little energy, trouble concentrating. Section E revealed no behavior indicators. Section I active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section N medications included antipsychotics and antidepressants. Review of Resident # 21's care plans revealed: Impaired cognitive function or thought process related to disease process (dementia), mental illness ([CONDITION(S)]), short and /or long-term memory loss with impaired decision making. Resident displays/reports the following, feeling down, depressed, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident exhibits behavior symptoms such as hallucinations, delusions, change in environment, cognitive impairment, and mental illness ([CONDITION(S)]). Resident uses [CONDITION(S)] medications related to Depression and [CONDITION(S)]. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 21's psychiatric consult dated 6/6/22 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Documented note: Pleasant elderly female taking several [CONDITION(S)]'s. Patient is confused and disorganized, difficult to obtain reliable information. She denies psych history. She is restless and wants family. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is taking psychotropics for above illness. Review of psychiatric consult dated 7/14/22 revalued pleasantly confused elderly female readmitted from the hospital. Patient has been followed in the past. She is confused, disorganized, but has been calm and easy to redirect. She has been compliant with medications and able to sleep. Psychotropics are medically necessary at this time for patient to maintain level of function and wellbeing. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue present psychotropics. Interview with Registered Nurse, Staff Educator (Staff L) on 08/10/22 at 1:34 PM revealed: When a resident is admitted , I review the record the next day. I check to make sure the Level I PASRR is in the chart. I check the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I check the Level I, including the diagnosis. I have not had to create a new Level I due to an inaccurate screening. The PASRR Level I's are also looked at by Admissions and Social Services but Nursing checks them for accuracy. Review of Resident # 21 's Level I PASRR with Staff L revealed Depression is not marked on the PASRR. Also, Anxiety Disorder and [CONDITION(S)] are not listed on the PASRR Level I. Staff L stated, I missed this when I reviewed her PASRR. If I had recognized this error, I would have gone into (the state mental health provider) and submitted a request for a new Level I. For [CONDITION(S)] I would also request a Level II review, but she does not have this diagnosis. For [CONDITION(S)], I don't think a Level II would have been requested. Now, I will need to submit for a new Level I PASRR because the one that was done at the hospital is not accurate.

Based on observation, record review and interview the facility failed to ensure pharmaceutical services and procedures were being followed for 2 (Resident # 63 and Resident # 20) out of 3 residents observed, as evidenced by Registered Nurse (Staff C) signed off on medications as given before administering to Resident # 63 and one medication not available to be administered to Resident #20 during medication administration observation with Licensed Practical Nurse (Staff D). Failed to discard twenty-five (25) expired packets of 92 Gravity set with needle free Y site Intravenous (IV) tubing supplies found in one (third floor east station medication storage room) out of two medication storage rooms observed. Failure to ensure accuracy in narcotic count for two residents (Resident # 41 and Resident # 54) on 2 (North Cart # 2 and 2nd Floor, South Cart # 1) out of 3 medications carts observed. There were 86 residents residing in the facility services at the time of this survey. The Findings Included: 1. On [DATE] at 7:51 AM, during medication administration observation with Staff D, a Licensed Practical Nurse (LPN) on north medication cart #1, Resident # 20's Artificial Tears Solution, one drop in both eyes, was not available to be administered. Review of the medical records for Resident # 20 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Bilateral Pre-[CONDITION(S)], presence of intraocular lens, and dry eye syndrome. Review of the Physician's Orders Sheet for [DATE] revealed Resident # 20 had orders that included but not limited to: Artificial Tears Solution ,d+[DATE] mg/ml (milligram/milliliters), instill 1 drop in both eyes four times a day for dry eyes. On [DATE] at 8:10 AM Staff D stated the medication is not available on the cart, when I am finished with her med pass, I will call the doctor to reorder, or I will check the orders for the stop date. If the medication is active, I will reorder in the system. Staff D re-ordered the medication through the facility's electronic health records system. Review of Resident # 20 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns-Brief Interview for Mental Status BIMS Score of 05 out of 15, indicating resident is severely impaired cognitively. Review of the facility's policy and procedures titled, Medication Ordering and Prescribing revision date ,d+[DATE] states: the facility will submit reorders for medication to the pharmacy in a consistent manner. Nurse will examine supply of medication remaining to ascertain when a reorder/refill is needed for the resident. As a guideline, the RX [Prescription] label indicated an Estimated Reorder Date ([NAME]), this is the date that the reorder should be requested. 2. During observation on [DATE] at 11:00 AM of the east wing medication storage room with Staff B, a Registered Nurse (RN) 25 packets of 92 Gravity set with needle free Y site IV tubing supplies dated [DATE], were found in the bottom cupboard of the storage room. On [DATE] at 11:11 AM, during an interview Staff B was asked about the expired supplies, Staff B stated: I am not sure where those supplies came from, I will notify a supervisor and they will let us know what to do with supplies that are past the expiration date. Review of the facility policy and procedures titled, Storage of Medications revision date ,d+[DATE] indicates: outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 3. On 08/ 09/ 2022 at 11:36 AM, observation of the north medication cart # 2 with Registered Nurse (Staff A), revealed the narcotic count for Resident #41 was incorrect, the narcotic count records showed [MEDICATION(S)] 0.25 milligrams (mg) tablet count was nine (9) in the narcotic book, last signed out on [DATE] at 9:00 AM, review of the medication blister pack showed a count of eight (8) tablets remaining. Review of Resident # 41's Electronic Medication Administration Record (EMAR) revealed the resident received [MEDICATION(S)] 0.25 mg, one tablet on ,d+[DATE]/ 2022 at 9:00 AM. A side-by-side search of the cart's narcotic box/drawer was conducted with Staff A and no loose pills were found to justify the discrepancy with the narcotic count. Review of the medical records for Resident # 41 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder Unspecified. Review of the Physician's Orders Sheet for [DATE] revealed Resident #41 had orders that included but not limited to [MEDICATION(S)] 0.25 MG one tablet by mouth two times a day for anxiety. Review of Resident # 41's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns-Brief Interview of Mental Status Score (BIMS) of 13 out of 15 indicating the resident is cognitively intact. On ,d+[DATE]/ 2022 at 11:41 AM, Staff A stated, I really do not know what happen here, I received 10 pills this morning at shift change, I gave 1 pill at 9:00 AM which leaves 9. I don't know why there is only 8 on the bingo card. In this situation I have to get the supervisor and try to figure out what happen here, I'm so confused right now. On ,d+[DATE]/ 2022 at 12:18 PM Staff A,RN reported he found an [MEDICATION(S)] 0.25 MG, one (1) tablet on the end of another bingo card and he will notify the Director of Nursing (DON) and the pill will be destroyed with the drug buster. Review of the facility's policy and procedures titled Controlled Substances revision date ,d+[DATE] indicated: procedures step 5-Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR). a. Date and time of administration b. Amount administered c. Remaining quantity d. signature of the nursing personnel administering the doses. Initials of the nurse administering the dose, completed after the medication has been administered. 4. On ,d+[DATE]/ 2022, at 11:30 AM, during observation of narcotic count on South Cart 1 Staff E, a Registered Nurse counted eight [MEDICATION(S)] tablet 0.25 mg, one (1) tablet at bedtime for Resident #54 in the packet, but the controlled drug sheet indicated nine as the remaining amount of [MEDICATION(S)] 0.25 mg tablet, one tablet by mouth at bedtime. Further review of the controlled drug sheet revealed a line was crossed out on the line for number eight dated [DATE] with the time and initialed and signed by a previous nurse that the medication was wasted. Staff E, Registered Nurse was asked about the discrepancy. Staff E reported that Resident #54 had refused the medication. Review of the medication administration log sheet revealed a nurse initialed on [DATE], that the medication was given to Resident #54. Review of Resident # 54's clinical records revealed the resident was admitted on [DATE]. Clinical diagnoses included but not limited to Alzheimer's disease, and Major Depressive disorder. Review of Resident #54's physician orders sheet revealed orders for [MEDICATION(S)] Tablet 0.25 milligram. Give 1 tablet by mouth at bedtime for anxiety dated [DATE]. Review of Resident # 54's care plan with next review date of [DATE] documented: The resident uses anti-anxiety medications related to anxiety disorder. The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. The resident will show decreased episodes of signs or symptoms of anxiety through the review date. Give anti-anxiety medications ordered by physician. Monitor/ record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/ aggression towards staff/others. On ,d+[DATE]/ 2022 at 1:00 PM, the Director of Nursing was informed about the discrepancy identified related to the controlled substance counted not matching the log sheet. The DON acknowledged there was a discrepancy. Review of the facility's policies and procedures for Controlled Substances dated ,d+[DATE] policy # 8.5 effective ,d+[DATE] procedure #6 indicates: When a dose of a controlled substance medication is removed from the container for administration but is refused by the resident or not given for any reason, the dose is not placed back in inventory. The dose must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single- dose ampules.

Based of observation, record review and interview, the facility failed to be free of significant medication errors, this affected 2 (Resident # 6 and Resident # 46) out 21 sampled residents. There were 86 residents admitted to the facility at the time of the survey. The findings included: 1. During the Medication Administration task on 8/10/2022 at 8:29 AM with Staff F, Registered Nurse on Cart 2 South, medications were prepared for Resident # 6 for administration by placing the medications in individual medication cups, the medications were then crushed. Staff F, was observed to crush [MEDICATION(S)]/[MEDICATION(S)] XL ER (Extended Release) 90 mg (milligrams) 1 tablet and applesauce was added to the cup. As Staff F, was preparing to proceed to Resident # 6's room to administer the medication, Staff F was asked whether he was going to give Resident # 6 the crushed [MEDICATION(S)] and he said, yes. Staff F was asked to check the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] # 6. During the review of the physician order, the medication was ordered on 7/8/2022 and documented, [MEDICATION(S)] XL tablet ER 24 hour 90 mg, Give 1 tablet by mouth one time a day for [CONDITION(S)] (Hypertension), Do Not Crush. During record review it was noted Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following blood pressures were documented for Resident # 6, 8/10/2022 at 06:56 AM-135 / 71 mmHg, while lying down and in the right arm and on 8/11/2022 at 09:42 AM-145 / 82 mmHg, while lying down and in the right arm. On 8/10/2022 at 10:25 AM, the observation was discussed with the Director of Nurses (DON). He voiced understanding about the [MEDICATION(S)] XL ER Do Not Crush order. 2. During the Medication Storage task on 8/10/22 at 9:30 AM, with Staff G, Registered Nurse Unit Manager, 1 vial of [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)] is a sedative and a Schedule IV controlled substance) was observed in the refrigerator for Resident #46. During additional interview with Staff G about the [MEDICATION(S)], it was found that the [MEDICATION(S)] was discontinued on 11/12/2021. Review of the narcotic sheet revealed the resident received [MEDICATION(S)] .5 ml/1 mg injection on 11/20/2021 after the medication was discontinued. During record review it was noted Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/2022 at 10:25 AM, the finding was discussed with the Director of Nurses (DON). During the review of the facility's policy on Oral Medication Administration revised on 08-2020, it was noted in the Special Considerations section 1. Refer to crushing guidelines prior to crushing any medication for confirmation that it can be pulverized. During the review of the facility's policy on Administration Procedures for All Medications revised on 08-2020, it was noted in Procedures III. 5 Rights (at a minimum) .1. Prior to removing the medication package/container from the cart/drawer: Check the MAR/TAR for the order.

Based on observation, interview, and record review, the facility failed to maintain dignity during dining for two residents (resident #65 and resident #28) observed during two separate dining observations. This had the potential to affect forty-seven residents who required assistance with eating. The Findings included: Record review of the facility's policy and procedures titled, Resident Rights, dated 02/01/2018, revealed, All residents will be treated with kindness, respect and dignity. The facility will adhere to standards of conduct concerning the rights of its residents in concert with the resident rights as outlined by the Centers for Medicare Services (CMS). Resident rights include but are not limited to: The right to be treated with dignity and respect. Dining observation of the South Station hallway on 10/29/2018 at 12:19 PM revealed, in room [ROOM NUMBER] there were three residents with a certified nursing assistant (Staff D) present. One resident was able to eat on their own, and another resident was getting assistance with eating by Staff D. The third resident, resident #65, was seated in her wheelchair with her meal on the bedside table in front of her. She was trying to lift the utensil so she could eat the food, but she could not do it. Resident #65 looked at Staff D and spoke to her in Spanish; the staff member said something back to her and continued to feed the other resident. Resident #65 continued to try to eat, but she could not do it. Further observation at 12:31 PM, Staff D finished with the other resident and started providing assistance with eating to resident #65. Interview with Staff D on 10/29/2018 at 12:48 PM, via translation, revealed that normally resident #65 could eat on her own, but today she needed assistance. She was going to assist the resident with eating after she finished with the other resident. However, she could have asked for another staff member to come and assist with the resident. A Second Dining Observation of the South Station hallway on 10/30/2018 at 12:20 PM revealed, the dining cart arriving to the unit. Further observation at 12:33 PM revealed, resident #28 in her room with the bedside table in front of her; she did not have her meal. The resident was yelling out in Spanish. Observation and interview on 10/30/2018 at 12:40 PM revealed, resident #28 in her room, still without her meal, speaking in Spanish. The nurse supervisor (Staff F) stated the resident was saying that she was hungry in Spanish; however, she did not go and retrieve the resident's meal. Further observation revealed that at 12:41 PM, the certified nursing assistant (Staff E) brought resident #28 her meal and provided assistance with eating. Interview with Staff E on 10/30/2018 at 1:02 PM, via translation, revealed that after assisting resident #65 with eating, then she was going to help resident #28. While she was provided assistance to one resident, the other resident had to wait for assistance with eating. Staff E said, she did not see any problems with it because that was the way they always helped, but was aware that residents should not have to wait a long time for assistance and that she could ask for another staff member to help resident #28. Interview with the Director of Nursing (DON) on 11/01/2018 at 11:55 AM revealed, there were other staff members on the unit that the certified nursing assistants (CNAs) could have asked for assistance with resident #65 and resident #28.

Based on record review and interview, the facility failed to ensure care plans were implemented for six residents out of twenty two residents whose care plans were reviewed as evidenced by failure to monitor behaviors and side effects for the use of [MEDICAL CONDITION] medications for five residents (resident #66, #8, #46, #103, and # 92) and failure to provide respiratory care for one resident (resident #215) out of fifteen residents receiving respiratory treatments during the time of the survey. The census at the time of the survey was eighty eight. The findings included: 1) Record review revealed, resident #66 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed, resident #66 had a BIMS (brief interview for mental status) score of 00. Resident #66 had impaired short and long memory and severely impaired decision making skills. Mood indicators including feeling down and depressed, poor appetite and trouble concentrating. Behaviors included, hallucination and delusions. Medications included antipsychotic's and antidepressants. Review of resident #66's care plan implemented 3/8/2018 revealed, risk for side effects of medication secondary to psychoactive medication use: Antidepressant for Depression, Antipsychotic due to [MEDICAL CONDITION]. Resident experiencing screaming episodes, hallucinations, delusions and sadness. Approaches included, monitor and document side effects of medications every shift and review effectiveness of medications. Review of resident #66's physician orders [REDACTED]. The [MEDICATION NAME] dose was reduced from twice to once daily on 10/9/2018. Trazadone HCL 100 mg tablet at bedtime for Major [MEDICAL CONDITION] ordered 10/7/2018. Review of resident #66's medication administration record (MAR) for (MONTH) (YEAR) revealed, inconsistent documentation of behaviors and side effects for the use of the [MEDICATION NAME] and [MEDICATION NAME]. The Medication Administration Record (MAR) had blanks on 10/4, 10/5, 10/13, 10/16, 10/17, 10/18, 10/19, 10/23, 10/24, 10/26, 10/27, and 10/28/2018. Review of the nursing progress notes for resident #66 revealed, no documentation of behaviors or side effects related to the use of the [MEDICAL CONDITION] medications. Interview with the Director of Nursing (DON) on 11/01/2018 at 1:59 PM revealed, the facility recently started to document the behaviors and side effects in the electronic health record (EHR). In the beginning of (MONTH) the nurses were still documenting the behaviors and side effects on a paper form. The last week of (MONTH) they started to enter the information electronically. There was a glitch in the system and the nurses could not enter the number of times a behavior occurred. Rather than to document a zero they left the area blank. They were supposed to document on paper until the problem with the electronic system was resolved. I have the paper documents for Resident # 66 for September, but I cannot find them for October. Review of the Electronic-MAR for (MONTH) (YEAR) with the DON confirmed there were gaps in the documentation for October. He said there should be entries twice daily, once each shift to document behaviors and side effects for the medications. He said the staff educator would be better able to explain how the documentation was done on the MAR. Interview with the Staff Educator (staff N) on 11/01/2018 at 2:33 PM revealed that: If the nurses place a check mark on the electronic MAR and initial the MAR, this means the nurse saw the resident to determine if they had any behaviors or side effects. The numbers entered in the boxes (#9 and #14) also indicates there were no behaviors, but the nurse checked the resident. Staff N then said: I am really not sure what the numbers mean. I will have to go check the MAR instructions to figure this out. We just started using the electronic MAR to document behaviors and side effects. Interview with the Registered Nurse (staff C) on 11/01/2018 at 2:49 PM revealed: Resident # 66 has behaviors. Sometimes she is quiet, but at other times she screams a lot. She gets [MEDICATION NAME] a mood stabilizer twice daily. She also takes [MEDICATION NAME] one time daily for [MEDICAL CONDITION]. She takes Trazadone once daily at bedtime for Depression. She is seen by the Psychiatrist. On the day shift I administer the [MEDICATION NAME] and [MEDICATION NAME]. For the [MEDICATION NAME], I monitor her for hallucinations. If she had any I have to document how many times. I also have to document if they have improved or if they got worse. This is done at the end of the shift. The behaviors monitored for the [MEDICATION NAME] include, hallucinations and I have to document the number of times during the days she had the behavior. Then we would document if the behavior improved or stayed the same after interventions. The side effects we monitor for all [MEDICAL CONDITION] medications would include dry mouth, [MEDICAL CONDITION], dizziness, [MEDICAL CONDITION], anxiety, agitation and drowsiness/sedation. I will also observe for appetite changes, [MEDICAL CONDITION], confusion and restlessness. Right now I have to document on paper because the electronic system will not allow me to enter the number of behaviors every shift. For last month and this month we have been documenting the behaviors and the side effects on paper. Staff C did not have the documentation for the month of (MONTH) (YEAR). 2) Record review of the face sheet revealed, resident # 46 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED].# 46 revealed, the following medications but not limited to [MEDICATION NAME] 50 milligrams (mg) by mouth at bedtime and 25 mg by mouth at bedtime for [MEDICAL CONDITION]. [MEDICATION NAME] 100 mg by mouth at bedtime for [MEDICAL CONDITION]. Give 1 tablet of [MEDICATION NAME] 0.5 mg three times per day related to anxiety disorder. Give 15 mg [MEDICATION NAME] 1 capsule by mouth at bedtime related to [MEDICAL CONDITION]. [MEDICATION NAME] 10 mg give 1 tablet by mouth one time a day for depression. Record review of the psychiatrist consult dated 08/12/2018 for resident # 46 revealed medications: A full explanation of the present medications were given again to assure compliance as resident remained somewhat resistant and oppositional. It is medically necessary for this resident to continue treatment of [REDACTED]. [MEDICATION NAME] 100 mg one tablet by mouth at bedtime. A full explanation of the present medication was given again. Record review of the progress notes dated 10/7/2018 for resident # 46 revealed, despite the medication being administered the resident continued with periods of anxiety. Record review of the psychotrophic care plan revised on 10/30/2018 for resident # 46 revealed, Resident uses psychotrophic medications related to [DIAGNOSES REDACTED]. Goal: Resident will remain free of drug related complications .behavioral impairment through review date. Interventions: Administer medications as ordered. Monitor / document for side effects and effectiveness. Monitor, record and report to medical doctor side effects and adverse effects of psychoactive medications. Observation and interview on 11/1/2018 at approximately 11:55 AM revealed, resident # 46 was in gerichair. He was not alert to place and time and was well groomed. Resident # 46 had stated in Spanish that he was good. Interview on 11/1/2018 at 2:41 PM with staff H, a Registered Nurse (RN) reveale, resident # 46 was alert to name only and was very confused. Resident # 46 was currently on 25 mg of [MEDICATION NAME] at bedtime for [DIAGNOSES REDACTED]. They were monitoring resident # 46 for [MEDICAL CONDITION] and he how he reacted. The psychiatrist decreased the [MEDICATION NAME] to 75 mg on 10/25/2018. He had a gradual dose reduction by the psychiatrist. Resident # 46 was monitored for anxiousness, nervousness and jitteriness. He received [MEDICATION NAME] 50 mg at night for [MEDICAL CONDITION] and had not received in report that he was not sleeping. Resident # 46 received [MEDICATION NAME] 10 mg daily for [MEDICAL CONDITION] and monitored for depression. Staff H, RN mentioned that resident # 46 was getting [MEDICATION NAME] 0.5 mg three times a day for anxiety. He was calmer and sometimes tried to get out of the wheel chair. The psychiatrist saw him on 08/12/2018, 08/18/2018 and the last time on 10/25/2018. The medications were doing what they were supposed to do and they kept monitoring resident # 46. Staff H, RN noted that she documented the behavior monitoring on paper. Staff H, RN explained: When we changed to computer, the computer did not let me put in if residents got worse or better, the time the behavior was monitored or how many times the behavior was seen. Record review of the electronic behavior monitoring sheet for (MONTH) (YEAR) and (MONTH) (YEAR) for resident # 46 revealed that when comparing the electronic behavior monitoring sheet with the paper behavior monitoring sheet the behaviors for anxiety disorder, [MEDICAL CONDITIONS] and antipsychotic usage were not signed off on several days and were not monitored on the electronic or paper behavior monitoring sheets. 3) Record review of the face sheet revealed that resident # 103 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED].# 103 revealed the following medications but not limited to Quetiapine [MEDICATION NAME] 25 miligrams (mg) give 2 tablets by mouth at bedtime for depression, on 10/5/2018 consult with psychiatrist, monitor for antipsychotic usage, monitor for depression usage, [MEDICATION NAME] 25 mg by mouth one time a day for depression. Record review of the nurse's note dated 10/8/2018 for resident # 103 revealed resident received in bed. Respirations even and unlabored at room air. No shortness of breathe, denied pain, oral medications given and well tolerated. Safety and control measures maintained. Call light within reach. Will continue to monitor. Record review of the psychiatrist evaluation dated 10/8/2018 for resident # 103 revealed initial evaluation was agitation, depressed and delusional. Judgment was fair and good. Mood: Depressed and anxious. Cognition: Cognitive changes new onset. Recommendations: the resident was taking [MEDICATION NAME] and [MEDICATION NAME] which had been needed in the past, at this time resident seemed to be overly sedated, at times her speech was unintelligible and soft and mumbling. She had no suicidal idea or plan and had poor recent memory. Will decrease [MEDICATION NAME] and continue a gradual dose reduction to be discontinued if needed. Psychoactive medications: [MEDICATION NAME] 25 mg oral daily. [MEDICATION NAME] 25 mg oral twice daily. [MEDICATION NAME] might have been used to help resident with depression and anxiety episodes. At this time it seemed resident was overly sedated and gradual dose reduction started on the latter. Will follow up. Record review of the psychotrophic care plan revised on 10/22/2018 for resident # 103 revealed, resident # 103 used Psychotrophic medications for depression. Goal: Will be free from side effects through next review date. Interventions: Administer medications as ordered. Monitor / document for side effects and effectiveness. Monitor / record occurrence for target behavior symptoms. Monitor, record and report to medical doctor side effects and adverse reactions of psychotrophic medications. Interview on 11/1/2018 at 10:39 AM with staff A, Licensed Practical Nurse (LPN) revealed, resident # 103 was alert to name. She needed assistance with her activities of daily living. She was on [MEDICATION NAME] 25 mg daily for depression. She did not have any episodes of sadness. She was on [MEDICATION NAME] 25 mg for a total of 50 mg. Resident # 103 was prescribed this medication for depression and was not aggressive and had no hallucinations. The order was written on 10/5/2018 and there was a telephone order to discontinue the [MEDICATION NAME] in the morning and continue with the PM dose. Resident # 103 saw the psychiatrist on 10/8/2018. The psychiatrist will follow up with supportive psychotherapy. Staff A, LPN noted that they had behavior monitoring sheets in the computer and on the Medication Administration Record. Staff A, LPN explained: We were doing the behavior monitoring in computer and something went wrong and we went paper last month. Now we are using paper for behavior monitoring. Observation on 11/1/2018 at 11:02 AM revealed that resident # 103 was in bed. She was not alert and non-verbal. She was well groomed. Record review of the behavior monitoring sheet for (MONTH) (YEAR) for resident # 103 revealed, when comparing the paper with the electronic behavior monitoring sheets there were several days that were blank for the depression behavior monitoring. The behavior monitoring for [MEDICATION NAME] and [MEDICATION NAME] usage were not monitored on several days in (MONTH) (YEAR) for resident # 103. 4) Record review of the face sheet revealed that resident # 8 was re-admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED].# 8 revealed, the following medications but not limited to [MEDICATION NAME] 10 mg 1 tablet by mouth daily for depression. Record review of the depression care plan revised on 08/21/2018 for resident # 8 revealed, At risk for adverse reaction related to use of antidepressant medications for [DIAGNOSES REDACTED]. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Give antidepressant medications ordered by physician. Observe / document side effects and effectiveness. Observe, document and report to medical doctor ongoing side effects of depression by antidepressant medications. Observation and interview on 10/31/2018 at 12:40 PM revealed, staff was assisting resident # 8 with eating. Resident # 8 was in a gerichair and had pureed food. She was well groomed. Resident # 8 was not alert. Interview on 11/1/2018 at 11:21 AM with staff C, Registered nursing (RN) supervisor revealed that resident # 8 was alert to name and needed extensive assistance. Resident # 8 was confused and stable. Resident # 8 was on [MEDICATION NAME] 10 mg 1 tablet daily and had no signs and symptoms of depression. Resident # 8 was monitored for depression. Staff C, RN supervisor noted that they documented behavior monitoring in the computer and on paper. Interview on 11/1/2018 at 4:17 PM with the Director of Nursing (DON) regarding behavior monitoring of staff revealed, that they had care plans for behaviors and side effects. They had glitches in the computer software system right now. They started psychotrophic meetings and the psychiatrist saw about 90 % of the residents and he saw new admissions. They made sure that the care plan was in place for appropriate interventions and for behavior and side effect monitoring. They were completing gradual dose reductions. The DON noted that he thought the nurses were monitoring the psychotrophic behaviors of the residents. They DON explained that they were switching to a new computer software system in steps. They added documents, then doctors order and the last part was the medication administration record in the middle of (MONTH) (YEAR). In (MONTH) (YEAR) they were completing the behavior monitoring in the computer. In (MONTH) (YEAR) the nurse told him that they could not chart the behaviors. The DON explained: You can't put no behaviors or how many times monitored in the computer system. They called corporate. They were told there were glitches in the computer software system. The glitches were not fixed and the weekend of the 11th the nurses were trained on paper. After (MONTH) 5, (YEAR), they went to paper for behavior monitoring. The staff were educated on the 6th. The DON was shown the blank behavior monitoring sheets (paper and electronic) for (MONTH) and (MONTH) (YEAR) for resident # 8, resident # 46 and resident # 103. The DON concluded: Staff could document no behavior, the choices were none occurred and do nothing and they were not able to put something and this occurred in (MONTH) (YEAR) until now. To put no behavior occurred would be false and they needed dose reduction. Nurses know how to monitor the behavior according to the care plan. Record review of the electronic behavior monitoring sheet for (MONTH) (YEAR) and (MONTH) (YEAR) for resident # 8 revealed, several behaviors for depression were left blank and were not documented as monitored by staff. Record review of the nurse notes for resident # 8 revealed, that there were no behavior nurse's notes for 10/5/2018 and 10/13/2018. 5) Record review of the medical facesheet for resident #92 revealed, the resident was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#92 was initially prescribed 100 milligrams (mg) of [MEDICATION NAME], an antipsychotic medication, to be given at bedtime, and 50 mg of the same medication to be given twice daily for [MEDICAL CONDITION]. Both dosages of the medication were discontinued on 10/09/2018, and reduced to 25 mg to be given twice daily. In addition, on 07/13/2018 the resident was prescribed 1 mg of [MEDICATION NAME], an antianxiety medication, to be given every 8 hours for anxiety, and on 07/14/2018 the resident was ordered 75 mg of [MEDICATION NAME], an anti-depressant medication, to be given once daily. Record review of the [MEDICAL CONDITION] Care Plan dated 07/16/2018, Revised 08/23/2018, 10/16/2018 and 10/23/2018, revealed resident #92 care planned for the use of [MEDICAL CONDITION] medications; with a goal dated of 01/14/2019. Interventions included, but were not limited to, administering medications as ordered and monitoring and documenting for side effects and effectiveness. Record review of the Medication Administration Records (MARs) for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed, resident #92 received the [MEDICAL CONDITION] medications as ordered by the physician. Record review of the Behavior Monitoring Records for the months of (MONTH) (YEAR) and (MONTH) (YEAR), in both electronic and hard copy format, revealed numerous days where resident #92's behaviors such as anxiety, depression and hallucinations were not monitored; as well as side effects of the [MEDICAL CONDITION] medications. Record review of the Nurses Notes for resident #92 for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed, no documentation of monitoring of behaviors and side effects that correlated to the numerous missing days on the behavior monitoring records. Interview with the Licensed Practical Nurse (Staff B) on 10/31/2018 at 11:41 AM revealed, she paid attention to the resident #92's behaviors and side effects of her [MEDICAL CONDITION] medications. When she gave the resident her medications, or monitored her behaviors, she charted in the computer system; she never documented on paper. Interview with the Nurse Supervisor (Staff C) on 10/31/2018 at 12:13 PM revealed, the facility started putting information into the computer between (MONTH) (YEAR) and (MONTH) (YEAR), but they were still documenting on paper; they were fully computerized in (MONTH) (YEAR). Some documentation was electronic, and some documentation was on paper. However, everything should be documented. Staff C stated, if there were days missing on the electronic behavior monitoring record, then they should be documented on the paper document; the nurses may have forgotten to document on the records. Interview with the Director of Nursing (DON) on 10/31/2018 at 12:43 PM revealed, he started to in-service staff on documenting on the behavior monitoring records; however, he confirmed that there were days where nursing staff should have documented that they were monitoring the resident #92's behaviors. Record review of the facility's policy and procedures titled, [MEDICAL CONDITION] Medication, dated 02/01/2018, revealed, [MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring.Nursing: Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline. Will monitor for the presence of target behaviors on a daily basis. Behaviors will be documented as warranted. 6) Record review of the facility's policy and procedures titled, Oxygen Administration, dated 10/2017, revealed, To provide adequate oxygenation of the tissues and prevent [MEDICAL CONDITION]. Verify physician order. Record review of the medical facesheet for resident #215 revealed, the resident was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#215 was prescribed Oxygen at 5 liters (L) every shift for shortness of breath (SOB) via nasal cannula. In addition, on 09/11/2018 the resident was ordered routine hospice care for a [DIAGNOSES REDACTED]. Record review of the [MEDICAL CONDITION] and [MEDICAL CONDITION] Care Plan dated 08/13/2018, Revised 08/22/2018, revealed resident #215 was care planned for [MEDICAL CONDITION] and end stage [MEDICAL CONDITION], with a goal date of 11/6/2018. Interventions included, but not limited to, give oxygen therapy as ordered by the physician. Observation on 10/29/2018 at 10:58 AM revealed, resident #215 was in his room receiving oxygen via nasal cannula. The oxygen flowmeter was set at 2.5 L; the resident was not in any pain or distress. Observation on 11/01/2018 at 10:09 AM revealed, resident #215 was in his room receiving oxygen; the oxygen flow meter was set at 3 L. The resident was not in any pain or distress, but would not respond to his name or answer any questions. Interview with the Licensed Practical Nurse (Staff A) on 11/01/2018 at 10:17 AM revealed, resident #215 was on hospice for end-stage [MEDICAL CONDITION], which was why he was on continuous oxygen. Staff A monitored the resident's oxygen (O2) saturation, lung sounds, and any coughing or problems swallowing. The resident received respiratory treatments, and she monitored his vital signs, and ensured his head of bed was elevated. Resident #215 was supposed to be receiving five liters of oxygen. Observation and interview on 11/01/2018 at 10:25 AM revealed, that resident #215's oxygen level was at 3 liters. Staff A was present and stated that it should be at 5 liters, and she adjusted the level. She thought that it was at the right level when she checked on the resident earlier.

Based on record review, observation and interview, the facility failed to provide proper treatment and adequate care for one resident (resident #11) reviewed for concerns with foot care out of twenty-two sampled residents. This facility practice has the potential to have an adverse effect on thirty-two residents in the facility dependent on staff for their Activities of Daily Living. The findings included: Record review of the face sheet for resident #11 revealed, the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The [DIAGNOSES REDACTED]. A review of the Nurse Practitioner note dated 10/26/2018 for resident # 11 revealed, Patient had generalized contractures, rigidity, limited ROM (Range of Motion), high risk for pain. A review of the Annual Minimum Data Set (MDS) dated (MONTH) 21, (YEAR) for resident #11 revealed, Cognitive Skills Brief Interview Of Mental Status (BIMS) coded as a six, which indicated that the resident cognitive skills were moderately impaired. Observation on 10/29/2018 at approximately 10:40 AM revealed, resident #11 was in her room, sitting in her wheelchair, her feet where slightly elevated, and barely touched the floor. The resident had involuntary kicking movements and appeared to be hitting the leg of an over-bed table placed directly in front of her. Observation on 10/29/2018 at 11:41 AM revealed, resident #11 remained in her room sitting in the same position. The resident hit the leg of the over bed table placed directly in front of her. The resident stated, Ay, ay, ay, I hurt my feet on this. Interview on 10/31/2018 at 12:37 PM, with staff C, a Certified Nursing Assistant (CNA) revealed, staff cared for resident # 11 during the morning shift. According to the CNA, resident #11 at times suffered episodes of confusion, required total assistance with care, and suffered from [MEDICAL CONDITION]. The CNA explained, she placed the table directly in front of resident #11 so she can place her hands on the table, it helps her feel safe. The CNA reported, she was aware that the resident hit her feet on the table and that she moves her legs a lot. Related to the over bed table, the CNA reported, Yes, I should not have it in front of her. During the interview, the CNA agreed to remove the resident's socks and observe the resident's feet for bruises. The Registered Nurse (RN), staff B, was present during the observation. Observation and interview on 10/31/2018 at approximately 12:47 PM revealed, all of resident #11's toenails appeared to have a yellowish discoloration, they also appeared thick, brittle and flaking off. Staff B reported, It looks like a fungal infection. During the interview, staff B and staff E both reported that the resident's feet condition was not addressed. The RN stated, she would notify the podiatrist. Interview on 10/31/2018 at 4:30 PM with staff B, a Registered Nurse revealed, the RN reported, the whole team observes for changes in the resident's skin condition. The nurses did weekly skin assessments and documented their findings in the facility's electronic system. Record review during the interview revealed, weekly skin treatment for [REDACTED].# 11's toenails. The RN explained, they normally did not assess the resident's toenails during their weekly skin treatments. Further review of nurses' notes and doctors' orders for resident #11 revealed, none of their notes or treatments addressed the resident's nail conditions. The RN reported, This is the first time I noticed the nails, we do not have treatment for [REDACTED]. I am going to notify the doctor now, to see what he has to say .