Every finding on record at Parkview Nursing & Rehabilitation Center

Based on observation, interview, record review, and review of the facility policy, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one sampled residents. Observations on 03/30/2026 and 03/31/2026 revealed R5's open-ended catheter tubing was loosely hanging in the trash receptacle. The findings include: Observation on 03/30/2026 at 4:48 PM revealed a catheter bag anchored to the bedside, and the end of the catheter tubing was in the trash can. Observation on 03/31/2026 at 10:25 AM and 3:48 PM revealed that the catheter tubing remained in the trash can. Review of facility policy titled Infection Prevention and Control Program and Plan, revised on 06/02/2025, revealed, the facility had an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible.Review of facility policy titled Indwelling Urinary Catheter Management revised on 06/27/2023 under General Guidelines revealed, changing indwelling catheters or drainage bags at routine fixed intervals was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstructions or when the closed system was compromised.Review of document titled How to Care for your Urostomy or Continent Diversion last reviewed on 05/14/2021 revealed, a urostomy is an opening called a stoma from the belly to the outside of the body. It lets you get rid of the body's urine. Urine moves from the kidneys and your stoma instead of through the bladder into a small plastic bag or pouch that is worn outside your body. The pouch protects you from odor and wetness you will need to learn how to care for the pouch, stomach and skin. Continued review revealed, general care included, 'empty the pouch first thing in the morning, pour out contents of the pouch when it's 1/3 to 1/2 full, wash your hands before and after touching the pouch, clean the end of the pouch with a moist paper towel or a baby wipe you may also rinse the pouch with water and drain the water close the end of the pouch by replacing the clamp a tube can be attached to the drain valve on your pouch and joined by a bedside collector, letting urine drain while you sleep. Review of the admission Record revealed the facility admitted Resident (R) 5 to the facility on [DATE] with diagnoses of paraplegia, complete, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, unspecified. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/22/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating R5 was cognitively intact.During an interview with R5 on 03/30/2026 at 4:49 PM, she stated she emptied her own urostomy by attaching the tubing of the catheter bag to the pouch. R5 stated she then placed the tubing over the trash can in case it leaked. R5 stated she did not wash her hands before or after draining her bag. She stated the facility had not provided her with alcohol-based hand rub or sanitizing wipes to cleanse her hands or the catheter tubing. She stated staff changed her wafer a few times a week. During an interview with Licensed Practical Nurse (LPN 2) on 03/31/2026 at 3:48 PM, he stated he provided care for R5's urostomy. He stated that he changed out the wafer about every three days or as needed. He stated the resident emptied her own urostomy bag into a catheter bag and that the staff emptied the catheter bag. The Surveyor asked LPN 2 to enter R5's room for observation. Upon observing the catheter tubing hanging in the trash can, he stated, that it was not good, and he would get a bag for the resident to put it in. LPN 2 stated R5 had the potential of getting a urinary tract infection (UTI) with the tubing hanging in the trash can.Observation on 04/02/2026 at 8:48 AM revealed R5's catheter tubing was in a plastic bag at the bedside. R5 stated LPN 2 put in there yesterday. R5 further stated the Director of Nursing had spoken to her about the catheter tubing. During an interview with Infection Preventionist on 04/02/2026 at 2:20 PM, she stated she was not aware that R5 kept her catheter tubing in the trash can and that it was a concern. She stated the tubing in the trash can would lead to infection. The IP stated she had spoken to R5 in the past about hand hygiene and provided her with sanitizing wipes. She stated R5 had only had 1 UTI in the last 6 months.During an interview with the Director of Nursing (DON) on 04/02/2026 at 2:26 PM, she stated that R5's catheter tubing being in the trash can was a concern and a potential for infection (UTI). She stated she had spoken to R5 this week after LPN 2 made her aware of the concern. She stated she was not 100% sure but thought R5 had hand sanitizer in her room for providing hand hygiene. During an interview with the Executive Director (ED) on 04/02/2026 at 3:45 PM, he stated it would be a concern for catheter tubing being in the trash can. He stated an outcome for R5 could be a urinary tract infection. He stated he would expect staff to provide R5 with hand hygiene items.

Based on observation, interview, and review of the facility policy it was determined that the facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs.The findings include: Observation on 03/30/2026 at 12:00 PM of the medication room on Wing 7 with Licensed Practical Nurse (LPN4) revealed the medication refrigerator was not locked. There were five bottles of Lorazepam 2 milligram per milliliter (30 ml) oral concentrate, one bottle with 2 ml, and one bottle with 6.75 ml in the refrigerator, unsecured. They were not in a separate lock box nor affixed to the inside of the refrigerator. Review of the facility policy, titled Storage and Expiration Dating of Medications and Biologicals, last revised 08/01/2024, revealed the facility, under controlled substances storage, would store all drugs and biologicals in locked compartments, including the storage of Schedule II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. The facility would ensure all controlled substances were stored in a manner that maintained their integrity and security. Additionally, controlled substances stored in the refrigerator must be in a separate container and double locked. During an interview on 03/30/2026 at 12:00 PM with LPN4, she stated the medication refrigerator should have been locked. She stated they did not have a lock box for controlled substances that need to be refrigerated. During an interview on 03/30/2026 at 3:44 PM with Unit Manager (1) W5 - W8, she stated the medication room lock and the medication refrigerator lock provided a second lock for narcotics. She stated she was not aware that narcotics in medication refrigerator needed to be in a secure lock box. She was informed of finding the medication refrigerator unlocked leaving narcotics easily accessible. UM (1) contacted ADON at that time. During an interview on 03/31/2026 at 9:25 AM with RN2, she stated the charge nurses had keys on individualized wings. She stated only charge nurse had the keys on individualized wings to medication refrigerator. She stated medication room and medication refrigerator locked, for a two-lock system. She stated the medication refrigerator should have been locked. On 04/02/2026 at 9:30 AM observation of the contents of narcotic box included: five full (30 ml) bottles lorazepam 2 mg/ml, one bottle with 2 ml and one with 6.75 ml secured. The lock box was not secured to the inside of the refrigerator. The medication refrigerator is on Wing 7. The medication refrigerator covers W6 - W8.During an interview on 04/02/2026 at 9:46 AM with Unit Manager 2, UM (2) Wing 9 - 10 it was stated that charge nurses had keys and only had keys to the medication refrigerator. All narcotics are counted at the end of each shift with oncoming and off going nurses. All narcotics that needed to be wasted required two nurses to observe waste and both to sign for waste.On 04/02/2026 at 9:46 AM observation of the contents of narcotic box included: one full 30 ml bottle of lorazepam 2 mg/ml. Only used for emergent needs, used for only one resident. Pharmacy was alerted to replenish the medication. Lorazepam injectable, two 1 ml vials in a sealed bag from the pharmacy. The medication refrigerator covers W9 - W10 combined when changed to private rooms. The narcotic box was secured but not affixed to inside of refrigerator.During an interview on 04/02/2026 at 3:12 PM with the Director of Nursing, she stated the facility is always making rounds, doing audits, and that it was highly unusual for the medication refrigerator to have been left unlocked. She stated the facility considered medication refrigerator and medication door lock a double-lock system. She stated she expected for narcotics to be locked in the secondary lock box, locked in the medication refrigerator, making certain both locks were secure and then making certain upon leaving the medication room door was securely locked.During an interview on 04/02/2026 at 3:40 PM with the Executive Director, he stated expectations of nursing staff were to make certain all medication refrigerators were always locked up. He stated whether there was an issue or if I found something I feel needed to be addressed, I would speak with my DON and I know she is going to address it. He stated he was aware that the locked narcotic boxes are supposed to be affixed in the medication refrigerator. He stated was not aware they were not affixed.

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to ensure interventions to prevent / decrease a resident's limitation in Range of Motion (ROM) were in place for two (2) of three (3) sampled residents, R6 and R7. The findings include: Review of the facility policy titled, Splints and Braces-Upper Extremity, reviewed 09/19/2025 stated the facility would provide splints and braces to the upper extremities in accordance with professional standards of practice, as outlined by [NAME]. The use of a supportive and protective device designed for a patient's upper extremity, such as a sling, brace, or splint, helped provide support, facilitate functional use, reduce pain, maintain alignment, correct deformities, or provide protection for a healing injury. For use in immobilizing an acute injury, a splint or brace helped prevent further soft-tissue, nerve, and vascular damage while allowing for swelling and helping to reduce pain during healing. Review of the facility policy titled, Restorative Nursing Regulatory Considerations, reviewed 12/18/2025 stated a resident may be started on a restorative nursing program when he or she is admitted with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arose during the course of stay or in conjunction with formalized rehabilitation therapy. Review of the facility policy titled, How to Manage a Restorative Program, reviewed 12/18/2025 stated a restorative nursing program referred to nursing interventions that promoted the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focused on achieving and maintaining optimal physical, mental, and psychological functioning. 1) Review of Resident #6's admission Record revealed the facility admitted the resident on 12/01/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non dominant side, and Muscle Weakness. Review of Resident #6's Comprehensive Care Plan with a review date of 03/04/2026 revealed the resident had an ADL self-care performance deficit, left-sided hemiparesis, and the resident's left hand was contracted. Further review of the care plan, physician's orders dated 01/18/2026, and the resident's Treatment Administration Record (TAR), revealed the resident was to have a hand splint applied on the left hand for up to 6 hours, on AM off PM. Observation on 03/30/2026 at 1:15 PM Resident not wearing splint, splint was sitting by the TV. Observation on 03/30/2026 at 3:42 PM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 9:56 AM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 9:41 AM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 12:00 PM Resident not wearing splint, splint was sitting by the TV. Observation on 04/01/2026 at 9:41 AM Resident not wearing splint, splint was sitting by the TV. During an interview with Licensed Practical Nurse (LPN) 7 on 04/01/2026 at 9:35 AM, she stated that Restorative Aides applied the splint for the residents that required it. However, if they are working on the floor, nurses applied the splint on. She stated there would be a negative outcome if the resident did not wear the splint. His left hand would get tighter; and the splint would prevent his fingers from drawing up to a fist. No documentation was found where the splint was placed but starting today it will be she stated. Observation on 04/01/2026 at 10:28 AM of resident wearing the splint, placed on by LPN 7. She put a timer on her phone for the 4 hours as a reminder for his splint to be on. During an interview with the Director of Nursing (DON) on 04/01/2026 at 11:44 AM, she stated she expected staff to follow resident care plans. She stated residents are at risk when care plans are not implemented. She stated there is potential for a negative outcome when an order stating splint appliance was ordered but not followed. During an interview with the Occupational Therapist on 04/01/2026 at 11:59 AM, she stated the resident is only able to tolerate wearing the splint for four hours before the order was discharged from 6 hours to 4 hours. Insurance benefits were also exhausted to where 4 hours are allotted. She stated the charge nurse was expected to place the splint on when restorative aides were unavailable. She stated quarterly screenings were performed to measure functional decline or improvement for those wearing a splint. She stated it is a way we are kept up to date with their progress. She stated there would be a negative outcome if the residents care plan was not followed for contracture splint care. 2) Review of the admission Record revealed the facility admitted Resident (R)7 to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, seizures, and obesity. Further record review revealed an order for a right resting hand splint to be applied in the morning and removed in the evening. There was an order for a palm protector to be applied to R7's left hand, on in the morning and off in the evening. Both orders were started 08/05/2025 and both orders were revised on 09/27/2025. The most recent (annual) Minimum Data Set (MDS) for R7, with Assessment Reference Date (ARD) 02/11/2026, was reviewed, which indicated the use of splints. Review of the Comprehensive Care Plan revealed R7 was care planned for a resting right-hand splint and left palm guard related to limited range of motion. Review of the most recent Nursing Restorative Program Evaluation for R7, signed on 03/25/2026, revealed the restorative program to include daily passive range of motion (PROM) and resting hand splint use to preserve range of motion and prevent contracture development. Observation of R7 on 03/30/2026 at 3:54 PM revealed no resting hand splint in place on the right side. The palm protector on R7's left hand was in place. Observation of R7 on 03/31/2026 at 10:35 AM again revealed no resting hand splint in place on the right side. The palm protector on R7's left hand was in place. Observation of R7 on 04/01/2026 at 2:41 PM again revealed no right-hand splint in place. It was noted on her bedside table pushed up against the far wall in her room. The palm protector on R7s left hand was in place. During an interview with Certified Nursing Assistant (CNA)11 on 04/01/2026 at 2:43 PM, she stated R7 should have a splint in place on the left hand at all times but was unaware of a right-hand splint. During an interview with Licensed Practical Nurse (LPN)7 on 04/01/2026 at 2:45 PM, she stated that the restorative CNA should be putting the splints in place every day, but they frequently get pulled to the floor due to short staffing. LPN7 then entered R7's room and put the right-hand splint in place and asked CNA11 to remember to take it off before they left for the day. During an interview with CNA12 on 04/02/2026 at 2:21 PM, she stated that CNAs are informed by the nurse in the morning if splints needed to be put on and the restorative aide would do it before she began working the floor. She further stated, the Kardex specifies how long the splints are supposed to be in place. During an interview with CNA7 on 04/02/2026 at 2:07 PM, she stated, the restorative aides usually put splints in place, but when they are not available, the CNA assigned to the resident puts them on. Additionally, she stated the CNAs are informed in the morning if they, or, the restorative aide, will be doing it for the day and that instructions for splints are in the Kardex. During an interview with LPN6 on 04/02/2026 at 2:14 PM, she stated, if an aide put a splint in place, the nurse was responsible for making sure it was put on correctly. She further stated that therapy trains the nursing staff as needed on individualized restorative programs for each resident. During an interview with LPN9 on 04/02/2026 at 2:25 PM, she stated, the Treatment Administration Record (TAR) showed specifics about which splints each resident wore, and when they are to be in place and removed. Additionally, she stated splint use is also listed in the care plan. During an interview with the Executive Director on 04/02/2026 at 3:41 PM, he stated he expected nursing staff to follow the care plans and orders regarding a resident's splint use. He further stated, they are prescribed for a reason. During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:05 PM, she stated she expected restorative CNAs to follow restorative programs and care plans regarding splinting and range of motion. She further stated, if a splint was not applied as ordered, it would cause skin issues and contractures.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for three out of three residents, Resident (R) R5, R6 and R7. The findings include: Observation of (R) 5 on 03/30/2026 at 4:48 PM revealed a catheter bag anchored to the bedside, and the end of the catheter tubing was in the trash can. Observation on 03/31/2026 at 10:25 AM and 3:48 PM revealed that the catheter tubing remained in the trash can. Review of the admission Record revealed the facility admitted Resident (R) 5 to the facility on [DATE] with diagnoses of paraplegia, complete, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, unspecified. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/22/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating R5 was cognitively intact. During an interview with R5 on 03/30/2026 at 4:49 PM, she stated she emptied her own urostomy by attaching the tubing of the catheter bag to the pouch. R5 stated she then placed the tubing over the trash can in case it leaked. R5 stated she did not wash her hands before or after draining her bag. She stated the facility had not provided her with alcohol-based hand rub or sanitizing wipes to cleanse her hands or the catheter tubing. She stated staff changed her wafer a few times a week. Review of the Comprehensive Care Plan (CCP) for R5 dated 09/29/2022 revealed a focus problem that stated, the resident has a urostomy catheter with total bowel incontinence related to complete paraplegia, interventions included; change urostomy bag and urostomy catheter as ordered for obstruction or when the closed system was compromised, check skin around urostomy wafer for signs and symptoms of rubbing or breakdown as ordered, explain to the resident or family regarding indwelling catheter, observe for and document pain due to catheter, observe for and report to physician any signs and symptoms of UTI, pain, burning, blood tinged urine, observe for signs and symptoms of discomfort on urination and frequency, obtain labs or diagnostics as ordered and fax results to the urologist, provide incontinent care using soap and water, then thoroughly dry the skin after each incontinent episode, urostomy care as ordered, keep catheter bag placed below the level of the bladder. On 03/31/2026 the CCP of R5 was revised to include resident often emptied urostomy bag per self and preferred to place the drainage bag over the trash can for concern of potential for leaking. Review of CCP for R5 dated 06/07/2023 revealed a focus problem indicating R5 had a history of urinary tract infection (UTI) and was at risk for recurrence. Interventions included encourage adequate fluid intake, antibiotic therapy as ordered and give antipyretics analgesics and antispasmodics as ordered, labs/diagnostics as ordered, observe and report to the physician any signs and symptoms of UTI, frequency, urgency, malaise, foul smelling urine, vital signs as ordered, notify physician of significant abnormalities. Review of CCP dated 10/23/2026 revealed R5 refused care at times, preferred to have bed in high position, had a history of canceling appointments. On 03/31/2026, the CCP was revised, R5 hyper focused on urostomy bag changing it several times a day and insisted on placing drainage bag over in trash can for fear of leaking. Interventions included, explain all procedures to the resident before starting and allow the resident to adjust to change, notify the physician for new orders as needed, praise and indication that resident progressed with improvement and behavior. Continued review revealed no new interventions were added with the revision on 03/31/2026. Continued review of the comprehensive care plan for R5 revealed no interventions were related to the resident's self-care of the urostomy, including hand hygiene. During an interview with Licensed Practical Nurse (LPN 2) on 03/31/2026 at 3:48 PM, he stated he provided care for R5's urostomy. He stated that he changed out the wafer about every three days or as needed. He stated the resident emptied her own urostomy bag into a catheter bag and that the staff emptied the catheter bag. The surveyor asked LPN 2 to enter R5's room for observation. Upon observing the catheter tubing hanging in the trash can, he stated, that it was not good, and he would get a bag for the resident to put it in. LPN 2 stated R5 had the potential of getting a urinary tract infection (UTI) with the tubing hanging in the trash can. During an interview with Infection Preventionist on 04/02/2026 at 2:20 PM, she stated she was not aware that R5 kept her catheter tubing in the trash can and that it was a concern. She stated the tubing in the trash can would lead to infection. The IP stated she had spoken to R5 in the past about hand hygiene and provided her with sanitizing wipes. She stated R5 had only had 1 UTI in the last 6 months. During an interview with the Director of Nursing (DON) on 04/02/2026 at 2:26 PM, she stated that R5's catheter tubing being in the trash can was a concern and a potential for infection (UTI). She stated she had spoken to R5 this week after LPN 2 made her aware of the concern. She stated she was not 100% sure but thought R5 had hand sanitizer in her room for providing hand hygiene. The DON stated she expected resident care plan interventions be followed. During an interview with the Executive Director (ED) on 04/02/2026 at 3:45 PM, he stated he expected resident care plans to be reviewed and revised as needed to reflect the care a resident needed. He stated he expected staff to follow resident care plans and the interventions that were in place. Review of Resident #6's medical record revealed the resident had a physician order and was care planned for hand splints for a left-hand contracture to be worn six hours per day. Review of the facility's policy for Comprehensive Care Plan, dated 08/29/2025, revealed the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his/her care. The policy further revealed the resident should be monitored to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. Review of Resident #6's admission Record revealed the facility admitted the resident on 12/01/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non dominant side, and Muscle Weakness. Record review revealed there was no documentation in the progress notes for Resident #6 in relation to staff documenting implementation of his care plan regarding his hand splint. Observation on 03/30/2026 at 1:15 PM Resident not wearing splint, splint was sitting by the TV. Observation on 03/30/2026 at 3:42 PM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 9:56 AM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 9:41 AM Resident not wearing splint, splint was sitting by the TV. Observation on 03/31/2026 at 12:00 PM Resident not wearing splint, splint was sitting by the TV. Observation on 04/01/2026 at 9:41 AM Resident not wearing splint, splint was sitting by the TV. During an interview with Minimum Data Status (MDS) 2 on 04/01/2026 at 2:21 PM, she stated care plans were initiated upon the resident's admission. She stated after the Restorative Aide assists with care; they are to mark complete. They are to relay any important information relating to the care provided so the nurse could document in progress notes. During an interview with LPN 7 on 04/01/2026 at 09:35 AM, she stated Restorative Aides applied splints on for the residents that required it. However, if they were working on the floor we nurses applied the splint on. She stated there would be a negative outcome if the resident did not wear a splint. His left hand would get tighter; and the splint would prevent his fingers from drawing up to a fist. No documentation was found where the splint was placed but starting today it will be she stated. During observation on 04/01/2026 at 10:28 AM of the R6 wearing the splint, placed on by LPN 7, she put a timer on her phone for the 4 hours as a reminder for his splint to be on. During an interview with the Director of Nursing (DON) on 04/01/2026 at 11:44 AM, she stated she expected staff to follow resident care plans. She stated residents are at risk when care plans are not implemented. She expected staff to follow physician orders, apply splints, and monitor for skin integrity and circulation. She stated there was potential for a negative outcome when the resident did not wear hand splints that are care planned for. During an interview with CNA 4 on 04/01/2026 at 9:49 AM, she stated she printed the physician orders at the start of her shift. She stated the care plan was part of the residents healing and it is important to follow. She stated she was trained to apply splints and if the resident would not wear it, that it would be considered neglect. She stated she used the drop-down boxes on PCC electronic record signaling completion of resident ADLs. Nurses are responsible for detailed information regarding care that will be under progress notes. During an interview with Occupational Therapist on 04/01/2026 at 11:59 AM, she stated R6's order was updated from a 6-hour to 4-hour splint wear due to insurance exhaustion. She stated he only was able to tolerate it for four hours as well. She stated restorative aides and nurses are trained to apply the splint. She stated quarterly screens are performed to measure functional improvement or decline from hand splints. She stated R6 would be at risk of increased contracture, skin breakdown, and pain stiffness due to the care planned not being followed. During an interview with CNA / RA 5 on 04/01/2026 at 2:47 PM, he stated he first checked for injuries or cuts before applying splints on the resident. He stated he followed the Kardex from PCC, which was the residents care plan. He stated there was a negative outcome if the residents care plan was not implemented. Failing to implement the care plan would result in a decrease in mobility. He stated he would apply hand splints if he was not working the floor. He stated the nurses were in charge of applying splints if they are working the floor and responsible for documentation. During an interview with Restorative with CNA / RA 13 on 04/02/2026 at 9:10 AM, she stated she retrieved residents care plan from PCC. She checked if there are updates from therapy. She stated therapy trained her on applying splints. R6's hand would not improve if the resident care plan was not implemented. During an interview with Administrator on 04/02/2026 at 03:39 PM, he stated he expected staff to follow the orders and care plans to be able to implement interventions for the residents. Review of facility policy labeled, Restorative Nursing Regulatory Considerations, reviewed 12/18/2025, revealed the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The policy additionally stated, a registered nurse or a licensed practical nurse must supervise the activities in a restorative nursing program. Review of facility policy, labeled, Comprehensive Care Plans and Revisions, reviewed 08/29/2025, revealed the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and would ensure that the care plan was reviewed and revised by and interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs. Record review of the admission Record revealed Resident (R)7 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, seizures, and obesity. Review of the physician orders revealed an order for a right resting hand splint to be applied in the morning and removed in the evening. Additionally, there was an order for an arm protector to be applied to R7's left hand, on in the morning and off in the evening. Both orders were started 08/05/2025 and both orders were revised on 09/27/2025. The most recent (annual) Minimum Data Set (MDS) for R7, with Assessment Reference Date (ARD) 02/11/2026, was reviewed, which indicated the use of splints. Further record review of the Comprehensive Care Plan revealed R7 was care planned for a resting right-hand splint and left palm guard related to limited range of motion. Observation of R7 on 03/30/2026 at 3:54 PM revealed no resting hand splint in place on the right side. The palm protector on R7's left hand was in place. Observation of R7 on 03/31/2026 at 10:35 AM revealed no resting hand splint in place on the right side. The palm protector on R7's left hand was in place. Observation of R7 on 04/01/2026 at 2:41 PM revealed no right-hand splint in place. It was noted on her bedside table pushed up against the far wall in her room. The palm protector on R7s left hand was in place. During an interview with Certified Nursing Assistant (CNA)11 on 04/01/2026 at 2:43 PM, she stated R7 should have a splint in place on the left hand at all times but was unaware of a right-hand splint. During an interview with Licensed Practical Nurse (LPN)7 on 04/01/2026 at 2:45 PM, she stated that the restorative CNA should put the splints in place every day, but they frequently get pulled to the floor due to short staffing. LPN7 then entered R7's room and put the right-hand splint in place. This was the first observation of R7 wearing her right resting hand splint since facility entry. During an interview with CNA12 on 04/02/2026 at 2:21 PM, she stated, CNAs are informed by the nurse in the morning if splints needed to be put on and the restorative aide would do it before she started working the floor. She further stated, the Kardex specified how long the splints are supposed to be in place. During an interview with LPN6 on 04/02/2026 at 2:14 PM, she stated, if an aide puts a splint in place, the nurse was responsible for making sure it was put on correctly. She further stated that therapy trained the nursing staff as needed on individualized restorative programs for each resident. During an interview with LPN9 on 04/02/2026 at 2:25 PM, she stated, the Treatment Administration Record (TAR) showed specifics about which splints a resident wore, when they were to be placed and removed. Additionally, she stated splint use is also listed in the care plan. During an interview with the Executive Director on 04/02/2026 at 3:41 PM, he stated he expected nursing staff to follow the care plans and orders regarding a resident's splint use. He further stated, they are prescribed for a reason. During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:05 PM, she stated she expected restorative CNAs to follow restorative programs and care plans regarding splinting and range of motion. She further stated, if a splint is not applied as ordered, it could cause skin issues and contractures.

Based on interview, record review, and review of the facility policy, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II Pre-admission Screening and Resident Review (PASARR). Resident (R) 11 admitted to the facility on [DATE]. On 10/08/2023, a new diagnosis of schizophrenia was added, however, the facility did not initiate a new level I PASARR. This affected one (1) of one (1) resident reviewed for PASARR. The findings include: Review of facility policy titled Pre-admission Screening and Resident Review, reviewed on 09/26/2025, revealed that the facility would ensure that potential admissions would be screened for possible serious mental disorders or intellectual disabilities and related conditions. The initial pre-screening was referred to as PASARR level I and is completed prior to admission to a nursing facility. A negative level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.Review of the admission Record revealed the facility admitted Resident (R) 11 to the facility on [DATE] with diagnoses of bipolar disorder, delusional disorder, and chronic kidney disease. Review of a handwritten physician letter dated 03/27/2025 revealed the patient was admitted with a diagnosis of schizophrenia. Family had confirmed she was diagnosed with schizophrenia in her 30's. Patient had experienced hallucinations and delusions with gradual dose reductions of anti-psychotic medication. Re-evaluation of resident symptoms had been completed, and all other diagnoses had been ruled out. Continue with the diagnosis of schizophrenia. Psych notes reviewed and agreed with the assessment.During an interview with the admission Director (AD) on 04/01/2026 at 10:14 AM, she stated R11 had a PASARR level I completed on admission, but she did not have a PASARR completed in October 2023 when the diagnosis of schizophrenia was added to the chart. The AD stated that a new mental health diagnosis would indicate a new PASARR would need to be completed. The AD stated she was unaware that a PASARR was not completed.During an interview with the Executive Director (ED) on 04/02/2026 at 3:58 PM; he stated that he and the two (2) social services staff were not at the facility in 2023. He stated he was unaware until now that R11 did not have a PASARR completed in 2023, and it would be taken care of.

Based on observation, interview, and facility policy review, the facility failed to assure the nutritive value of food was not compromised and destroyed because of prolonged holding on a steam table. The deficient practice had the potential to affect 163 of the facility's 163 residents who consumed food from the kitchen. Observation on 03/17/2025 at 3:20 PM, revealed macaroni and cheese and greens were placed on the steam table an hour and ten minutes prior to the evening meal being served. The findings include: Review of the facility policy titled, Food Temperature Control, revised 06/28/2024, revealed the food temperatures were to be maintained during mealtimes to ensure residents received safe food served at acceptable temperatures. Continued review revealed food was to be prepared by methods that conserved the nutritive value, flavor, and appearance. Review of the facility policy titled, Cleaning Schedule, reviewed on 04/30/2024, revealed food was not to be placed on the steam table more than 30 minutes before a meal service began. Observation on 03/17/2025 at 3:20 PM, during the initial tour of the kitchen, revealed macaroni and cheese and greens stored on the steam table for that evening's dinner meal. In interview on 03/17/2025 at 3:21 PM, the Dietary Manager (DM) stated she was not aware food had already been stored on the steam table for that evening's meal. In interview on 03/17/2025 at 3:30 PM, the Dietary [NAME] confirmed placing the macaroni and cheese and greens on the steam table at approximately 3:10 PM. He stated however, the evening dinner meal was not scheduled to be initiated until 4:30 PM (an hour and 20 minutes after the macaroni and cheese and greens were placed on the steam table).

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure infection control procedures to prevent the spread of infection were followed for 1 of 33 sampled residents, (Resident (R)139); and for all residents residing on the 900 hall/unit who used ice from the ice cooler. 1. Observation on 03/19/2025 revealed staff failed to use appropriate Personal Protective Equipment (PPE) when providing care for R139 who required Enhanced Barrier Precautions (EBP). 2. Observation on 03/18/2025 revealed staff, after overfilling a resident's used cup with ice, and then to proceed to pour the excess ice, off the top of the cup, back into the clean cooler of ice. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, revised 06/03/2024, revealed the facility should use Enhanced Barrier Precautions (EBP) during high-contact resident care activities. Per review, the high-contact resident care activities included: wound and/or indwelling medical devices even if the resident was not known to be infected or colonized with a Multidrug Resistant Organism (MDRO). Record review revealed the facility admitted R139 initially on 01/22/2024, with diagnosis which included: hemiplegia and hemiparesis affecting the left non-dominant side following cerebral infarction; Type 2 diabetes mellitus; and peripheral vascular disease. Further review of the record revealed R139 was admitted with a gastrostomy tube (g-tube) in place at the time of admission due to dysphagia following cerebral infarction. Additionally, review of R139's record revealed the resident had a foley catheter (indwelling catheter), a stage 4 pressure wound to the coccyx: and the g-tube. Review of R139's comprehensive care plan dated 11/25/2024, revealed the facility developed a care plan for urinary catheter which noted enhanced precautions were indicated. Observation of foley catheter care for R139 on 03/19/2025 at 10:39 AM, revealed Certified Nursing Assistant (CNA) 8 and CNA 9 failed to don necessary PPE (a gown) while providing the resident's catheter care. Observation of wound care for R139 on 03/19/2025 at 2:19 PM, revealed Registered Nurse (RN) 3 and CNA 10 entered the resident's room to complete wound care without donning necessary PPE (gowns). Continued observation revealed RN 3 and CNA 10 proceeded with performance of R139's wound care without donning a gown prior to completion of the procedure. Observation of g-tube site care for R139 on 03/19/2025 at 2:40 PM, revealed RN 3 failed to don the necessary PPE (a gown) prior to or when performing the g-tube site care. In interview on 03/19/2025 at 11:52 AM, CNA 9 stated she had been nervous and failed to put a gown on. The CNA said the signage was above R139's bed indicated EBP were necessary, and the PPE was kept in the bottom drawer of the resident's dresser. CNA 9 further stated PPE was used to prevent the spread of infection. In interview on 03/19/2025 at 11:25 AM, CNA 8 assigned to R139's care, stated he was from another state and had not been trained to wear gowns. He said he had worked here (at the facility) for six months. The CNA reported being trained on EBP at the facility; however, did not recall being trained that a gown was needed when performing catheter care. CNA 8 stated he would wear a gown when residents had Contact / Barriers precautions. He said he was not aware of anything being in the room that communicate EBP was needed for R139. The CNA further stated he received information through shift report or from the CNA care plan that said he needed to wear a gown with catheter care. In interview on 03/19/2025 at 11:30 AM, Licensed Practical Nurse (LPN) 8 regarding EBP, stated EBP was used for residents who had a catheter, tracheostomy, wounds and/or a feeding tube. She said she was to use gowns and gloves when providing care for residents with any of those. The LPN reported the PPE was kept in all the residents' rooms in the drawers, which were labeled EBP. She further stated there was a sign over those residents' beds to communicate the necessity of EBP for staff. In interview on 03/19/2025 at 2:53 PM, RN 3 stated she observed EBP (when providing resident care), which included handwashing and use of gloves. She reported she did not know if gowns were included in EBP and said EBP was new to her. The RN said she had been employed (at the facility) approximately two weeks and had just gotten out of orientation. She further stated the purpose of EBP was to decrease contamination and the spread of infection. In interview on 03/20/2025 at 4:33 PM, Infection Prevention (IP) Nurse 4 stated high contact tasks included g-tube, wound, and foley catheter care. She said it was her expectation that staff wear PPE during those high contact tasks to prevent the spread of infection. IP 4 reported the PPE was checked daily by the IP Nurses, who also noted the levels of gowns to reflect usage of the gowns. She stated the IP's rounded daily and observed staff for compliance with PPE. The IP Nurse explained staff were educated in mandatory monthly in-services and through video presentation with explanation during new hire orientation. She said everyone sees the video and the IP Nurses reviewed, signed, and went into depth with explaining infection control to new hires. IP Nurse 4 stated staff were also educated by the IP Nurses on where the PPE was located in the resident's room. She reported additional PPE was available in the designated stock room on the 200 hall that could be accessed by all nurses at any time. The IP Nurse further stated the audit findings were reported in the facility's Quality Assurance Performance Improvement (QAPI) Committee meetings. In interview on 03/20/2025 at 4:53 PM, the Director of Nursing (DON) stated the high contact tasks included g-tube, wound, and foley catheter care. She said it was her expectation staff wear PPE during those high contact tasks to prevent the spread of infection. The DON further stated the IP Nurses shared the findings of their audits and if a systemic problem was identified, a focused education would be completed. In interview with the Administrator on 03/20/2025 at 5:13 PM, he stated he expected staff to follow the facility's policy for EBP to prevent the spread of infection. 52040 2. Review of the facility policy, Ice Chests, reviewed on 06/03/2024, revealed all ice handlers were educated to not return unused iced to an ice storage chest. However, observation on 03/18/2025 at 9:39 AM, revealed CNA 5 was delivering fresh ice to residents on the 900 hall/unit. Per observation, CNA 5 filled a used resident's cup (R29's) over the opened cooler of clean ice. Further observation revealed after overfilling the used cup she then poured the excess ice from the top of the cup back into the clean ice in the cooler. In interview on 03/18/2025 at 9:40 AM, CNA 5 stated she should been more cautious. RN 3, who was also present during the interview with CNA 5, immediately removed the cooler with ice from use to empty it and clean it. In interview on 03/20/2025 at 4:40 PM, the Assistant IP Nurse stated ice should never be dumped back into a cooler of clean ice. In interview on 03/20/2025 at 4:50 PM, the DON stated she expected the facility's, Ice Chest policy to be followed by staff. In interview on 03/20/2025 at 5:13 PM, the Administrator stated he expected the facility's, Ice Chest policy to be followed by staff.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure treatment and care in accordance with professional standards of practice for 1 of 7 residents sampled during medication pass out of the total sample of 33, (Resident (R)4). Observation revealed medication observed under R4's bed, lying on her bedside table, and lying in her hand while she was lying on her bed with eyes closed. The findings include: Review of the facility policy, Administration of Medications, reviewed 09/16/2024, revealed the facility was to ensure medications were administered safely and appropriately. Review revealed the definition of a medication error was noted as the observed or identified preparation or administration of medications or biologicals which were not in accordance with . 3. Accepted professional standards and principles which applied to professionals providing services. Per review , the facility procedure included medication administration was the responsibility of individuals, who through certification and licensure, were authorized to administer medications in a skilled nursing facility. Continued policy review revealed staff responsible for medication administration were to adhere to the 10 Rights of Medication Administration, which included ensuring: right drug; right resident; right dose; right route; right time and frequency; right documentation; right assessment; right to refuse; right evaluation/response; and right education and information. Review of R4's electronic medical record (EMR) revealed the facility admitted the resident on 07/26/2019, with diagnoses which included: multiple sclerosis, attention-deficit hyperactivity disorder, and Parkinson's Disease. Review of the Minimum Data Set (MDS) Assessment for R4, with an Assessment Reference Date (ARD) of 12/27/2024, revealed the facility assessed with a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Review of R4's comprehensive care plan (CCP) documentation revealed the facility had not identified an intervention for the resident being able to take her medications unsupervised. Observation on 03/17/2025 at 1:03 PM, revealed a circular white tablet lying under R4's bed. During interview with R4, at the time of observation, she stated the nurse set her medication cup on her bedside table that morning, told her There they are, and walked away. R4 stated she accidentally knocked the medication cup over. The resident reported an aide came into her room later, and picked the medication up off the floor. She said the aide returned the medication (from off the floor) back into the medication cup, and placed the cup on her bedside table. R4 reported she took the medication at that time. Review of the facility' Electronic Medication Administration Record (eMAR) for R4, located in the EMR, under the Reports tab, revealed the resident's ordered medications listed. Continued review revealed the following medications were documented as administered as AM meds, with no specific time, to R4: Buspirone HCl (used to treat anxiety) 5 milligram (mg); Bupropion HCl (an antidepressant) 150 mg; Duloxetine HCl (used to treat anxiety, depression and nerve damage from diabetes) 60 mg; Duloxetine HCl 30 mg; Dapagliflozin Propanediol (to treat diabetes) 5 mg; Aldactone (diuretic to treat high blood pressure and heart failure) 25 mg; Folic Acid (B vitamin supplement) 800 micrograms (mcg); Furosemide (diuretic) 40 mg; Metformin (to treat diabetes) HCl 500 mg; Aspirin (blood thinner) 81 mg; Docusate Sodium (stool softner) 250 mg; Ferrous Sulfate (iron supplement) 325 mg; Omeprazole (to treat gastrointestinal reflux disease [GERD] and heartburn) 20 mg; Potassium Chloride (to treat low potassium levels) 20 milliequivalents (meq); Pramipexole Dihydrocholride (to treat Parkinson's disease) 0.5 mg; and Vitamin B-12 1000 mcg. In interview on 03/17/2025 at 1:10 PM, Registered Nurse (RN) 2 stated the nurse who had completed the morning medication pass for R4 was at lunch. The State Survey Agency (SSA) Surveyor notified RN 2 of there being a white tablet under R4's bed, and he retrieved the tablet. The RN identified the tablet as Metformin 500 mg and then disposed of the tablet. In interview on 3/17/2025 at 3:39 PM, Licensed Practical Nurse (LPN) 2 she stated she was responsible for that morning's med pass which included R4's medications. LPN 2 further stated R4 took all the medication in the medication cup and implied it was while she (the LPN) was present in the room. She further stated she was unaware of one of the medications dropping (on the floor. In interview on 03/17/2025 at 3:43 PM, Certified Nursing Assistant (CNA) 3 stated he entered the room of R4 at about 11:00 AM to assist her, and noticed several pills lying on the floor. He stated he picked the pills up, put them in a medicine cup, and then placed the cup on the resident's bedside table. The CNA reported he witnessed R4 consume the pills after he put the cup on the bedside table. He stated, I must have missed one if there was one under the bed. CNA 3 said he did not notify anyone of the medication being on the floor. When the SSA Surveyor asked him what he should have done when he saw the medication on the floor, he stated I should have told the nurse. Continued review of R4's medical record revealed LPN 2 had placed an Alert Note in the Progress Notes section of the EMR. Per review, at 4:03 PM on 03/17/2025, LPN 2 documented this nurse went into residents [sic] room to give medication, medication placed in residents [sic] hand. This nurse was unaware that resident did not take medication. This nurse was alerted that resident spilled medication and did not take medication, alerted aprn [sic] and alerted POA about change in condition. Further review revealed the LPN noted no new orders at this time, and R4 was assessed for pain and denied having any pain. In addition, review revealed LPN 2 noted No adverse reactions noted at this time. Will continue plan of care. Observation on 03/20/2025 at 9:41 AM, revealed R4 lying on her bed with eyes closed with a medicine cup containing multiple medications in her left hand and a white tablet lying on the overbed table. The SSA Surveyor was joined in observation by another SSA Surveyor. Observation revealed R4 woke up and said she was very sleepy that morning, then proceeded to close her eyes again and fell back to sleep. The SSA Surveyors asked LPN 9, who completed the morning medication pass, and LPN 10, the Unit Coordinator, to join their observation of R4 and the medications located in the resident's hand. Observation further revealed LPN 9 woke R4 up and witnessed the resident take all the medications located in the medication cup and from the overbed table. In interview on 03/20/2025 at 9:50 AM, LPN 9 stated she was normally very cautious when passing residents' medication; however, might have gotten busy and failed to watch R4 take her medication. Review of R4's eMAR, in conjunction with LPN 9 and LPN 10, revealed the following medications had been documented as administered to the resident that morning: Buspirone HCl 5 mg; Bupropion HCl 150 mg; Duloxetine HCl 60 mg; Duloxetine HCl 30 mg; Dapagliflozin Propanediol 5 mg; Aldactone 25 mg; Folic Acid 800 mcg; Furosemide 40 mg; Metformin HCl 500 mg; Aspirin 81 mg; Docusate Sodium 250 mg; Ferrous Sulfate 325 mg; Omeprazole 20 mg; Potassium Chloride 20 meq; Pramipexole Dihydrochloride 0.5 mg; and Vitamin B-12 1000 mcg. In interview on 03/20/2025 at 9:52 AM, LPN 10/Unit Coordinator stated LPN 9 was a young nurse. She reported she would educate LPN 9 (on proper medication administration). In interview on 03/20/2025 at 4:40 PM, the Assistant Infection Prevention (IP) Nurse stated residents ingesting medication off the floor was unacceptable. In interview on 03/20/2025 at 4:50 PM, the Director of Nursing (DON) stated she expected nurses to observe residents taking their medications. She said the nurses were trained during their orientation on how to properly pass (residents') medication. The DON reported if a CNA found medication on the floor they should give it to the nurse immediately. She further stated she did not condone residents consuming medications off the floor. In interview on 03/20/2025 at 5:13 PM, the facility's Administrator stated he expected the nurses to watch residents taking their medications. He stated it would have been possible for anyone to have taken the medication when it was lying on the floor if it was not witnessed as being taken during the medication pass.

Based on observation, interview, record review, and facility policy review, the facility failed to promote residents' personal privacy for 1 of 5 residents sampled for wound care, out of the total sampled residents of 33, (Resident (R)87). During observation of wound care for R87 on 03/20/2025, the wound care nurse failed to close the window blind, exposing R87 to view by anyone outside within sight of the resident's window. The findings include: Review of the facility policy titled, Resident Rights, reviewed 11/19/2024, revealed the resident had a right to be treated with respect and dignity. Review of the Admission Record for R87 revealed the facility admitted the resident on 09/28/2022, with diagnoses to include: paraplegia, limitation of activities due to disability, and neuromuscular dysfunction of bladder. Record review revealed R87 had wounds requiring treatment to her buttock and foot. Review of the Quarterly Minimum Data Set (MDS) Assessment with a Assessment Reference Date (ARD) of 02/01/2025, revealed the facility assessed R87 to have a Brief Interview for Mental Status (BIMS) score of a 14 out of 15, indicating the resident was cognitively intact. During observation of R87's wound care on 03/20/2025 at 9:20 AM, the wound care (WC) nurse failed to close the resident's window blinds which exposed her to view of anyone near the window while in the facility's main entrance parking lot. During interview with the WC nurse on 03/20/2025 at 9:50 AM, she stated she should have pulled the window blind closed to protect R87's privacy. She further stated R87 often refused to have the window blind closed; however, she failed to ask the resident if it was okay to close it. During interview with R87 on 03/20/2025 at 11:00 AM, she stated it did not make her feel very good knowing the window blind was left open. R87 stated anyone could look through her window and see her (exposed). She further stated there was a lot of people walking by and they could have seen her (exposed). During interview with the Director of Nursing (DON) on 03/20/2025 at 4:49 PM, she stated she expected staff to provide privacy for residents all the way around. The DON reported staff should knock before entering a resident's room, close the privacy curtain and close the window blinds prior to performance of care. She further stated it was a dignity issue because someone could have walked by (R87's window) and observed the resident exposed. During interview with the Administrator on 03/20/2025 at 5:02 PM, he stated R87's window blind should have been pulled closed. He stated it was a big dignity issue with the nurse exposing her (R87) to the public.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure the residents responsible party received a written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of six (6) sampled residents (Resident #1). The findings include: Review of a facility policy titled, Resident Room Relocation, dated 08/09/2023, revealed the Social Services staff would provide an explanation in writing to the resident, family, and/or resident representative of why the move was required. Review of Resident #1's Admission Record revealed the facility admitted the resident on 02/04/2019 with diagnoses to include: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia following cerebral infarction, and Aphasia following cerebral infarction. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/12/2024, revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of eleven (11) out of fifteen (15) indicating the resident was cognitively intact. Review of a Nursing Progress Note, dated 12/15/2023, revealed Resident #1 was transferred to another room due to his roommate testing positive for COVID-19. During an interview with Family Member (FM) #1 on 03/19/2024 at 9:50 AM, he stated the family was not notified of Resident #1's room change. He stated they came to visit with the resident and found he was no longer in the same room. FM #1 stated he was told by staff that Resident #1 was moved due to his roommate testing positive for COVID. During an interview with Registered Nurse (RN) #2 on 03/21/2024 at 10:40 AM, she stated the Charge Nurse or Social Services would notify the family or guardian of a room change but normally someone from the social services office should make that notification. She stated this information would typically be documented in a nursing progress note. During an interview with Social Services on 03/21/2024 at 11:30 AM, she stated per facility policy, they would notify a resident's responsible party of a room change. She stated she could not recall if Resident #1's responsible party was notified of his room change. Social Services also stated that typically the social services office was responsible to make a room change notification unless it was after hours or on the weekends and whoever was doing the room change should make the notification. During an interview with the Director of Nursing (DON) on 03/21/2024 at 12:25 PM, she stated the nurse that was assigned to Resident #1 on 12/15/2023 should have made Resident #1' responsible party aware of the room change and documented the notification in a nursing progress note. The DON stated she had attempted to call the Licensed Practical Nurse (LPN) assigned to Resident #1 to see if she could remember making the notification and had just forgotten to document it. She further stated her attempts were unsuccessful. The DON stated she expected staff to follow facility policy on notifications and document accordingly. During an interview with the Administrator on 03/21/2024 at 1:45 PM, he stated social services was responsible for room change notifications. He stated he expected families/guardians to be notified of resident room changes. The Administrator further stated it was very important that proper notification be made because it could be disruptive to the resident.

Based on interview, record review and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan which included measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial well-being for one (1) of (3) three sampled residents (Resident #1). Review of Resident #1's medical record revealed the resident had an behaviors of cursing, yelling, and wandering into other resident's rooms, however, there was no behavior care plan initiated. The findings include: Review of the facility's policy, Comprehensive Care Plan, dated 08/23/2023, revealed the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his/her care. The policy further revealed the resident should be monitored to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. Closed record review of Resident #1's Admission Record revealed the facility admitted the resident on 01/11/2024 with diagnoses which included Acute on Chronic Combined Systolic and Diastolic Congestive Heart Failure, Unspecified Dementia, Type II Diabetes Mellitus with other Circulatory Complications, Generalized Anxiety Disorder and Cognitive Communication Deficit. Review Resident #1's Minimum Data Set (MDS) Assessment, dated 01/15/2024, revealed the facility was unable to complete a Brief Interview Mental Status (BIMS) assessment. Further review of the record revealed a staff assessment for Mental Status was completed and revealed the resident was unable to recall the current season, location of room, staff names and faces or if he/she was in a nursing home. Review of Resident #1's Behavior/Intervention Monthly Flow Record, dated January 2024, revealed an onset of behaviors of yelling, combativeness with care, and anxiousness were documented on January 14, 21, 22, 23, 26, and 27. Review of Resident #1's Progress or Nurses's Notes, dated 01/21/2024, revealed the resident was in his/her room singing loudly and calling out for his/her spouse. Further review revealed staff redirected the resident to sing quietly. Review of Resident #1's Progress Note dated 01/22/2024 and 01/23/2024, revealed the resident was cursing and yelling at staff and other residents; however was easily redirected by asking resident to sing a song. Further review of the notes, dated 01/27/2024, revealed the resident was yelling, cursing and going from room to room looking for his/her spouse. Staff were unable to redirect him/her and a call to the provider was initiated. Review of Resident #1's medical record and care plan revealed there was no care plan initiated for behaviors. In an interview with Registered Nurse (RN) Minimum Data Status (MDS) Nurse #1, on 02/07/2024 at 10:36 AM, she stated care plans were initiated upon the resident's admission. She further stated a behavior care plan should be initiated at the onset of behaviors and revised with any new changes for the resident. In an interview with Registered Nurse (RN) #1 on 02/06/2024 at 2:28 PM, she stated she was aware Resident #1 was having behaviors of yelling, cursing and wandering into other resident's room. She stated the resident should have had a Behavior Care Plan initiated on the first date of onset of behaviors. In an interview with Licensed Practical Nurse (LPN) #6 on 02/06/2024 at 2:48 PM, she stated if a resident had a new onset of behaviors, a behavior care plan should be initiated. In an interview with the Social Services Director on 02/07/2024 at 11:02 AM, she stated when residents were admitted with behaviors or certain diagnoses such as Depressions, these were indications a behavior care plan needs to be initiated. She stated she also reviews hospital records for indications of behaviors and uses the information in development of care plans. In an interview with the Director of Nursing (DON) on 02/07/2024 at 9:59 AM, she stated the comprehensive care plan documentation should start with a baseline and as behaviors started with Resident #1, the care plan should have been initiated. She further stated when the nurses observes a resident exhibit behaviors the nurses should update the care plan if needed, follow care plan interventions, document, call the provider and call psychiatric services, if directed by the provider. In an interview with the Executive Director on 02/07/2024 at 10:10 AM revealed he/she expects the nursing staff to initiate and follow resident care plans as per the facility policy. He/She stated Resident #1 should have had a behavior care plan initiated with onset of behaviors.

Based on observations, interviews, record review and facility policy, it was determened the facility failed to ensure all drugs and biological's were stored in locked compartments for one resident (Resident #2) in a samples size of seven (7) residents. Staff placed Resident #2's medication on top of medication cart and walked away leaving two medications on top of the cart unsecured. Additionally, staff left Resident #2's medication on sink, in residents room, and walked out of the room leaving the medication unsupervised and unsecured. The findings include: Review of facility policy, General Dose Preparation and Medication Administration, with revision date of 01/01/2013 revealed; Staff should take all measures by facility policy and applicable law to include: observe the resident's consumption of the medication(s). Review of facility policy, Administration of Medications, revised 07/14/202 revealed; all medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Letterhead facility documentation, provided by Executive Director on 12/08/2021, revealed facility did not have an accident policy on medication storage. However, facilty did have the Event Management System policy. Review of facility policy, Event Management System Policy, with review date of 05/05/202 revealed; Purpose is to provide an environment that is free from accident hazards, over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents, that includes: identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. Review of provided Executive Director's list of wanderers, dated 12/08/2021 at 10:50 AM, revealed (8) eight wanderers in the facility. Wanderers consisted of residents from unit's 100, 300, 500, 600, and 900. 1. Observation on 12/01/2021 at 9:20 AM, revealed Registered Nurse (RN) #1 placing medication cup of [MEDICATION(S)] Dry Mouth Liquid (Mouthwash--not intended to be swallowed, but to be swished for (30) seconds then spit out), and [MEDICATION(S)] Suspension nose spray(a steroid to be used intranasal route only with maximum total daily dose to not exceed 2 sprays in each nostril) on top of the medication cart and walking off from the medication cart. 2. Observation on 12/01/2021 at 9:28 AM, revealed RN #1 entering double occupancy room and placing Resident #2's medication cup of [MEDICATION(S)] Dry Mouth Liquid (Mouthwash) on sink and informing Resident #2 of this. After providing Resident #2 with his/her other medications, RN #2 left the room. Medication cup of [MEDICATION(S)] Dry Mouth Liquid (Mouthwashes) was left on sink in the double occupancy room. Record review revealed facility last admitted Resident #2 on 04/12/ with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly MDS, dated [DATE], revealed Resident #2 had been assessed as requiring limited assistance for activities of daily living (ADLs) and assessed as having a Brief Interview Mental Status of (15) fifteen. However, Resident # 2 was assessed as having Dementia, but had not bee assessed as being able to self-administer medications. Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, order for [MEDICATION(S)] Suspension 50 mcg/ACT (2) two sprays in each nostril as needed for allergies daily. with start date of 04/19/2021 and no end date notated. Review of Electronic Mediation Administration Record (EMAR), dated 11/01/2021-11/30/2021 and 12/01/2021-31/2021, revealed [MEDICATION(S)] Dry Mouth Liquid (Mouthwashes), give (1) one application by mouth two times a day for dry mouth, with order date 12/30/2019; and [MEDICATION(S)] Suspension fifty (50) micrograms (mcg)/ACT (2) two sprays in each nostril as needed for allergies daily, with order date of 04/19/2021. Review of Resident #2's care plan, target date of 12/22/2021, revealed; resident has impaired visual function relate to right eye [CONDITION(S)] with history of retinal detachment and limited vision in his/her left eye. Additionally, care plans for: ADL self care performance deficit related to visual impairment, revealed: Administer dry mouth liquid as ordered for dry mouth, notify MD as needed (PRN) if ineffective. The resident has oral/dental health problems related to dry mouth with the following intervention: Administer Dry mouth Liquid mouthwash as ordered and observe for effects. Interview with RN #1, on 12/02/2021 at 10:36 AM, revealed [MEDICATION(S)] Dry Mouth Liquid (Mouthwashes) was left on the sink and the resident does not take it right then during medication administration nor will he/she come ask for it. RN #1 stated she leaves it on the sink and resident takes it himself/herself and was told they say supposed to. RN #1 further stated, Resident #2 was pretty with it and does everything on his/her own. Interview with Director of Nursing (DON), on 12/08/2021 at 3:41 PM, revealed; Resident #2 was not authorized to self administer medication, and [MEDICATION(S)] Dry Mouth Liquid (Mouthwashes) or any medication should not be left in room,and the outcome could be negative too much or too little medication(s). Additionally, DON stated that medications were to be placed in medications carts and locked if staff walk away from the carts, because a different resident could take the medications. DON stated the facility does have wanderers. Interview with Nurse Practitioner (NP) #1, on 12/08/2021 at 2:50 PM, revealed; that it was not preferable leave [MEDICATION(S)] Dry Mouth Liquid (Mouthwashes) in resident's room because residents may stash it, not take it or take multiple doses at once. NP#1 further stated she did not see any standing orders for Resident #2 to self administer medication and documentation would be charted if a resident is to self administer medication. Additionally, NP #1 revealed medication should not be left on a medication care because someone could grab the medication and take it, a confused resident could grab and take it.

Based on observation, record review, interviews, and facility policy; it was determined the facility failed to implement fall interventions for Resident #5 in a sample size of (7) seven residents. Resident #5's fall mat was observed rolled up and tucked beside the closet away for the right side of residents bed, with Resident #5 occupying the bed at the time. The findings include: Review of facility policy, Resident Assessment Instrument & Care Plan, with review date of 05/10/2021, revealed; The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40. The care plan includes measure objectives, timeframes to meet the patient's cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs. Observation on 11/30/2021 at 3:40 PM and 4:30 PM, revealed one of the two fall mats for Resident #5 rolled up against the wall closet at foot of residents bed; and not on the right side of the resident's bed while bed was occupied by Resident #5. Record review revealed the facility admitted Resident #5 on 03/09/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly MDS, dated [DATE], revealed resident was assessed as requiring extensive assistance with activities of daily living (ADLs), and no fall history notated Review of Brief Interview Mental Status (BIMS) dated 11/29/2021 revealed Resident #5 had been assessed as having a BIMS of (08) signifying moderate cognitive impairment. Review of 07/25/2020 fall investigation revealed Resident #5 was found lying beside the bed, in the floor. Immediate interventions placed included floor mat to bedside for safety. Review of Resident #5 fall care plan, with target date of 12/22/2021, revealed the following interventions/tasks initiated on 07/25/2020--bilateral fall mat at bedside for safety. Interview with Licensed Practical Nurse (LPN) #1, on 11/30/2021 at 4:30 PM, revealed fall mat should have been in place and was for safety of the resident. Interview with MDS Nurse #1, on 12/07/2021 at 12:12 PM revealed residents care plans should be followed at all times by staff, and the purpose of the care plan is to provide individualized personalized care for the betterment of the resident. Additionally, MDS Nurse #1, revealed the outcome of not following the care plan, would be that it can cause harm to the resident. Interview with Director of Nursing (DON), on 12/08/2021 at 3:41 PM, revealed the purpose of fall mats was to prevent injuries if a resident falls out of bed, for safety, and is an intervention so the resident will not get injured if they fall.

Based on observation, interviews, record review and facility policy, the facility failed to ensure resident information was kept confidential in one (1) residents record ( Resident #3) in a sample size of seven (7) residents. Registered Nurse (RN) #1 walked away from medication cart in hallway leaving Resident #3's electronic medication (EMAR) record screen open and unlocked, allowing view of Resident #3's electronic chart. The findings include; Review of facility policy, Disclosure of Protected Health Information (PHI) Release of Information, reviewed date of 03/18/2021 revealed; The facility maintains the confidentiality of the residents medical information contained in the residents record, regardless of the form or storage method of the records. The resident is assured confidential treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility policy, Notice of Privacy Practices, reviewed date of 03/18/2021 revealed, Facility Responsibilities: Facility is required to maintain the privacy of resident health record. Observation, on 12/01/2021 at 9:00 AM, revealed Registered Nurse (RN) #1 walking off from medication cart during medication pass with screen of Resident #3 EMAR's information on the screen and visible to individuals passing by in the hallway. Record review revealed facility admitted Resident #3 on 03/17/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Annual MDS dated [DATE] revealed resident was assessed as requiring extensive assistance with activities of Daily living(ADLs), a Brief Interview Mental Status (BIMS) of eleven (11)-signifying moderate cognitive impairment, and impaired vision. Interview with Registered Nurse (RN) #1, on 12/02/2021 at 10:36 AM, revealed when staff walks off they should lock the screen and lock the cart of course. Additionally, one should always lock the screen and she was nervous. Interview with DON, 12/08/2021 at 3:41 PM, revealed the screen should be locked or shut off because that is information on the resident, and the outcome would be a HIPPA violation. Interview with Nurse Practitioner, 12/08/2021 at 2:50 PM, revealed that if a screen is left up and walked away from then it is a potential HIPPA violation.

Based on observation, record review interviews and facility policy it was determined the facility failed to maintain a safe environment and prevent the development and transmission of communicable diseases and infections for Resident #4 in a sample size of Seven (7) residents. Additionally, Registered Nurse (RN) #1 administered eye drops in Resident #3's eyes with gloves that had touched medication cart, medication bottles, computer, badge and uniform of RN #1. The findings include: Review of facility policy, Transmission-based Precautions and Isolation Procedures, revised 04/20/2020, revealed; Contact Precautions: contact precautions are intended to prevent transmission of infections that are spread by direct (e.g. person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves worn upon entering (i.e., before making contact with the resident or residents environment) the room or cubicle. Prior to leaving the room or cubicle, the PPE is removed and hand hygiene is performed. Review of facility policy, Infection Prevention and Control Program (IPCP) and Plan, revised on 09/02/2020, revealed the organization wide infection prevention and control program (IPCP) is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel. The risk of development of a healthcare associated infection (HAI) is minimized through an organization wide IPCP including the implementation of antibiotic stewardship activities. Goals of the IPCP: to reduce the risk of acquisition and transmission of healthcare-associated infections, identify and correct problems relating to IPCP, monitor for any occurrence of infection and implement appropriate control measures. Interventions are designed to incorporate relevant guidelines for infection prevention and control activities and methods to reduce the risks associated with procedures, medical equipment and medical devices include the following: the appropriate use of personal protective equipment (PPE); applicable precautions, as appropriate, based on the following, the potential for transmission, the care, treatment and service setting. Review of facility policy, [CONDITION(S)] (Clostridioides) Difficile reviewed 07/25/2019, revealed gloves are to be worn when entering the room of a resident who had diarrhea caused by C-difficile; Gowns and gloves are removed before leaving the resident's room and hands must be washed immediately following hand hygiene guidelines. Items such as stethoscopes , sphygmomanometer, and rectal thermometers are dedicated to use on that resident only. Meal trays are bagged prior to removal from the room and are then placed on the tray cart. Alternatively, disposable items may be used. Signage provided by facility for Contact Isolation revealed, Contact Precautions to prevent the spread of infection, 1. perform hand hygiene before and after patient contact, 2. wear gloves upon entering this room, 3. wear a gown upon entering this room , if necessary, 4. use dedicated or single use disposable patient equipment; when this is not possible, disinfection of common use items is recommended, 5. contact Infection Prevention if you have questions. 1. Observation of Registered Nurse (RN) #1, at 12/01/2021 at 9:00 AM, revealed RN #1 leaving medication cart to get gloves for placement of eye drops in Resident #3's eyes. Upon returning to the cart, retrieving medication and going into residents room; Resident #3 was brushing teeth. RN #1 stated she would place drops when resident had finished. RN #1 left the room of Resident #3 wearing same gloves and proceeded to pull Resident #2's medications from the medication care, touching the screen of the computer, touching medications, retrieving name badge from management staff and placing the name badge on uniform. Resident #3 rolled from his/her room at 9:08 AM with RN #1 (still wearing the same gloves) placing the eye drops in the resident's right eye, pulling up the brow and pulling down the lower lid to open up the eye. Interview with RN #1, 12/02/2021 at 10: 36 AM, revealed the process of placing eye drops in a residents eye and the use of gloves during the process. RN #1 stated if administer eye drops put gloves on, put drops in the eye, she has resident lay back and pulls up the brow and pulls down the lower lid to open the eye. RN #1 stated that she should not touch anything prior to putting the eye drops in and glove on. She stated she had went to the nursing desk and had gotten a pair of gloves and put gloves on first and touched things before giving the meds. RN #1 stated she should have got the meds, then put the gloves on, before putting the eye drops in the residents eyes. 2. Record review revealed facility admitted Resident #411/22/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Provided Brief Interview Mental Status (BIMS) listing, dated 11/30/2021, and provided by Social Service Director revealed Resident #4's BIMS to be (7) seven, signifying severe cognitive impairment. Review of Resident #4's Order Summary Report, dated 11/30/2021, revealed Resident to be on contact isolation due to [CONDITION(S)] Difficile (C-diff--an organism that lives in the intestines and can cause problems in people who have other gut organisms treated by antibiotics). C-diff can spread from person to person causing [CONDITION(S)], an inflammation of the colon- causing diarrhea, by producing a toxin unlike most bacteria and reproduces by making spores that can live a long time outside the body and other inanimate surfaces for up to five (5) months. Order Summary Report revealed order start date of 11/22/2021. Review of CNA care plan (Kardex) revealed no isolation precautions notated. However, signage was on door. Observation of Resident #4's room, 11/30/2021 at 9:22 AM, revealed Resident #4 to be on Contact Isolation for C-diff. Observation of Signage on Resident #4's door revealed Contact Isolation. Observation, on 11/08/2021 at 11:00 AM revealed Certified Nursing Assistant (CNA) #1 going into isolation room of Resident #4 with no gloves or gown on, CNA #1 retrieved the mug of Resident #4 for the room bring it into the hallway and dipping ice into it from a community ice chest being used to dispense ice to all residents. CNA #1 then went back into the room and donned a gown and gloves on with another CNA going into the room, and CNA #1 turned around and came out of the room doffing the gown and rolling it up in her hands and bring it with her into the hallway touching the ice cooler cart and walking down the hallway to the nutrition room. CNA #1 came out of the nutrition room and took the gown to the soiled utility room on the unit and placed in trash within the room. Interview with CNA #1, 11/30/2021 at 11:20 AM, revealed she was not paying attention, and did not work on that unit a lot. Additionally, CNA #1 stated she was supposed to place the gown in trash can in the residents room; with CNA #1 stating the purpose of the isolation precautions was to keep from spreading germs and all. Interview with Registered Nurse (RN) #2, 11/30/2021 at 11:10 AM, revealed staff should wear PPE (have to wear gown, gloves-when go in the room) in the room when providing care to Resident #4. Additionally, RN #2 stated that Resident #4's mug should not have been brought out of the room. Attempted interview with Unit Manager (UM) , 11/30/2021 at 11:30 AM, with UM #1 stating she had to speak with CNA #1, UM #1 was asked to come speak with me afterwards, UM #1 did not speak to me after. Interview with Infection Control Nurse (IFCN) #1, 12/02/2021 at 10:26 AM, revealed put on gloves to put eye drops in that nothing is to be touched prior to touching the eye. Additionally, IFCN stated gowns, gloves, masks and now face shield; are to be worn if a person has C-diff. IFCN stated that a residents mug should not be brought out of the room, and C-diff is a spore based bacteria and those spores can drop. Documentation provided by IFCN, on 11/30/2021 at 5:00 PM, revealed Resident #4 was on contact isolation for C-diff. Interview with Director of Nursing (DON), on 12/08/2021 at 3:41 PM, revealed staff were to wear PPE going into the room (Resident #4's contact isolation room) and to discard it before coming out of the room with the outcome as possible spread. DON stated it would be the same outcome for the cup due to coming from a room of contamination. Additionally, DON stated when placing eye drops in residents eyes gloves should not touch anything else prior to eye drops. Interview with Nurse Practitioner (NP) #1, on 12/08/2021 at 2:50 PM, revealed that staff take a chance of spreading C-diff to other residents or to self--gowns should be taken off in the residents room and hands should be washed. Additionally, NP #1 stated she would not recommend taking a mug out of the room to put ice in it, and this is an infection control problem. Additionally, NP #1 stated that staff should wear gloves when touching face due to manipulating the eye, and should not touch anything else due to infection prevention.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the resident's environment remained as free from accidents hazards as possible for two (2) of seven (7) sampled residents, Resident #5 and Resident #7. Observation revealed two (2) oxygen canisters present in Resident #7's room, not in use, leaning against the wall, with one (1) canister not in a carrier. In addition, Resident #5 was observed lying on his/her bed with his/her fall mat not lying on the floor beside the bed as required. The fall mat was observed to be rolled up and tucked beside the closet not near the resident's bed. The findings include: Review of the facility's policy titled, Event Management System Policy, with a review date of 05/05/2020 revealed it's purpose was to provide an environment that as free from accident hazards, over which the facility had control. Per interview, the facility was to provide the supervision and assistive devices that each resident required to prevent avoidable accidents. Continued review revealed the facility was to: identify potential hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce the hazard(s) and risk(s); and monitor the interventions for effectiveness and modify the interventions as necessary. Review revealed all patients were to receive the supervision and asssitance they required as per their care plan to help reduce the risk of an event (incident). Further review revealed if an event occurred the facility would assess, report, investigate, and determine the root cause of the event in an effort to minimize the potential for recurrence. In addition, the policy had been designed to assist the facility in identifying and reducing events for resident which included: falls, unwitnessed or witnessed; medication discrepancies; and wandering or other behaviors. 1. Review of the facility's policy titled, Compressed Oxygen Cylinders, revised 08/26/2021, revealed the policy addressed ensuring the safety of residents, associates, and visitors through the safe handling of compressed oxygen cylinders. Per review, portable oxygen cylinders were to be attached to an oxygen stand designed to hold the cylinders or a therapy apparatus when the oxygen was in use. Continued review revealed the medical gas (oxygen) cylinders were to be stored in a manner which protected the cylinders from mechanical shock that could damage the cylinder or valve. Review revealed the oxygen cylinders were also to be protected from tampering by any unauthorized individuals. Review of the facility's list of residents who wandered dated 12/08/2021 at 10:50 AM, provided by the Executive Director revealed the facility had identified (8) eight resident wanderers. Per review, the residents who wandered were located on the 100, 300, 500, 600, and 900 halls of the facility. Observation on 11/30/2021 at 9:20 AM, in Resident #7's room, revealed two (2) oxygen (O2) canisters lying against the wall of the room, with O2 Canister #1 located in an oxygen carrier which had been leaned against the wall, and O2 Canister #2 situated in a plastic sling lying against the corner of the wall near the adjoining wall closet. Record review revealed the facility admitted Resident #7 on 09/16/2021, with the following diagnoses: [CONDITION(S)] ([CONDITION(S)]); Dependence on Supplemental Oxygen; Unspecified Dementia without Behavioral Disturbance; History of Falling; and Heart Failure. Review of Resident #7's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident as cognitively intact. Continued review of the MDS Assessment revealed the facility had also assessed Resident #7 to have care needs related to his/her Dementia, Depression, [CONDITION(S)], Vision (due to diagnoses of [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]) and Oxygen therapy. Further interview revealed Resident #7 had additionally been assessed to require extensive assistance with his/her Activities of Daily Living (ADLs). Interview on 11/30/2021 at 9:20 AM, with Resident #7 revealed the O2 canisters located in his/her room had probably been there for about a week. Interview on 11/30/2021 at 9:25 AM and 9:55 AM, with Licensed Practical Nurse (LPN) #2, revealed O2 canisters should not be stored on the floor, without being in a carrier or a rack. Per interview, the O2 canisters should not be stored in a resident's room. LPN #2 further stated that the O2 canister(s) should not be stored on the floor due to the danger of an explosion if turned over or fell over. In addition, LPN #2 revealed the O2 canisters should be stored on an oxygen transport carrier to decrease the risk of dropping them or having them fall over. Interview with the Nurse Practitioner (NP) on 12/08/2021 at 2:50 PM, revealed O2 canisters should not be located in resident's room unless the O2 was in use. Per interview, if O2 canisters were left in a resident's room all the time they could get knocked over. Further interview revealed if O2 canisters were in a sling and the attached straps of the sling were lying on the floor, there was the potential it could be a tripping hazard for a resident or staff. Interview on 12/08/2021 at 3:41 PM, with the Director of Nursing (DON) revealed 02 canisters were brought to residents' rooms for placement to use when in their wheelchairs. Per interview, the O2 canisters were to be removed from a resident's room if empty, or not in use. The DON further stated if the O2 canisters were not attached to a carrier on the wheelchair there could be a negative outcome if the canister got knocked over as it was a compressed air cyclinder. 2. Review of the facility's policy titled, Fall Management, with review date of 08/02/2021, revealed it's purpose was for promoting patient safety, and to reduce falls for patients by proactively identifying, care planning, and monitoring of patients fall indicators. Per review, the facility was to assess the patient, reassess with any fall event for fall risks; and identify appropriate interventions to minimize the risk of injury related to falls. Further review revealed the facility's definition of adequate supervision referred to an intervention and means of mitigating the risk of an accident for a patient. In addition, the policy noted facilities were obligated to provide adequate supervision to prevent accidents. Review of the facility's policy titled, Resident Assessment Instrument & Care Plan, with a review date of 05/10/2021, revealed the facility was to develop and implement a comprehensive person-centered care plan for each of its residents, which was consistent with the residents rights. Per review, the care plan should include measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. Continued review revealed the care plan was to contain the services to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. Observation on 11/30/2021 at 3:40 PM and 4:30 PM, revealed Resident #5 lying on his/her bed, with a fall mat located on the left side of the bed. Continued observation revealed one (1) of Resident #5's two (2) fall mats was lying rolled up against the wall closet at the foot of the resident's bed, and not located on the right side of his/her bed as required. Record review revealed the facility admitted Resident #5 on 03/09/2020, with the following diagnoses: Alzheimer's Disease with Late Onset; Delusional Disorders; Difficulty in Walking; and History of Falling. Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed the facility had assessed the resident to have a BIMS score of eight (8) indicating moderate cognitive impairment. Further review of the MDS Assessment revealed as requiring extensive assistance with all ADL's. In addition, review of the MDS Assessment revealed no documented evidence of the resident's fall history had been noted. Review of the facility's 07/25/2020 Fall Investigation documentation revealed staff had found Resident #5 lying on the floor beside his/her bed. Further review revealed the immediate interventions the facility implemented was the placement of floor mats to Resident #5's bedside for safety. Review of Resident #5's Comprehensive Care Plan revealed the facility had care planned the resident for falls. Per review of the falls care plan, which had a target date of 12/22/2021, revealed the following intervention had been initiated on 07/25/2020: bilateral fall mats at the resident's bedside for safety. Interview on 11/30/2021 at 4:30 PM, with Licensed Practical Nurse (LPN) #1 revealed both of Resident #5's fall mats, which were for his/her safety, should have been in place to his/her bedside as required. Interview with the Nurse Practitioner (NP) on 12/08/2021 at 2:50 PM, revealed the purpose of fall interventions for a resident was to decrease the chance of falls. Per interview, the NP stated having padding (floor mats) beside a resident's bed was for his/her safety, and mainly was to decrease the potential of injury related to a fall. The NP further stated injury could be the outcome if a resident's fall interventions were not in place as required. Interview on 12/08/2021 at 3:41 PM, with the Director of Nursing (DON) revealed a resident's fall mats were for his/her safety, and was an intervention placed to prevent injuries if a resident was to fall out of his/her bed.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure infection control practices were implemented related to following the screening process of individuals entering facility, and ensuring red zippered plastic wall barrier to COVID-19 unit was secured. The findings include: Review of facility policy titled, Standard and Transmission Based Precautions: Guide to Infection Prevention and Control, dated 10/07/2020 revealed purpose of the policy was to provide a framework to minimize the risk of potential exposure to COVID-19 in the long-term care (LTC) facility. It stated the facility would follow the core principles of COVID-19 Infection Prevention as outlined below and defined by CMS and CDC to mitigate COVID-19 entry into the facility. The facility would screen all who enter the facility for signs/symptoms (s/s) of COVID-19 (e.g. temperature checks, questions or observations about signs or symptoms) and would deny entry of those with signs and symptoms. Review of facility policy titled, COVID-19 Mitigation and Management, dated 06/16/2020, revealed the facility would screen 100% of all visitors, vendors, and contractors prior to entering the facility with temperature checks and questionnaire a about symptoms and potential exposure. Review of the facility guidance for screening to be done form, not dated revealed to ask name, check temperature and if temperature was greater than 99, recheck; if recheck still 99 or above, call Executive Director (ED) or Director of Nursing (DON). Ask every question, every time, to every person; after they pass temperature check and answer all questions. Ask them to clean face shield, and use hand sanitizer before leaving desk; and make sure mask is worn properly, covering mouth and nose. Review of Coronavirus Screening (for Visitors) Transmission Based Precautions: guide to Infection Prevention and Control form, last revised 10/16/2020, revealed the following questions: 1. Fever - temperature of >100.0, if Yes, do not allow visit. 2. S/S of COVID-19 - chills, repeated shaking with chills, mew/change in cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste of smell, sore throat, congestion, runny nose, nausea, vomiting, diarrhea, new sputum production, hemopsytosis - if yes, do not allow. 3. Have you been diagnosed with [REDACTED]. 4. Have you had close personal contact with a COVID-19 diagnosis - If yes, do not allow visit. 5. Restricted - international travel to countries with sustained transmission (see CDC website for current list) or cruise ship travel in last 14 days. -if yes, do not allow visit. 6. If applicable for person under arrangementor certain other visitors, document the result and date of most recent COVID-19 test. If date is outside of the time frame, the facility required for testing, do not allow visit. Surveyor entered facility on 11/16/2020 at 12:40 PM, and the person at the entrance of the facility obtained surveyor's temperature ; however, failed to ask any signs/symptoms of COVID-19 questions. Interview with Screener/Certified Nursing Assistant (CNA) #1, on 11/18/2020 at 1:55 PM, revealed she was supposed to take the surveyor's temperature and ask all the questions. She stated she failed to ask the COVID screening questions to the surveyor because she did not know to ask the questions. However, review of COVID-19 Screener Competency form dated 08/26/2020, revealed Screener/CNA #1 had signed the form indicating she understood that she was to screen individuals visiting the facility for fever, respiratory systems, history of travel to high-risk places, and/or contact/or exposures with individuals with symptoms or history of travel to high risk places. In addition, the form indicated she demonstrated the documentation requirements when utilizing the visitor screening tool for individuals visiting the facility. Interview with Staff Development Coordinator (SDC), on 11/18/2020 at 4:39 PM, revealed the screening process was taught to all staff and the form says on the bottom to ask all the questions to staff and visitors. The SDC stated the screening process was taught to staff by the Infection Control Nurse (IFCN), the night-time supervisor, and herself. She further revealed that the screeners had to go through the screening process and they had to pass competencies before able to screen anyone. Interview with the IFCN/Assistant Director of Nursing (ADON), on 11/18/2020 at 3:52 PM, revealed screenings were completed at the front entrance, and included asking the infection control questions, and taking temperatures. The IFCN/ADON stated the screener was supposed to ask visitors their name and purpose of visit, and write on visitor log. Then the screener should ask the screening questions, take the person's temperature, and document the answers and temperature on form. She further revealed the screener should then have the visitor sanitize hands and notify them there was COVID in the building. She stated vendors sat at front door and maintenance would take care of the vendor so they would not have to come in building. Interview with Administrator, on 11/20/2020 at 11:09 AM, revealed screeners were supposed to take visitors' temperature and ask the visitor a series of questions. The Administrator stated the staff were trained through competencies prior to screening anyone. 2. Review of facility policy titled, Standard and Transmission Based Precautions: Guide to Infection Prevention and Control, Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV2), dated 10/07/2020 revealed the facility would follow core principles of COVID-19 Infection Prevention as outlined below and defined by Center for Medicare and Medicaid Services (CMS) and CDC (Center for Disease Control and Prevention). Airborne transmission of COVID 19 could occur under special circumstances and there was enough virus present in the space to cause infections in people who were more than six (6) feet away or who passed through a space soon after infectious person had left; or in enclosed spaces within which an infectious person either exposed susceptible people at the same time or to which susceptible people were exposed shortly after the infectious person had left the space. Further review of the policy revealed dedicated Health Care Personal (HCP) would be assigned to the COVID 19 care unit and to the extent possible restrict access of ancillary personnel to the unit and ensure that HCP practice control measures are in common areas. Observation on 11/18/2020 at 1:20 PM, revealed a sign posted outside the entrance to the 200 COVID Unit which read Do not enter the red zone unless you are authorized behind the wall. Further observation revealed Laundry Aide #1 was at the double doors receiving laundry from staff on the COVID Unit. She had already passed through the red zippered wall and had failed to zip it closed. Interview with Laundry Aide #1, on 11/18/2020 at approximately 1:28 PM, revealed she was standing at the double doors of the COVID Unit with a laundry bin wearing gloves, shield, and mask. She stated the staff in the unit opened the door and put the dirty linen in the bin. She stated she normally zipped up the red zipper plastic wall before proceeding to the double doors but did not this time. Interview with the Maintenance Assistant, on 11/19/2020 at 2:48 PM, revealed he helped set up the COVID Unit, and there was a plastic wall with zipper that sealed off the entire COVID hall placed before the double doors into the unit. He stated this was done this way to provide a space for staff to don the required PPE before entering the unit and to prevent infection from coming through to the rest of building. He revealed the red zipper on plastic wall should stay zipped at all times and only be unzipped to go through the barrier and zipped back up immediately once through the barrier. Interview with Housekeeping and Laundry Manager, on 11/19/2020 at 4:39 PM, revealed when laundry staff pick up laundry they unzipped the plastic wall and go to double doors to receive laundry. She stated the staff should zip it closed prior to going to double doors and do the same when exiting. She revealed the barrier needed to stay zipped at all times for infection control prevention. Interview with IFCN/ADON, on 11/19/2020 at 5:03 PM, revealed they followed CDC, and Corporate guidelines, and were in touch with the health department on a daily basis. The ICFN/ADON stated the red zipper should be zipped at all times because it was a barrier to the COVID Unit. She revealed she expected staff to ensure the zipper was closed at all times except when entering or exiting through the barrier. Interview with Administrator, on 11/20/2020 at 11:09 AM, revealed the zippered barriers were to separate the COVID Unit from the general population. The Administrator stated this separated the hall from the rest of the building and kept airborne or droplets from dispersing from the COVID Unit to the rest of building. She revealed she expected the zippered barriers to be zipped at all times.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered comprehensive care plan for one (1) of thirty-five (35) sampled residents. Resident #163 was receiving [MEDICAL TREATMENT] three (3) times per week. Interventions implemented related to receiving [MEDICAL TREATMENT] included communication with the [MEDICAL TREATMENT] center. However, there was no documented evidence that the facility coordinated care with the [MEDICAL TREATMENT] center for ten (10) of fifteen (15) treatments received at the [MEDICAL TREATMENT] center. The findings include: Review of the facility's care plan policy, revised 07/23/2009, revealed the Care Plan should address, to the extent possible, interventions for preventing avoidable declines in functioning or functional levels, resident-specific interventions, and standards of current professional practice. Review of Resident #163's medical record revealed the facility admitted the resident on 11/28/2018, with [DIAGNOSES REDACTED]. Review of Resident #163's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Stats (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The MDS also revealed the resident was receiving [MEDICAL TREATMENT] services. Review of Resident #163's physician orders [REDACTED]. Review of Resident #163's care plan dated 11/06/2019 revealed interventions including coordinating the resident's care in collaboration with the [MEDICAL TREATMENT] center and communication with the [MEDICAL TREATMENT] center regarding medication, diet, and lab results. Review of a list received from the [MEDICAL TREATMENT] center revealed Resident #163 had received [MEDICAL TREATMENT] at an off-site center fifteen (15) times from 12/03/2019 through 01/09/2020. However, review of the communication sheets between the facility and the [MEDICAL TREATMENT] center revealed no evidence of any communication taking place between the facility and the [MEDICAL TREATMENT] provider for ten (10) of those visits. Further review of the communication sheets revealed three (3) of the five (5) communication sheets were not completed and contained no post [MEDICAL TREATMENT] vital signs or assessment of the access site. Observation of Resident #163 revealed the resident was in his/her room, alert, and able to answer questions appropriately. The resident stated the facility gets me ready for [MEDICAL TREATMENT] and gave me a notebook to take with me to the [MEDICAL TREATMENT] center. Interview on 01/09/2020 at 5:17 PM with the Unit Manager revealed the nurses are responsible for filling out the communication forms and placing them in the binder and sending the binder with the resident to the [MEDICAL TREATMENT] center. She stated Resident #163 had a binder that had several communication forms inside that were incomplete. Further review with the Unit Manager revealed she had never followed up to see if the communication forms were filled out completely. The Unit Manager stated she understood the importance of having complete communications with the [MEDICAL TREATMENT] center. The Unit Manager further stated she should have identified that the communication forms were not being returned and were not being completed. Interview on 01/09/2020 at 5:23 PM with the Director of Nursing (DON) revealed a communication form was required to be sent with every resident who went to the [MEDICAL TREATMENT] center. The DON stated the [MEDICAL TREATMENT] center was then responsible to fill out the form and send it back to the facility, and the facility nurse was then responsible to complete the post [MEDICAL TREATMENT] section. The DON stated the communication forms were part of the medical record and should be placed in the resident's record once completed. The DON stated she had not identified any concerns with the forms not being completed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop a person-centered care plan for one (1) of three (3) sampled residents, to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment (Resident #2). Resident #2 had behaviors of hitting out at other residents and visitors, and squeezing their face, however, the facility failed to develop a care plan to address the resident's behaviors. The findings include: Review of the facility policy, Care Planning and Interventions revised 07/23/09 revealed, The interdisciplinary team meets on a scheduled basis and develops an individualized care plan. Interdisciplinary means that professional disciplines, as appropriate, work together to provide the greatest benefit to the resident. The Care Plan includes measure objective, timeframe's to meet the resident's cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs. Record review revealed the facility admitted Resident #2 on 10/04/10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/02/19, revealed the Brief Interview of Mental Status (BIMS) was not attempted due to the resident being rarely/never understood. The resident was severely cognitively impaired and unable to be interviewed. Further review of the MDS assessment revealed there were no behaviors identified during the look back period. Review of the facility Incident Reports for Resident #2 revealed on 07/16/19, the resident was hitting another resident in face, on 09/04/19, the resident tapped a resident on the back and grabbed the resident's face, and on 09/24/19, the resident grabbed another resident's face. However, review of the Resident #2's Comprehensive Care Plan revealed no care plan was developed to address the resident's behaviors until 10/02/19, which was three (3) months after the first incident was reported. Further review revealed the care plan addressed the resident's behavioral symptoms of hitting, punching, grabbing, and pinching other residents when in social settings, with interventions for resident to be monitored by all management team members and be provided diversional activities during social programs held in lobby. Interview with the Director of Nursing (DON), on 10/25/19 at 2:08 PM revealed the Comprehensive Care Plan should have been initiated when first incident occurred by the nursing staff on the unit and should have been updated with new interventions at the time of each additional incident. She stated she did not believe the resident was intentionally trying to hurt the residents but was motivated as a way to communicate and interact with others.

Based on interview, record review, facility Incident Report review, and facility policy review, it was determined the facility failed to report an allegation of abuse immediately, not later than two (2) hours after the allegation was made for one (1) of three sampled residents (Resident #1). Resident #1 was struck in the face and head by Resident #2 on 09/24/19; however, the facility failed to report the incident to the appropriate State agencies per facility policy. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect, last reviewed 04/15/19, revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone.In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve the abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Record review revealed the facility admitted Resident #1 on 03/18/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment, dated 08/26/19 revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Record review revealed the facility admitted Resident #2 on 10/04/10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 08/02/19 revealed a BIMS was not attempted due to the resident is rarely/never understood. Review of Resident #1's Nurses Notes, dated 09/04/19 at 2:17 PM revealed the Therapist reported that Resident #1 was sitting in lobby when Resident #2 grabbed Resident #1's face and squeezed as hard as he/she could and the therapist was able to assist removing his/her hand from residents' face. Resident #1 reported Resident #2 had punched him/her in the back five (5) times before the resident grabbed his/her face. Resident #2 was circling the lobby and every time he/she came by Resident #1, Resident #2 would punch Resident #1 in the back. Resident #2 was removed from the area and Resident #1 requested to be taken back to room. Resident #1 revealed he/she was shaken up. Resident #1's brother was notified and MD was notified. Review of a facility Incident Report on 09/05/19 at 8:56 AM, revealed Resident #2 hit Resident #1 in back and grabbed his/her face. Further review revealed Resident #1 was overly excited with activities and swings arms around in the air. Resident #1 was removed from lobby and assessed for injuries, none found. Resident was placed in bed per request. Further review of the Incident Report revealed there was no documented evidence the appropriate agencies were notified of the alleged abuse. Review of Resident #1's Nurse's Notes, dated 09/24/19 at 12:49 PM revealed Resident #2 grabbed Resident #1 face while out in lobby and caused pain to face. The incident was reported to the Unit Manager and Resident #1's brother was called. Further review revealed the brother wanted to know who the other resident was, and was told due to HIPPA rules, she could not tell him and he stated then I will have to call the police since this is probably the same person. The note also revealed Resident #1 stated I have only reported this twice but it has happened at other times. I asked if the other times were when residents were in the lobby with music activities and this resident said no it happens at other times too. Review of a facility Incident Report dated 09/24/19 at 9:02 AM revealed during music activity, Resident #2 propelled around in lobby and grabbed another resident's face. Resident moved away from other resident and placed at a different table (Resident #1). Further review of the incident report revealed there was no documented evidence the incident was reported to the appropriate state agencies. Interview with Resident #1's brother on 10/22/19 at 2:33 PM revealed he had spoke to the Administration at the facility and they would not tell him who the resident was that hit the resident responsible due to privacy laws so he had no recourse but to call the police and filed a complaint against the facility and the resident. The police revealed since the resident was not of sound mind, they could not do anything about it. Interview with Social Services Director on 10/23/19 at 1:01 PM revealed she did not witness the incident on 09/24/19. She stated she believed if Resident #2 knew a resident, in his/her own mind, he/she showed that by touching/squeezing the person. She stated she does not believe the resident was intentionally trying to harm someone. She revealed she was unaware if the incident had been reported and since is was normal behavior for Resident #2, she did not know why it should be reported. Interview with the Director of Nursing (DON) on 10/25/19 at 1:38 PM revealed she had not reported any of the incidences of Resident #2's behavior with hitting and pinching other residents since she was sure the resident was not doing it to hurt other residents but was a form of communication. She stated the resident was being transferred to a locked facility by the resident's father due to his/her behaviors

Based on observation, interview, record review, review of Hospital Physician Discharge, and facility policy review; it was determined the facility's system to ensure one (1) of three (3) residents was free from a significant medication error was ineffective. Resident #1 was assessed and care planned he/she was allergic to [MEDICATION(S)], however, on [DATE], staff failed to check the resident's allergies prior to administering the medication per facility policy and the computer failed to flag the resident was allergic to the medication. Resident #1 had an anaphylactic reaction (swelling) and was hospitalized in the Intensive Care Unit (ICU) due to threatened airway and anticipated need for intubation (open airway for breathing) due to swelling. The findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration, last revised [DATE], revealed prior to administration of medication, facility staff should check for allergies to the medication. Record review revealed the facility admitted Resident #1 on [DATE] and he/she was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition was intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #1's Allergy Report dated [DATE] revealed the resident was allergic to [MEDICATION(S)]. Review of Resident #1's Comprehensive Care Plan for resident is allergic to [MEDICATION(S)], dated [DATE] revealed an intervention to not give medication listed on allergy list. Review of a Progress Note/Alert Note dated [DATE] at 8:17 AM revealed Resident #1 had vomited three (3) times this shift and was given [MEDICATION(S)] (nausea/vomiting)which was ineffective. Further review revealed Licensed Practical Nurse (LPN) #1 received new orders for a one (1) time dose of [MEDICATION(S)] 12.5 mg intramuscularly (IM). Review of a verbal Physician's Order, dated [DATE] at 7:39 AM revealed to administer [MEDICATION(S)] Solution (Promethazine HCI); inject 12.5 mg IM one time only for nausea/vomiting. Review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on [DATE] even though it was listed the resident was allergic to it. Review of an Investigation Documentation Report prepared by RN #1 dated [DATE] and last revised [DATE] revealed Resident #1 had received administration of an IM injection of 12.5 mg [MEDICATION(S)] and after two (2) hours resident still had nausea/vomiting and tongue was swollen with resident unable to speak. Review of Health Status Note dated [DATE] at 2:43 PM by RN #1 revealed Resident #1 was sent to local hospital related to nausea and vomiting with possible allergic reaction to treatment provided and resident was admitted to the hospital. Review of the Hospital Physician discharge date d [DATE] revealed Resident #1 was admitted to the Intensive Care Unit (ICU) in critical condition for threatened airway and anticipated need for intubation due to allergic angioedema (swelling due to receiving agent he/she had known allergy for). Interview on [DATE] at 7:00 PM with Resident #1 revealed a very low guttural voice. Resident #1 stated his/her voice had been that way since he/she was administered [MEDICATION(S)]. Interview with LPN #1 on [DATE] at 8:29 AM revealed Resident #1 had nausea/vomiting all night with [MEDICATION(S)] administered;however it was ineffective. LPN #1 stated she discussed this with the Advanced Registered Nurse Practitioner (ARNP) when he came in on the morning of [DATE] and the ARNP told her to give the resident [MEDICATION(S)] IM 12.5 mg. LPN #1 stated she was going off duty and entered the order in the computer while RN #1 administered the medication. LPN #1 stated she did not notice the resident was allergic to [MEDICATION(S)] at the time she was putting the order in but noticed it later. She stated to her knowledge the ARNP did not look at the resident's chart before the order was given. Interview with RN #1 on [DATE] at 4:13 PM revealed LPN #1 received an order from the ARNP for [MEDICATION(S)] after Resident #1 continued to have nausea and vomiting after receiving [MEDICATION(S)]. RN #1 stated LPN #1 entered the order in the computer while she obtained the medication from the Emergency Drug Kit (EDK) and administered it. RN #1 further revealed she had not noticed Resident #1 had an allergy to [MEDICATION(S)] until after Certified Nurse Aide (CNA) #1 came to her about Resident #1 still being sick and she checked on Resident #1. She stated she assessed Resident #1 and knew something was wrong and called the ARNP and the Unit Manager (UM). RN #1 stated she went to the computer and typed in the resident's name pulling up the resident's profile and it showed the [MEDICATION(S)] allergy. Interview on [DATE] at 12:05 PM with CNA #1 revealed after Resident #1 had received the injection of [MEDICATION(S)], he/she was still sick and the resident was unable to speak and not looking right. CNA #1 stated the resident's tongue started to swell and she removed the resident's dentures out to help with the resident's lips getting huge afterwards. Interview with UM #1 on [DATE] at 5:36 PM revealed RN #1 had come to him distraught and had told him that she had administered [MEDICATION(S)] to Resident #1 and the resident was allergic to it. He stated he went to Resident #1's room and and the resident's tongue was swollen and he/she was in obvious [MEDICATION(S)]. He revealed they treated the resident with Solumedrol (steroid), placed oxygen on the resident, gave breathing treatments, and called 911 with the ambulance arriving within a few minutes. UM #1 stated LPN #1 had communicated with the ARNP and obtained the [MEDICATION(S)] order and RN #1 had obtained the medication from the EDK box and administered it. UM #1 stated the computer system was suppose to flag allergies but when the medication was put in it did not flag. Interview with the ARNP on [DATE] at 6:08 PM revealed he had given the verbal order for [MEDICATION(S)] without opening the computer, looking at the resident's allergies, or the nurse providing him with any information other than the resident had been sick through the night without relief from [MEDICATION(S)]. The ARNP stated he had to attend to the resident after he/she had been given the medication he/she was allergic to. Interview with the Director of Nursing (DON) on [DATE] at 4:45 PM revealed the ARNP had given the verbal order for [MEDICATION(S)] at the nursing station without opening the computer or looking at the resident allergies. The DON stated the medication was obtained from the EDK by RN #1 and there was no alert from the computer system related to the medication being a known allergen. **The facility implemented the following actions to correct the deficient practice: 1. On [DATE]-[DATE], all licensed nurses were inserviced by Staff Development Coordinator (SDC) on abuse and neglect with emphasis on following the care plan, medication administration, epi-pens, care plans, verifying allergies on the Point Click Care system (PCC) in computer, to review dashboard daily for medication alerts (order alerts); and, the nurse should take orders, and put the order in PCC first before administering medication him/herself. 2. On [DATE], Unit Managers completed a 100% audit of all residents allergies with attention to current medication list and if any medication was on the resident's allergy list. 3. On [DATE], the DON suspended the Nurse that gave injection pending further investigation. 4. On [DATE], the DON reviewed all medication errors in the last six (6) months to identify if any errors related to allergies. 5. On [DATE], a Quality Assessment Performance Improvement (QAPI) meeting was held with Medical Director present to report issues and ongoing audits. 6. On [DATE] through [DATE], the SDC educated all nurses that Epi-pens are located in the crash carts in facility and they were reinstructed on how to use Epi-pens. 7. On [DATE], the SDC did a 100% audit to ensure all crash carts had epi-pens and checked expiration dates to ensure they are still viable. 8. On [DATE], the SDC educated APRN's within the facility regarding giving verbal orders to licensed nurses to always request a list of allergies before giving and new orders. 9. On [DATE], LPN #6 updated Resident #1's allergy list to include severe anaphylactic reaction to [MEDICATION(S)]. 10. On [DATE], the DON obtained witness statements from both nurses 11. Starting on [DATE], the Administrative Nursing staff will conduct on-going audits to continue to identify any issues with nurses not reviewing allergies prior to passing medications. Five (5) opportunities will be reviewed during ed passes daily times seven (7) days on all shifts, then weekly times two (2) weeks on all shifts, then monthly times two (2) months. 12. On [DATE], the Allegation of Compliance (AOC) will be discussed in Quality Assurance meeting for additional recommendations and/or follow-up. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of inservices of licensed nurses dated [DATE]-[DATE] revealed all licensed nurses were educated on abuse and neglect with emphasis on following the care plan, medication administration, epi-pens, care plans, verifying allergies on the (PCC) Point Click Care system, to review dashboard daily for medication alerts (order alerts); and, that the nurse that takes orders should put the order in PCC first before administering medication him/herself. Interviews on [DATE] with RN #1 at 4:13 PM and UM #1 at 4:43 PM, and on [DATE] with LPN #1 at 8:29 AM, RN #3 at 12:34 PM, LPN #5 at 1:20 PM, the Staff Development Coordinator (SDC) at 1:50 PM, and LPN #3 at 2:30 PM, revealed they were inserviced on abuse and neglect, care plan, medication administration, epi-pens, verifying allergies on the PCC system; to review dashboard daily for medication alerts (order alerts) and that nurses taking orders, is to put the order in PCC first before administering medication him/herself. 2. Review of an audit dated [DATE] revealed all residents medications and allergy lists were reviewed to ensure the residents were not prescribed any medications he/she had been identified as being allergic to. No concerns were identified. 3. Review of Suspension Pending Investigation Form, dated [DATE] revealed the DON suspended RN #1. Interview on [DATE] at 4:13 PM with RN #1 revealed she had been suspended related to the medication error with Resident #1. 4. Review of an audit conducted by the DON dated [DATE] revealed all medication errors in last (6) six months were reviewed related to allergies. Interview on [DATE] at 3:30 PM with the DON revealed no other medication errors related to allergies were identified. 5. Review of a written statement by the Medical Director dated [DATE] revealed he was notified of the medication error involving Resident #1 and was informed of plan of correction going forward with agreement of the AOC. Interview on [DATE] at 3:00 PM with DON revealed a QAPI meeting related to the medication error on [MEDICATION(S)] was held. 6. Review of inservice of nurses dated [DATE]-[DATE] revealed all nurses were educated regarding Epi-pens being located in the crash carts and on how to use Epi-pens. Interview on [DATE] at 1:30 PM with SDC revealed she had educated nurses on how to use the epi-pens Interviews on [DATE] with RN #1 at 4:13 PM and UM #1 at 4:43 PM, and on [DATE] with LPN #1 at 8:29 AM, RN #3 at 12:34 PM, LPN #5 at 1:20 PM, the revealed they received education related to where epi-pens were located and how to use them. 7. Review of audits of all crash carts dated [DATE] revealed the crash carts were checked to ensure all contained epi-pens and expiration dates were viable with no concerns identified. Observation of four (4) of four (4) crash carts in the facility on [DATE] and [DATE] revealed there were epi-pens in crash carts with viable expiration dates Interview on [DATE] at 1:30 PM with SDC revealed she checked the epi-pens on the crash carts to ensure the epi-pens had not expired. 8. Review of the written statement by SDC dated [DATE] and interview on [DATE] at 1:50 PM revealed all APRN's were educated to always request a list of allergies for a resident prior to giving verbal orders for medication for a resident. Interview on [DATE] at 6:08 PM with a ARNP revealed he had received education related to requesting a list of allergies before giving verbal orders to licensed nurses. 9. Review of Resident #1's allergy list revealed it was updated with severe anaphylactic reaction to [MEDICATION(S)]. 10. Review of witness statements revealed on [DATE] statements were obtained from RN #1 and LPN #1 related to the administration of [MEDICATION(S)] to Resident #1. 11. Review of on-going audits of medication passes revealed audits were conducted starting on [DATE] of five opportunities daily on all shifts, then weekly times two to identify any issues with nurses not reviewing allergies prior to passing medications with no concerns identified. Interviews on [DATE] with the SDC at 1:30 PM and UM at 1:00 PM revealed they had completed audits of medication passes. Interview on [DATE] with RN #4 at 1:35 PM revealed she was audited during a medication pass when she was on the floor. 12. Review of meeting notes of Quality Assurance (QA) meeting dated [DATE] revealed the QA team discussed the AOC, with continuation of audits and the allergies not being flagged in PCC. Interview on [DATE] at 3:30 PM with the DON revealed they discussed allergies not being flagged in system and audits continuing to be done related to med passes and allergies of the residents.

Based on observation, interview, record review, review hospital Physician Discharge, and facility policy review; it was determined the facility failed to ensure medications were administered per professional standards of quality and as outlined by the comprehensive care plan, for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned on [DATE] to not give medication listed on allergy list. However, on [DATE], Registered Nurse (RN) #1 administered [MEDICATION(S)] without checking to see if the medication was on the resident's allergy list per facility policy and professional standards of quality. Resident #1 was hospitalized in the Intensive Care Unit (ICU) for threatened airway and anticipated need for intubation. The findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration, last revised [DATE] the policy set forth the procedures relating to general dose preparation and medication administration. Further review revealed staff should check for allergies prior to medication administration. Record review revealed the facility admitted Resident #1 on [DATE] and he/she was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition was intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #1's Allergy Report dated [DATE] and Comprehensive Care Plan, dated [DATE] revealed the resident was allergic to [MEDICATION(S)]. However, review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on [DATE]. Review of the facility investigation prepared by RN #1 dated [DATE] revealed Resident #1 had an IM injection of 12.5 mg of [MEDICATION(S)] and after two (2) hours of receiving it the resident's tongue was swollen with resident unable to speak. Review of the Hospital Physician Discharge, dated [DATE] revealed Resident #1 was admitted to the ICU in critical condition for threatened airway and anticipated need for intubation due to allergic angioedema (swelling from agent he/she had known allergy for). Interview with RN #1 revealed she did not check the allergies of Resident #1 prior to giving [MEDICATION(S)] IM. Interview with UM #1 on [DATE] at 5:36 PM revealed RN #1 told him she administered [MEDICATION(S)] to Resident #1, and the resident was allergic to it. He stated Resident #1 had an anaphylactic reaction and they treated the resident with Solumedrol, placed oxygen on the resident, gave breathing treatments, and called 911 with the ambulance arriving within a few minutes. Interview with the Director of Nursing (DON) on [DATE] at 4:35 PM revealed the ARNP gave a verbal order for [MEDICATION(S)] IM without looking at the resident allergies or opening a computer, and RN #1 administered the medication that was obtained from ARNP. **The facility implemented the following actions to correct the deficient practice: 1. On [DATE]-[DATE], all licensed nurses were inserviced by Staff Development Coordinator (SDC) on abuse and neglect with emphasis on following the care plan, medication administration, epi-pens, care plans, verifying allergies on the Point Click Care system (PCC) in computer, to review dashboard daily for medication alerts (order alerts); and, the nurse should take orders, and put the order in PCC first before administering medication him/herself. 2. On [DATE], Unit Managers completed a 100% audit of all residents allergies with attention to current medication list and if any medication was on the resident's allergy list. 3. On [DATE], the DON suspended the Nurse that gave injection pending further investigation. 4. On [DATE], the DON reviewed all medication errors in the last six (6) months to identify if any errors related to allergies. 5. On [DATE], a Quality Assessment Performance Improvement (QAPI) meeting was held with Medical Director present to report issues and ongoing audits. 6. On [DATE] through [DATE], the SDC educated all nurses that Epi-pens are located in the crash carts in facility and they were reinstructed on how to use Epi-pens. 7. On [DATE], the SDC did a 100% audit to ensure all crash carts had epi-pens and checked expiration dates to ensure they are still viable. 8. On [DATE], the SDC educated APRN's within the facility regarding giving verbal orders to licensed nurses to always request a list of allergies before giving and new orders. 9. On [DATE], LPN #6 updated Resident #1's allergy list to include severe anaphylactic reaction to [MEDICATION(S)]. 10. On [DATE], the DON obtained witness statements from both nurses 11. Starting on [DATE], the Administrative Nursing staff will conduct on-going audits to continue to identify any issues with nurses not reviewing allergies prior to passing medications. Five (5) opportunities will be reviewed during ed passes daily times seven (7) days on all shifts, then weekly times two (2) weeks on all shifts, then monthly times two (2) months. 12. On [DATE], the Allegation of Compliance (AOC) will be discussed in Quality Assurance meeting for additional recommendations and/or follow-up. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of inservices of licensed nurses dated [DATE]-[DATE] revealed all licensed nurses were educated on abuse and neglect with emphasis on following the care plan, medication administration, epi-pens, care plans, verifying allergies on the (PCC) Point Click Care system, to review dashboard daily for medication alerts (order alerts); and, that the nurse that takes orders should put the order in PCC first before administering medication him/herself. Interviews on [DATE] with RN #1 at 4:13 PM and UM #1 at 4:43 PM, and on [DATE] with LPN #1 at 8:29 AM, RN #3 at 12:34 PM, LPN #5 at 1:20 PM, the Staff Development Coordinator (SDC) at 1:50 PM, and LPN #3 at 2:30 PM, revealed they were inserviced on abuse and neglect, care plan, medication administration, epi-pens, verifying allergies on the PCC system; to review dashboard daily for medication alerts (order alerts) and that nurses taking orders, is to put the order in PCC first before administering medication him/herself. 2. Review of an audit dated [DATE] revealed all residents medications and allergy lists were reviewed to ensure the residents were not prescribed any medications he/she had been identified as being allergic to. No concerns were identified. 3. Review of Suspension Pending Investigation Form, dated [DATE] revealed the DON suspended RN #1. Interview on [DATE] at 4:13 PM with RN #1 revealed she had been suspended related to the medication error with Resident #1. 4. Review of an audit conducted by the DON dated [DATE] revealed all medication errors in last (6) six months were reviewed related to allergies. Interview on [DATE] at 3:30 PM with the DON revealed no other medication errors related to allergies were identified. 5. Review of a written statement by the Medical Director dated [DATE] revealed he was notified of the medication error involving Resident #1 and was informed of plan of correction going forward with agreement of the AOC. Interview on [DATE] at 3:00 PM with DON revealed a QAPI meeting related to the medication error on [MEDICATION(S)] was held. 6. Review of inservice of nurses dated [DATE]-[DATE] revealed all nurses were educated regarding Epi-pens being located in the crash carts and on how to use Epi-pens. Interview on [DATE] at 1:30 PM with SDC revealed she had educated nurses on how to use the epi-pens Interviews on [DATE] with RN #1 at 4:13 PM and UM #1 at 4:43 PM, and on [DATE] with LPN #1 at 8:29 AM, RN #3 at 12:34 PM, LPN #5 at 1:20 PM, the revealed they received education related to where epi-pens were located and how to use them. 7. Review of audits of all crash carts dated [DATE] revealed the crash carts were checked to ensure all contained epi-pens and expiration dates were viable with no concerns identified. Observation of four (4) of four (4) crash carts in the facility on [DATE] and [DATE] revealed there were epi-pens in crash carts with viable expiration dates Interview on [DATE] at 1:30 PM with SDC revealed she checked the epi-pens on the crash carts to ensure the epi-pens had not expired. 8. Review of the written statement by SDC dated [DATE] and interview on [DATE] at 1:50 PM revealed all APRN's were educated to always request a list of allergies for a resident prior to giving verbal orders for medication for a resident. Interview on [DATE] at 6:08 PM with a ARNP revealed he had received education related to requesting a list of allergies before giving verbal orders to licensed nurses. 9. Review of Resident #1's allergy list revealed it was updated with severe anaphylactic reaction to [MEDICATION(S)]. 10. Review of witness statements revealed on [DATE] statements were obtained from RN #1 and LPN #1 related to the administration of [MEDICATION(S)] to Resident #1. 11. Review of on-going audits of medication passes revealed audits were conducted starting on [DATE] of five opportunities daily on all shifts, then weekly times two to identify any issues with nurses not reviewing allergies prior to passing medications with no concerns identified. Interviews on [DATE] with the SDC at 1:30 PM and UM at 1:00 PM revealed they had completed audits of medication passes. Interview on [DATE] with RN #4 at 1:35 PM revealed she was audited during a medication pass when she was on the floor. 12. Review of meeting notes of Quality Assurance (QA) meeting dated [DATE] revealed the QA team discussed the AOC, with continuation of audits and the allergies not being flagged in PCC. Interview on [DATE] at 3:30 PM with the DON revealed they discussed allergies not being flagged in system and audits continuing to be done related to med passes and allergies of the residents.

Based on observation, interview, record review, facility policy review, and hospital record review, it was determined the facility's system to ensure there was no significant medication errors for one (1) of three (3) sampled residents was followed according to facility policy (Resident #1). Resident #1 was found unresponsive on 12/29/17 at 4:20 AM and was sent to the hospital where it was determined the resident had [MEDICATION NAME] (narcotic pain medication) in his/her system. The resident was administered [MEDICATION NAME] and admitted to the hospital with [REDACTED]. The facility determined Licensed Practical Nurse (LPN) #1 failed to ensure to administer [MEDICATION NAME] to the right resident (Resident #2-Res) and administered the [MEDICATION NAME] to Resident #1. The significant mediation error resulted in Resident #1 being admitted to the Intensive Care Unit and the resdient returned to the facility with a decline in Activities of Daily Living (ADL), a downgrade in diet, and on continuous oxygen continuously. The findings include: Review of facility policy, Administration of Medication, not dated, revealed all medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help diagnosis. In addition, medication administration is the responsibility of the nursing professional to be aware of the classification, action, correct dosage, and side effects of a medication before administration. Furthermore, the nurse is to bring the medication cart to an area adjacent to the resident's room, check the Medication Administration Records (MAR), read each order entirely, remove the medication from the drawer, and read the label three (3) times. The Nurse should use one (1) of three (3) methods to ensure the correct resident. 1. Compare the name on the arm band with the name on the MAR/Treatment Administration Record (TAR) and compare with the resident's photo to the resident. 2. Ask the resident his or her full name and compare it to the name on the MAR/TAR and compare the resident's photo to the resident. 3. If there is no photo or armband, and the resident is unable to tell you his or her full name, then validate the resident's identity with a second associate who is familiar with the resident and compare with the resident's name to the MAR/TAR. Then initial each medication in the correct box on the MAR indicated [REDACTED] Review of facility policy from the Pharmacy Services and Procedures Manual titled, General Dose Preparation and Medication Administration, dated 12/01/07, revealed prior to administration of medication, facility staff should take all measures required by facility policy and Applicable Law, including, but not limited to: verifying each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Record review revealed the facility admitted Resident #1 on 11/27/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 10/12/17 revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Further review of the MDS dated [DATE] revealed the resident required limited assist with transfers and ambulation, and was not receiving oxygen. Observation on 01/23/18 at 1:03 PM revealed Resident #1 was lying in the bed with eyes closed with oxygen at 3.5 liters per nasal cannula. Resident #1 answered a few yes/no questions; however, did not remember the recent hospitalization . Review of Nurse's Note written by Licensed Practical Nurse (LPN) #1 dated 12/29/17 at 8:44 AM, late entry for 12/29/17 at 4:20 AM revealed Certified Nurse Aide (CNA) #1 notified the nurse Resident #1 was in distress and the nurse immediately went to the resident's room. The resident was noted to be having an active [MEDICAL CONDITION] and was foaming at the mouth. Staff turned resident to the side and nurse noted the resident was unresponsive. The nurse performed a sternum rub with no response from the resident. The nurse let the CNA stay by resident's side while she called 911. EMS (Ambulance) arrived and the resident was transported to the emergency room , Family and Nurse Practitioner were notified. Review of Hospital History and Physical, dated 12/29/17, revealed the nursing home staff reported the resident was having a [MEDICAL CONDITION], unresponsive, and foaming at the mouth. Assessment revealed the resident's pupils were pinpoint, equal and nonreactive, and resident unresponsive. The resident was administered [MEDICATION NAME] (anecdote for narcotic induced respiratory depression) 0.4 mg Intramuscularly as well as by Intravenous drip at 5:48 AM. A urine clean catch drug screen was conducted and the resident's tested positive for [MEDICATION NAME] at 6:24 AM; however, the medication was not listed on the resident's medication list. The hospital called the nursing home at 6:50 AM about the [MEDICATION NAME] not being on the medication list and was told the resident's roommate receives [MEDICATION NAME]. Review of the Hospital Discharge Planning assessment dated [DATE] at 9:27 AM revealed the resident was admitted into Intensive Care at the hospital with wrong medication ([MEDICATION NAME]) at the facility and now has opioid-induced respiratory distress. Adult Protective Services requested a [MEDICATION NAME] level on 12/29/17 at 9:32 AM; however, hospital concerned of accuracy since the resident had already received [MEDICATION NAME]. The serum level was collected on 12/30/17 at 6:58 AM and was a value of 62 with a reference range of 100-400 nanograms (ng)/milliliters (ml) after the resident had received [MEDICATION NAME] for twenty-four (24) hours. Review of Resident #1's December 2017 physician's orders [REDACTED].; however, review of Resident #2's (Resident #1's roommate) physician's orders [REDACTED]. Review of Resident #2's December 2017 MAR indicated [REDACTED]. In addition, review of the [MEDICATION NAME] Narcotic Count Sheet revealed four (4) tablets of [MEDICATION NAME] was signed out on 12/29/17 at 2:00 AM. Review of Resident #1's ADL flow sheets the week prior to hospitalization dated 12/21/17-12/28/17 and the ADL flow sheet for 01/05/18-01/11/18 revealed Resident #1 had a decline in ADLs after the medication error. Review of the 12/21/17-12/28/17 ADL flow sheet revealed Resident #1 required limited assist for bed mobility, transfers, ambulation in room, dressing and toileting. However, review of the ADL flow sheet for 01/05/18-01/11/18 after return from the hospital on [DATE] revealed the resident required extensive assist with bed mobility, transfers, ambulation and toileting. Review of December 2017 physician's orders [REDACTED]. In addition, Resident #1 returned on Oxygen continuously. Interview with LPN #1 on 01/25/18 at 9:41 AM revealed she had been a nurse for two (2) years. She further revealed at the start of her career she began working at this facility and was confused about the policies and procedures of medication pass. In addition, she stated other staff members informed her with incorrect information and therefore caused her to get into trouble. She stated she had received an inservice in August 2017 regarding medication administration which consisted of the patient's five (5) rights including the right medication and right patient. She further stated to ensure the right resident this included to verify the name on the bracelet, the door, or call the resident by name if oriented. She revealed on 12/29/17 she was passed the medication cart keys for Resident #1 and #2 around 10:30 PM on 12/28/17 and no one had access to the keys by her until day shift arrived around 7:00 AM on 12/29/17. She stated there was a lot of residents with flu that night that were sick. She revealed approximately 2:00 AM on 12/29/17 she was at the nurse's desk, not at the resident's door per policy, and pulled the [MEDICATION NAME] from the medication cart for Resident #2 and placed applesauce on top of the medication. She stated she came into Resident #1 and #2 room and called out Resident #2's name and told him/her it was time for his/her 2:00 AM medication. She stated she did not compare the resident to the photo on the MAR indicated [REDACTED]. She revealed Resident #2 then asked to sit on the commode to use the bathroom and she explained to the resident that he/she had a [MEDICAL CONDITION] and a catheter. She stated she then placed the medication with the applesauce in the resident's mouth with a spoon and gave the resident a drink and carried the empty cups out of the room. She revealed she changed a dressing for Resident #2 around 4:00 AM and at 4:20 AM, CNA #1 found Resident #1 foaming at the mouth, eyes rolling back in his/her head, shaking, and unresponsive. She then called the ambulance and the resident was sent to the hospital for evaluation. She stated that morning on 12/29/17 she was suspended for a medication error. Interview with CNA #1 on 01/24/18 at 3:06 PM revealed she had been in the room with the nurse around 4:00 AM helping the nurse with a dressing change on Resident #2 and on the way out of the room she made mention to LPN #1 that Resident #1 was sawing logs this morning (meaning the resident was snoring very loudly). She stated approximately thirty (30) minutes later she was performing a bed check and explained to Resident #1 it was time to go to the bathroom and noticed he/she was foaming at the mouth and breathing funny. She stated she hollered for the nurse. She revealed she placed the resident on his/her side and then the nurse came in and noticed the resident was unresponsive with shallow breathing. Interview with the Unit Manager on 01/25/18 at 2:20 PM revealed Resident #1 had never had a [MEDICAL CONDITION] while a resident at the facility but took [MEDICATION NAME] for [MEDICAL CONDITION] disorder. Furthermore, she stated she had the understanding from the physician the resident had the adverse effects due to the [MEDICATION NAME] ingestion. Interview with Staff Development Coordinator (SDC) on 01/25/18 at 2:08 PM revealed during the Quality Assurance (QA) meeting the Medical Director determined the resident received Resident #2's [MEDICATION NAME] at 2:00 AM on 12/29/17 due to the peak time of [MEDICATION NAME]. Interview with the Advanced Registered Nurse Practitioner (ARNP) on 01/25/18 at 10:16 AM revealed the peak of [MEDICATION NAME] was 1.5 to 2 hours after administration which verifies the medical directors initial comment on the self reported incident. She further stated the half-life of the medication is six (6) to eight (8) hours. Furthermore, administering [MEDICATION NAME] would decrease the amount of [MEDICATION NAME] in the system and would show a decrease blood serum level if the level was drawn after the [MEDICATION NAME] was administered. She further stated she agreed with the Medical Directors initial conclusion which stated Resident #1 inadvertently received Resident #2's [MEDICATION NAME] at 2:00 AM on 12/29/17 as Resident #1 began developing adverse effects of [MEDICATION NAME] when the medication would have reached its peak. She further stated [MEDICAL CONDITION] and respiratory distress and failure is an adverse effect of [MEDICATION NAME]. She revealed the resident has had a decline since return from the hospital which could have been due to the [MEDICAL CONDITION] or medications in the hospital. She revealed the resident had not had [MEDICAL CONDITION] in the past. She further revealed therapy was working with the resident to improve his/her status. She stated the resident's oxygen was new since return from the hospital and hoped to wean the resident off the oxygen. She further stated this significant medication error could have been prevented and expects residents to receive medications as ordered and staff to follow the five rights for medication administration. Interview with the Director of Nursing (DON) on 01/23/18 at 10:50 AM revealed LPN #1 denied a medication error however, the conclusion was determined the medication error occurred. She stated she believes the error was an accident and not intentional. She revealed the conclusion was determined with assistance from the Medical Director regarding the timing of the peak of the [MEDICATION NAME] and when Resident #1 began symptoms. She stated she expects staff to follow the policy and administer medications as ordered. **The facility implemented the following actions to correct the deficient practice: 1. The SDC was educated by the Regional Nurse Consultant on 12/29/17 on Medication Administration Policy, Medication Error Policy, and Abuse and Neglect. 2. The SDC began education with all Administrative Nurses and floor nurses on 12/29/17 and concluded on 01/01/18. A Medication Post Test was also given and the nurses were required to score 100%. Staff members on leave are required to receive the education and completing the Post Test prior to working the floor. 3. Beginning 12/30/17, a Medication Pass Audit was started on the nurses passing medications which included two (2) medication pass audits per shift times seven (7) days, one (1) medication pass audit per shift times seven (7) days, five (5) medication pass audits weekly times four (4) weeks, then monthly times two (2) months, then quarterly. These Medication Pass Audits were to include a narcotic medication pass as well. The SDC, ADON, or an RN are responsible for completing the audits. 4. Beginning 12/30/17, a Medication Administration Audit was started on the nurses passing medications which included two (2) medication pass audits per shift times seven (7) days, one (1) medication pass audit per shift times seven (7) days, five (5) medication pass audits weekly times four (4) weeks, then monthly times two (2) months, then quarterly. 5. On 12/29/17, resident's on wings 5, 7, and 8, (which LPN #1 worked) with BIMS of an eight (8) or greater were interviewed by the Social Worker on medication pass, pain, and care with no concerns identified. 6. On 12/29/17, residents on wings 5, 7, and 8 with a BIMS of seven (7) and lower were administered a skin assessment with no concerns identified. 7. The DON reviewed Medication Errors for the last three (3) months on 12/29/17-12/30/17 to determine trends and none identified. 8. The MDS team on 12/29/17-12/30/17 audited care plans for all active residents with current Pain Care Plans and updated the care plans to include the intervention of pain medications as ordered by the physician. In addition, all care plans in the building were updated with a pain care plan on 12/29/17. 9. An Ad Hoc Quality Assurance (QA) Meeting was conducted on 01/02/18 which included the Medical Director, DON, Administrator, MDS, and Social Services in which the [MEDICATION NAME] overdose error, the investigation, and plans to prevent reoccurrence. was reviewed. **The State Survey Agency validated the following actions to remove the Harm: 1. Review of In-Service Sign In Sheet dated 12/29/17 revealed the Staff Development Coordinator (SDC) was educated on the Medication Policy, Medication Error Policy, and Abuse Policy by the Regional Nurse Consultant. Interview with the SDC on 01/25/17 at 2:08 PM revealed the Regional Nurse Consultant (RNC) educated her on 12/29/17 on the Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. She stated the RNC also educated that the results of administering the wrong medication could result in death. She further stated if the staff do not follow the five (5) rights of medication administration an error could occur. 2. Review of the In-Service Sign In Sheet starting date 12/29/17 revealed the SDC educated all Administrative Nurses and floor nurses by 01/01/18. The staff on leave will receive the in-service before returning to work on the floor. Review of Nurse's Medication Pass In-Service Post Tests revealed all post tests were completed by 01/01/18. All nurses made a 100% on the test before returning to the floor to work. Interview with the SDC on 01/25/17 at 2:08 PM revealed on 12/29/17 she began education to staff on the Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. She stated the education was completed on 01/01/18 except for staff on leave. She further stated she called some of them and the ones unable to reach were not allowed to work until the training was completed. Interview with Unit Manager on 01/25/18 at 2:20 PM revealed she received education of the above on 12/29/17 by the SDC. She stated the education included to ensure you administered the right medication to the right resident. Interview with LPN #2 on 01/24/18 at 8:54 AM, RN #1 at 9:27 AM, LPN #3 at 1:13 PM, LPN #4 on 01/25/18 at 1:51 PM, and LPN #5 at 2:35 PM revealed they received education the end of December, first of January on Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. The nurses revealed the education included to ensure you administered the right medication to the right resident. In addition, the nurses revealed they received a post test and had to make a 100% before returning to work on the floor. Interview with DON on 01/24/18 at 1:30 PM revealed staff must make a 100% on post test before returning to floor. 3. Review of Medication Pass Audits revealed on 12/30/17 two medication pass audits to include a narcotic pass were completed per shift and continued seven (7) days a week, then one (1) medication pass audit per shift for seven days to include a narcotic pass, then five (5) medication pass audits weekly times four (4) weeks to include a narcotic pass, the audits to continue monthly times two (2) months to include a narcotic pass, then quarterly to include a narcotic pass. Interview with the SDC on 01/25/18 at 2:08 PM revealed she performs the audits and continues with them as planned. Interview with RN #1 on 01/24/18 at 9:27 AM revealed he had a medication pass audit today. Interview with LPN #2 on 01/24/18 at 8:54 AM revealed she has received several medication pass audits including passing a narcotic Interview with LPN #4 on 01/25/18 at 1:51 PM, RN #1 at 1:42 PM, LPN #5 revealed the SDC observed them perform a medication pass which included narcotics. 4. Review of Medication Administration Audit performed on the staff performing the Medication Pass revealed this was completed on 12/30/17 on two medication pass audits to include a narcotic pass were completed per shift and continued seven (7) days a week, then one (1) medication pass audit per shift for seven days to include a narcotic pass, then five (5) medication pass audits weekly times four (4) weeks to include a narcotic pass, the audits to continue monthly times two (2) months to include a narcotic pass, then quarterly to include a narcotic pass. Interview with the SDC on 01/25/18 at 2:08 PM revealed she performs the Medication Administration Audits on staff as scheduled. Interview with the Unit Manager on 01/25/18 at 2:20 PM revealed she assists with performing the Medication Administration Audits as scheduled. 5. Review of Facility Census dated 12/29/17 revealed residents on wings 5, 7, and 8, (which LPN #1 worked) with BIMS of an eight (8) or greater were interviewed by the Social Worker on medication pass, pain, and care with no concerns identified. Interview with the Licensed Social Worker on 01/25/18 at 2:03 PM revealed she interviewed residents with BIMS eight (8) and greater on 12/29/17 regarding pain, medication pass, and care. No concerns were identified. 6. Review of Facility's Skin Integrity Data Collection Form dated 12/29/17 revealed residents on wing 5, 7, and 8 with a BIMS of seven (7) and lower were administered a skin assessment and no concerns were identified. Interview with the Unit Manager on 01/25/18 at 2:20 PM revealed she performed skin assessments on residents that had a BIMS less than 8 on 12/29/17 with assist from nursing staff. 7. Review of Medication Error List dated 12/29/17-12/30/17 provided by the DON revealed the last three (3) months of medication errors were reviewed by the DON with no errors resulting with the wrong medications given to the wrong resident as well as no adverse effects noted with medication errors. Interview with the DON on 01/25/18 at 10:44 AM revealed she audited all medication errors in the last three (3) months on 12/29/17 and no trends were identified. 8. Review of Facility Census dated 12/29/17-12/30/17 revealed an audit of care plans for all active residents with current Pain Care Plans were updated to include the intervention of pain medications as ordered by the physician by the MDS team. Interview with the MDS Coordinator on 01/25/18 at 1:42 PM revealed he and his assistant performed an audit on all residents that had a narcotic order to ensure the resident had a pain care plan which stated pain medications as ordered on [DATE]. He further stated we decided to ensure all residents in the facility had a pain care plan as all residents are at risk for pain. 9. Review of In-Service Sign-In Sheet dated 01/02/18 revealed an Ad Hoc Quality Assurance meeting to review [MEDICATION NAME] medication overdose for Resident #1 and plan of action. Interview with the SDC on 01/25/18 at 2:08 PM revealed she was part of the Ad Hoc QA meeting on 01/02/18 and determined the resident received the [MEDICATION NAME] at 2 AM on 12/29/17 due to the peak time of the medication. She stated the discussion continued regarding the interventions put into place and the plan going forward. Interview with the DON on 01/25/18 at 10:44 revealed she attended the Ad Hoc QA meeting with the Medical Director on 01/02/18 and reviewed the cause of the overdose and plan forward.

Based on observation, interview, record review, facility policy review, review of hospital records, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #16, it was determined the facility failed to meet professional standards of quality for one (1) of three (3) sampled residents (Resident #1). On 12/29/17, the Licensed Nurse failed to ensure she administered medication to the right Resident. The Licensed Nurse administered Resident #1 another resident's (Resident #2/Resident #1's roommate) [MEDICATION NAME] 10 milligrams (mg) four (4) tablets at 2:00 AM and Resident #1 was found unresponsive at 4:20 AM on 12/29/17. Resident #1 was sent to the hospital where test results revealed the resident had [MEDICATION NAME] in his/her system. Resident #1 was admitted to the hospital Intensive Care Unit with [DIAGNOSES REDACTED]. The resident had a decline in Activities of Daily Living, a downgrade in diet, and was now on oxygen. The findings include: Interview with the Director of Nursing (DON) on 01/24/18 at 3:35 PM revealed the facility does not have a certain standards of practice for medication pass. She stated the facility's company uses a variety of sources and combines those sources to develop best practices for the facility. Review of the KBN, AOS #14, Patient Care Orders, last revised October 2015, revealed licensed nurses should administer medication and treatment as prescribed by Physician, physician assistant, dentist or advanced practice registered nurse. This includes preparing and giving medication in the prescribed dosage, route, and frequency. Review of facility policy from the Pharmacy Services and Procedures Manual titled, General Dose Preparation and Medication Administration, dated 12/01/07, revealed prior to administration of medication, facility staff should take all measures required by facility policy and Applicable Law, including, but not limited to: verifying each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Review of facility policy, Administration of Medication, not dated, revealed the Nurse should use one (1) of three (3) methods to ensure the correct resident. 1. Compare the name on the arm band with the name on the MAR/Treatment Administration Record (TAR) and compare with the resident's photo to the resident. 2. Ask the resident his or her full name and compare it to the name on the MAR/TAR and compare the resident's photo to the resident. 3. If there is no photo or armband, and the resident is unable to tell you his or her full name, then validate the resident's identity with a second associate who is familiar with the resident and compare with the resident's name to the MAR/TAR. Then initial each medication in the correct box on the MAR indicated [REDACTED] Record review revealed the facility admitted Resident #1 on 11/27/14 with [DIAGNOSES REDACTED]. Review of Nurse's Note written by Licensed Practical Nurse (LPN) #1 dated 12/29/17 at 8:44 AM, late entry for 12/29/17 at 4:20 AM revealed Resident #1 was found to be having an active [MEDICAL CONDITION] and was foaming at the mouth. The nurse performed a sternum rub and the resident was unresponsive. The nurse call 911 and EMS (Ambulance) arrived and the resident was transported to the emergency room . Review of Hospital History and Physical, dated 12/29/17, revealed the nursing home staff reported the resident was having a [MEDICAL CONDITION], unresponsive, and foaming at the mouth. Assessment revealed the resident's pupils were pinpoint, equal and nonreactive, and resident unresponsive. [MEDICATION NAME] (anecdote for narcotic induced respiratory depression) was administered Intramuscularly as well as by Intravenous drip at 5:48 AM. The resident tested positive for [MEDICATION NAME] at 6:24 AM but [MEDICATION NAME] was not listed on the resident's medication list. The hospital called the nursing home at 6:50 AM and was told the resident's roommate receives [MEDICATION NAME]. Review of the Hospital Discharge Planning assessment dated [DATE] at 9:27 AM revealed the resident was admitted into Intensive Care with opioid-induced respiratory distress. Review of Resident #1's December 2017 physician's orders [REDACTED].#2's (Resident #1's roommate) December 2017 physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 01/25/18 at 9:41 AM revealed on 12/29/17 at approximately 2:00 AM she was at the nurse's desk, and pulled the [MEDICATION NAME] from the medication cart for Resident #2 and placed applesauce on top of the medication. She revealed she entered Resident #1 and #2 room and called out Resident #2's name and told him/her it was time for his/her 2:00 AM medication. She stated Resident #2 asked to sit on the commode to use the bathroom and she explained to the resident that he/she had a [MEDICAL CONDITION] and a catheter. She stated she did not compare the photo on the MAR indicated [REDACTED]. She stated she then placed the medication with the applesauce in the resident's mouth with a spoon and gave the resident a drink and carried the empty cups out of the room. She revealed at about 4:20 AM, CNA #1 started to get Resident #1 up and the resident was foaming at the mouth, his/her eyes were rolling back in his/her head, and he/she was shaking, and unresponsive. She stated she called the ambulance and the resident was sent to the hospital for evaluation. She stated that morning on 12/29/17 she was suspended for a medication error. Interview with LPN #2 on 01/24/18 at 8:54 AM revealed nurses are to ensure accurate identification of the residents by either checking the name on the door with the MAR, or resident's identification bracelet with the MAR, or if the resident is cognitive can ask their name and compare with the picture on the MAR. Interview with Staff Development Coordinator (SDC) on 01/25/18 at 2:08 PM revealed during the Quality Assurance (QA) meeting on 01/02/18 the Medical Director determined the resident received Resident #2's [MEDICATION NAME] at 2 AM on 12/29/17 due to the peak time of [MEDICATION NAME]. Interview with the Advanced Registered Nurse Practitioner (ARNP) on 01/25/18 at 10:16 AM revealed she agreed with the Medical Directors initial conclusion that Resident #1 inadvertently received Resident #2's [MEDICATION NAME] at 2:00 AM on 12/29/17 as Resident #1 began developing adverse effects of [MEDICATION NAME] when the medication would have reached its peak. She stated a [MEDICAL CONDITION] and respiratory distress/failure is an adverse effect of [MEDICATION NAME]. She stated this significant medication error could have been prevented and expects licensed staff to administer medications as ordered and follow the five rights (right resident, medication, route, dose, and time) for medication administration. Interview with the Director of Nursing (DON) on 01/23/18 at 10:50 AM revealed LPN #1 denied a medication error; however, the conclusion was determined the medication error occurred. She stated she expects staff to administer medications as ordered and to follow the five rights of medication administration. **The facility implemented the following actions to correct the deficient practice: 1. The SDC was educated by the Regional Nurse Consultant on 12/29/17 on Medication Administration Policy, Medication Error Policy, and Abuse and Neglect. 2. The SDC began education with all Administrative Nurses and floor nurses on 12/29/17 and concluded on 01/01/18. A Medication Post Test was also given and the nurses were required to score 100%. Staff members on leave are required to receive the education and completing the Post Test prior to working the floor. 3. Beginning 12/30/17, a Medication Pass Audit was started on the nurses passing medications which included two (2) medication pass audits per shift times seven (7) days, one (1) medication pass audit per shift times seven (7) days, five (5) medication pass audits weekly times four (4) weeks, then monthly times two (2) months, then quarterly. These Medication Pass Audits were to include a narcotic medication pass as well. The SDC, ADON, or an RN are responsible for completing the audits. 4. Beginning 12/30/17, a Medication Administration Audit was started on the nurses passing medications which included two (2) medication pass audits per shift times seven (7) days, one (1) medication pass audit per shift times seven (7) days, five (5) medication pass audits weekly times four (4) weeks, then monthly times two (2) months, then quarterly. 5. On 12/29/17, resident's on wings 5, 7, and 8, (which LPN #1 worked) with BIMS of an eight (8) or greater were interviewed by the Social Worker on medication pass, pain, and care with no concerns identified. 6. On 12/29/17, residents on wings 5, 7, and 8 with a BIMS of seven (7) and lower were administered a skin assessment with no concerns identified. 7. The DON reviewed Medication Errors for the last three (3) months on 12/29/17-12/30/17 to determine trends and none identified. 8. The MDS team on 12/29/17-12/30/17 audited care plans for all active residents with current Pain Care Plans and updated the care plans to include the intervention of pain medications as ordered by the physician. In addition, all care plans in the building were updated with a pain care plan on 12/29/17. 9. An Ad Hoc Quality Assurance (QA) Meeting was conducted on 01/02/18 which included the Medical Director, DON, Administrator, MDS, and Social Services in which the [MEDICATION NAME] overdose error, the investigation, and plans to prevent reoccurrence. was reviewed. **The State Survey Agency validated the following actions to remove the Harm: 1. Review of In-Service Sign In Sheet dated 12/29/17 revealed the Staff Development Coordinator (SDC) was educated on the Medication Policy, Medication Error Policy, and Abuse Policy by the Regional Nurse Consultant. Interview with the SDC on 01/25/18 at 2:08 PM revealed the Regional Nurse Consultant (RNC) educated her on 12/29/17 on the Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. She stated the RNC also educated that the results of administering the wrong medication could result in death. She further stated if the staff do not follow the five (5) rights of medication administration an error could occur. 2. Review of the In-Service Sign In Sheet starting date 12/29/17 revealed the SDC educated all Administrative Nurses and floor nurses by 01/01/18. The staff on leave will receive the in-service before returning to work on the floor. Review of Nurse's Medication Pass In-Service Post Tests revealed all post tests were completed by 01/01/18. All nurses made a 100% on the test before returning to the floor to work. Interview with the SDC on 01/25/18 at 2:08 PM revealed on 12/29/17 she began education to staff on the Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. She stated the education was completed on 01/01/18 except for staff on leave. She further stated she called some of them and the ones unable to reach were not allowed to work until the training was completed. Interview with Unit Manager on 01/25/18 at 2:20 PM revealed she received education of the above on 12/29/17 by the SDC. She stated the education included to ensure you administered the right medication to the right resident. Interview with LPN #2 on 01/24/18 at 8:54 AM, RN #1 at 9:27 AM, LPN #3 at 1:13 PM, LPN #4 on 01/25/18 at 1:51 PM, and LPN #5 at 2:35 PM revealed they received education the end of December, first of January on Medication Administration Policy, Medication Error Policy, Pharmacy Policy, and Abuse and Neglect. The nurses revealed the education included to ensure you administered the right medication to the right resident. In addition, the nurses revealed they received a post test and had to make a 100% before returning to work on the floor. Interview with DON on 01/24/18 at 1:30 PM revealed staff must make a 100% on post test before returning to floor. 3. Review of Medication Pass Audits revealed on 12/30/17 two medication pass audits to include a narcotic pass were completed per shift and continued seven (7) days a week, then one (1) medication pass audit per shift for seven days to include a narcotic pass, then five (5) medication pass audits weekly times four (4) weeks to include a narcotic pass, the audits to continue monthly times two (2) months to include a narcotic pass, then quarterly to include a narcotic pass. Interview with the SDC on 01/25/18 at 2:08 PM revealed she performs the audits and continues with them as planned. Interview with RN #1 on 01/24/18 at 9:27 AM revealed he had a medication pass audit today. Interview with LPN #2 on 01/24/18 at 8:54 AM revealed she has received several medication pass audits including passing a narcotic Interview with LPN #4 on 01/25/18 at 1:51 PM, RN #1 at 1:42 PM, LPN #5 revealed the SDC observed them perform a medication pass which included narcotics. 4. Review of Medication Administration Audit performed on the staff performing the Medication Pass revealed this was completed on 12/30/17 on two medication pass audits to include a narcotic pass were completed per shift and continued seven (7) days a week, then one (1) medication pass audit per shift for seven days to include a narcotic pass, then five (5) medication pass audits weekly times four (4) weeks to include a narcotic pass, the audits to continue monthly times two (2) months to include a narcotic pass, then quarterly to include a narcotic pass. Interview with the SDC on 01/25/18 at 2:08 PM revealed she performs the Medication Administration Audits on staff as scheduled. Interview with the Unit Manager on 01/25/18 at 2:20 PM revealed she assists with performing the Medication Administration Audits as scheduled. 5. Review of Facility Census dated 12/29/17 revealed resident's on wing 5, 7, and 8, (which LPN #1 worked) with BIMS of an eight (8) or greater were interviewed by the Social Worker on medication pass, pain, and care with no concerns identified. Interview with the Licensed Social Worker on 01/25/18 at 2:03 PM revealed she interviewed residents with BIMS eight (8) and greater on 12/29/17 regarding pain, medication pass, and care. No concerns were identified. 6. Review of Facility's Skin Integrity Data Collection Form dated 12/29/17 revealed residents on wing 5, 7, and 8 with a BIMS of seven (7) and lower were administered a skin assessment and no concerns were identified. Interview with the Unit Manager on 01/25/18 at 2:20 PM revealed she performed skin assessments on residents that had a BIMS less than 8 on 12/29/17 with assist from nursing staff. 7. Review of Medication Error List dated 12/29/17-12/30/17 provided by the DON revealed the last three (3) months of medication errors were reviewed by the DON with no errors resulting with the wrong medications given to the wrong resident as well as no adverse effects noted with medication errors. Interview with the DON on 01/25/18 at 10:44 AM revealed she audited all medication errors in the last three (3) months on 12/29/17 and no trends were identified. 8. Review of Facility Census dated 12/29/17-12/30/17 revealed an audit of care plans for all active residents with current Pain Care Plans were updated to include the intervention of pain medications as ordered by the physician by the MDS team. Interview with the MDS Coordinator on 01/25/18 at 1:42 PM revealed he and his assistant performed an audit on all residents that had a narcotic order to ensure the resident had a pain care plan which stated pain medications as ordered on [DATE]. He further stated we decided to ensure all residents in the facility had a pain care plan as all residents are at risk for pain. 9. Review of In-Service Sign-In Sheet dated 01/02/18 revealed an Ad Hoc Quality Assurance meeting to review [MEDICATION NAME] medication overdose for Resident #1 and plan of action. Interview with the SDC on 01/25/18 at 2:08 PM revealed she was part of the Ad Hoc QA meeting on 01/02/18 and determined the resident received the [MEDICATION NAME] at 2 AM on 12/29/17 due to the peak time of the medication. She stated the discussion continued regarding the interventions put into place and the plan going forward. Interview with the DON on 01/25/18 at 10:44 revealed she attended the Ad Hoc QA meeting with the Medical Director on 01/02/18 and reviewed the cause of the overdose and plan forward.

Based on observation, interviews and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible and failed to ensure adequate supervision was provided to prevent accidents for one resident (#65), not in the selected sample. The facility failed to ensure staff was following the mechanical lift manufacturer's guidelines, the facility's, "Mechanical Lift policy" and Resident #65's daily care guide. On 01/12/11, CNA #1 failed to secure Resident #65 in the mechanical lift prior to transferring the resident from the bed to the wheelchair. Findings include: A review of the facility's "Mechanical Lift Policy", undated, revealed lifts may be operated by one trained associate, unless that associate felt more comfortable using a "two assist" or it was indicated on the care plan and/or care guide the resident needed a "two assist" transfer. A review of the facility's policy "Incident Management", dated 11/2008, revealed each resident received adequate assistance and oversight as defined in an individualized plan of care that reduced the risks for incidents. A review of the lift manufacturer's "Training Checklist", dated 2009, revealed the "Support Vest" must be applied with the resident in a seated position and should be connected using the "belt clip". A record review revealed Resident #65 was readmitted to the facility, on 09/06/10, with [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as cognitively intact and required extensive assistance of two persons for transfers. The MDS revealed the resident had limitations on one side of the body affecting the upper and lower range of motion. A review of the "Daily Care Guide", dated 01/11/11, revealed Resident #65 used the sit-to-stand lift with transfers. The care guide specified transfers as a "3", as referenced by the key at the bottom of the care guide as a "two assist" for transfers. An observation, on 01/12/11 at 7:45 AM, revealed Certified Nurse Aide (CNA) #1 transferred Resident #65 from the bed to the wheelchair utilizing the sit-to-stand lift. The accessory for upper torso support, referred to as a "Support Vest", had a "belt clip" which was not secured around the waist of the resident. An interview with CNA #1, on 01/12/11 at 7:45 AM, revealed he did not secure the "belt clip" because the resident was not in the lift for a long period of time. He revealed the resident could be transferred with "one assist". An interview with CNA #1, on 01/12/11 at 11:35 AM, revealed he was trained to use the "belt clip" while using the sit-to-stand lift, but was distracted during the observation. He revealed the purpose of the "belt clip" was to help support the resident's upper trunk while in the "Support Vest". CNA #1 revealed he used the care guide to determine how much assistance a resident needed with transfers. The care guide for Resident #65 specified a "two assist" with transfers, however, CNA #1 stated, "I usually transfer the resident by myself." An interview with the Staff Development Coordinator (SDC), on 01/12/11 at 11:30 AM, revealed she was responsible for ensuring staff were trained on the proper use of the sit-to-stand lift. Training and competency checks was completed on 12/28/10. She stated the staff were told, "If there is a strap, buckle it." The purpose of the "belt clip" was to prevent a resident from falling in the event the resident's arms fell inside the "Support Vest".

Based on observation, interviews and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible and failed to ensure adequate supervision was provided to prevent accidents for two residents (#7 and #15) in the selected sample of 30. The facility failed to ensure staff was trained appropriately regarding therapy recommendation and manufacturer's guidelines for the safe use of the sit-to-stand lift (assistive device). The facility failed to provide oversight to ensure that staff was using the assistive device appropriately with residents. This failure resulted in Resident #7 sustaining a fractured left Femur (thigh bone), during an assisted transfer using the sit-to-stand lift, on 06/12/10. Additionally, the facility failed to ensure the "Incident Management" policy and procedure was followed as the facility's investigation was ineffective in identifying the causal factor of the incident and ;therefore, failed to implement effective interventions to prevent a recurrence. The facility failed to ensure Resident #15 was assessed for the safe use of a lift chair prior to the resident using the assistive device. On 11/22/10, Resident #15 fell from the lift chair after using the remote controls independently. The facility failed to ensure interventions were implemented to prevent the resident from having access to the remote controls of the lift chair. Findings include: A review of the facility's policy and procedure, " Incident Management", dated 11/2008, revealed "Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence." Further review of the policy revealed procedures included timely investigations of incidents and assessment of causal factors and/or trends and implementation of reasonable and appropriate action plans, reducing the risk of recurrence. Falls, reportable incidents, incidents with injury, required additional investigation. Subsequent investigation included assessment of possible contributing clinical and environmental factors. A thorough investigation included determination and documentation of a conclusion, if possible, and development of a plan of action to reduce the risk of recurrence. 1. Observations, on 12/02/10 at 8:20 AM through 9:45 AM, revealed the facility utilized six (6) sit-to-stand lifts. Each lift was equipped with an accessory for upper torso support, referred to as a "SupportVest". Four of the six sit-to-stand lifts were equipped with an accessory referred to as a "calf strap", which was applied to the lower legs to secure the legs and feet during transfer. Two of the six lifts were not equipped with a "calf strap". A review of the manufacturer's "instruction guide", dated 07/07/09, revealed the need to attach and tighten the (calf) strap around the lower legs, just below the knees. Further review of the guide revealed a "Caution" statement, "Lifting and transferring a patient always involves a degree of risk....A complete understanding of the contents of instructions is essential". An interview with the Director of Education for the lift manufacturer, on 12/02/10 at 3:45 PM, revealed the company encouraged the facility to ensure the calf straps were used with residents who were weak in one leg to prevent the resident's calf from "drifting off the foot plate". Record review revealed the facility admitted Resident #7 on 08/03/07 with [DIAGNOSES REDACTED]. A review of the Comprehensive Care Plan, with an onset date of 06/30/09 and last updated on 03/14/10, revealed the problem, "Potential for falls related to [DIAGNOSES REDACTED]. A review of the "Communication to Nursing/Restorative Staff" from Occupational Therapy, dated 04/10/10, revealed recommendations for the assistance of two staff with the use of the sit-to-stand lift for transfers. Detailed instructions referred to the need for one staff member to be positioned in front of the resident and one person to be positioned behind the resident, to assist with sitting balance. The recommendation further stated if the resident was unable to be assisted to a full sitting position, the sit-to-stand lift should not be used. A Precaution statement included the reminder for all straps on the sit-to-stand lift to be fastened for all transfers. Nurses notes, dated 06/12/10 at 4:50 AM, revealed Resident #7 sustained a fall resulting in an injury (fracture to the left Femur), during an assisted transfer to the bed from a shower chair, using the sit-to-stand lift. After the fall, the resident was transported to the hospital at 3:15 PM and returned to the facility, on 06/15/10, with a [DIAGNOSES REDACTED]. An interview with Resident #7's primary physician, on 12/01/10 at 10:15 AM, revealed "The fracture was caused by twisting of the bone". Additionally, the physician stated the Xray report revealed the resident had Osteopenia and a calcium supplement was ordered the day of the interview. An interview with Resident #7's spouse, on 11/30/10 at 11:15 AM, revealed Resident #7 sustained a fracture to the left Femur, during a transfer with the sit-to-stand lift. The spouse stated he/she had difficulty with the explanation presented by the facility as the resident fell after slipping from the lift. The spouse stated that if the sit-to-stand was used properly, the resident would not be able to slip away from the lift. The spouse described Resident #7 as having little to no mobility on the left side of his/her body, due to a brain injury. A review of the facility's investigative report, dated 06/12/10 at 4:50 PM, revealed the resident was transferred using a sit-to-stand lift. The resident's feet slid "forward" and the resident was lowered to the floor and assisted to the bed. The resident was assessed for pain and vital signs with no problems identified. Charge Nurse (CN) #1 documented the names of the staff involved, which included Certified Nurse Aide (CNA) #13 and CNA #36. The report stated the resident was being transferred from the bed. The investigative report included interviews with two staff members, CNA #13 and CNA #36. A review of the investigative statement made by CNA #13, on 06/14/10, revealed she was in the process of transferring Resident #7 from a shower chair to the bed, using the sit-to-stand lift. CNA #13 described Resident #7 as non-weight bearing and it was necessary for the resident to support his/her weight, using the arms. The resident's legs slide out from under him/her and the resident was lowered to the floor and assisted to bed. CNA #36 lowered the lift, while she and CN #1 supported and assisted the resident to the floor. CNA #36 then summoned assistance for the resident's transfer back to bed. A review of the investigative statement made by CNA #36 and documented by Unit Manager #1, on 06/15/10, revealed CNA #36 stated on entrance to the resident's room, she observed Resident #7's left leg "bent at the knee and hanging out". She observed CNA #13 attempt to reposition the resident's leg "back in" and the resident's right leg "came out and the resident's knees started to bend" and "The resident was hanging by the arms". CN #1 and CNA#13 held the resident under the arms and lowered the resident to the floor. The resident was positioned on his/her knees and a blanket was placed on the floor and the resident was placed on the blanket on his/her stomach. Afterwards, the resident was assisted to bed by seven people. Review of the investigative report revealed a statement was documented above the signature of CNA #36, which stated, "This associate states that the 'calf straps' were not in place when she entered the room". An additional statement, which was partially mingled with the signature of CNA #36 revealed, "It had already been removed by staff". A review of the investigative statement made by CN #1, on 06/14/10, revealed during the transfer of the resident, using the sit-to-stand lift, the resident's feet began sliding and the resident was hanging by his/her arms. CNA #36 lowered the resident's bed to the lowest position, while CN #1 and CNA #13 supported the resident and CNA #36 lowered the lift. "The resident did not fall" and he/she was "lowered to the ground to his/her knees on seated position". An interview with CNA #6, on 12/01/10 at 2:55 PM, revealed she was summoned to Resident #7's room by CNA #13, on 06/12/10 at 4:50 AM. On entrance to the room, she observed CNA #13 as the only staff member present. Resident #7 was suspended from the lift with the left foot off the foot rest. As she attempted to replace the resident's left foot back on the footrest, the resident's right foot slipped off the footrest. CNA #6 stated she observed the resident's legs were not secured to the shin support by a calf strap. CNA #6 stated the calf strap was not usually removed, until the resident was sitting down securely. While the investigation did not include a conclusion and identification of the potential underlying cause(s) related to the fall and the use of the lift, interview with CNA #6 and review of the investigative statements identified that staff did not follow the recommendations of therapy for the number of staff required to assist with the transfer using the lift nor did they follow the manufacturer's guideline to use the calf strap. Additionally, there was no evidence the facility identified an issue with the capability of the staff in using assistive devices appropriately or that the facility evaluated and/or retrained based on such identification. Furthermore, there was no revision to care directed at prevention of a recurrence, based on the investigative findings. Interviews conducted with five CNAs (CNA #21, CNA #22, CNA #15, CNA #16 and CNA #39), on 12/02/10 at 9:10 AM through 5:00 PM, revealed the staff had not received in-service/training regarding the appropriate and safe use of the lifts, to include the need to ensure the accessories were applied correctly and consistently and in accordance with the manufacturer's guidelines and the individual care plan. An interview with the Staff Development Coordinator (SDC), on 12/01/10 at 3:35 PM, revealed the facility had not provided staff in-service/training regarding the safe and proper use of the sit-to-stand lift. The only instruction provided was on the job per a "preceptor" assigned to new hires. Further interview with the SDC, on 12/02/10 at 10:25 AM, revealed competency of new staff was not verified and documented on hire, although the facility had developed a form to use for the purpose, and no training was provided after the resident sustained [REDACTED]. An interview with the Administrator and the DON, on 12/03/10 at 2:40 PM, revealed the capability of preceptors assigned to train staff regarding the use of mechanical lifts was verified by "spot checks" only. The interview revealed the facility had no established system to ensure staff providing care consistently followed the resident's care plan and manufacturer's guideline, related to the safe use of the sit-to-stand lift. 2. A record review revealed the facility admitted Resident #15 on 09/09/10 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #15 as having modified independent with cognition and required extensive assistance with activities of daily living. A review of the "Fall Risk Evaluation", dated 11/22/10, revealed the facility assessed and determined Resident #15 was a high risk for falls. A review of an Incident Follow-Up and Recommendation Form, dated 11/22/10, revealed Resident #15 used the remote to the resident's lift chair and subsequently slid out with no injuries documented. There was no evidence in the record that the facility had assessed Resident #15 and determined the resident was safe in the use of the lift chair, prior to or after the 11/22/10 incident. A review of the Comprehensive Care Plan, dated 11/22/10, for the problem, "At Risk for Falls related to history of falls" revealed interventions included placing the lift chair remote out of reach at all times. A review of the Certified Nursing Care Plan, dated 11/30/10, revealed interventions to include placing the remote control out of the resident's reach. Observations, on 11/30/10 at 4:35 PM and 5:40 PM, and on 12/01/10 at 8:35 AM, revealed the remote control to the resident's lift chair was within Resident #15's reach. An interview with CNA #43, on 12/01/10 at 10:40 AM, revealed while Resident #15 was physically able to use the lift chair remote independently, his/her cognitive status varied throughout the day. An interview with CNA #44, on 12/1/10 at 10:43 AM, revealed Resident #15 was physically able to use lift chair remote independently, his/her cognitive status was fifty/fifty (varied). Furthermore, the CNA had found Resident #15 using the lift chair remote control at least five times in the last month and on the day of this interview. An interview with LPN #1, on 12/01/10 at 10:52 AM, revealed she was unsure whether Resident #15 could safely use the lift chair independently. However, on 11/31/10 she found Resident #15 using the lift chair remote and had to lower the resident's chair to the upright position. She then placed the remote control beside the resident. An interview with Registered Nurse Unit Manager #1, on 12/01/10 at 10:20 AM, and on 12/03/10 at 2:40 PM, revealed she did not assess the resident's safety to use the lift chair when family brought the chair to the resident's room. She felt Resident #15 was not safe to use the lift chair due to cognitive impairment. She stated Resident #15 "fiddled" with the lift chair remote if it was within reach. She never received reports from staff observing the resident using the lift chair remote to lift the chair independently, prior to incident. While the facility developed an intervention to prevent Resident #15 from having access to the remote control of the lift chair, staff did not ensure the remote control was inaccessible to the resident and there was no evidence the facility had assessed Resident #15 for the safe use of such an assistive device. Furthermore, an interview with the Administrator on 12/01/10 at 2:35 PM, revealed the facility did not have written policies and procedures to address assessments of residents for the use of the assistive devices.