Every finding on record at Pavilion at Brandon Wilde

Based on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed prior to date of hire for one of seven new hire employees and reference checks were completed for seven of seven new hire employees. The deficient practice could result in a staff with an unknown criminal background having access to residents. 1.Review of employee records for the Administrator revealed he was hired on 12/01/25. The required GCHEXS fingerprint background check was completed on 12/02/25.During an interview on 04/17/26 at 3:42 PM, the Human Resources Director (HRD) stated GCHEXS background checks are completed for all employees except nurses and are required to be completed prior to the start date. The HRD stated the Administrator is not a facility employee but is a corporate employee based out of Iowa. 2.Review of employee records for the Administrator, Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) 1, LPN 3, Registered Nurse (RN) 1, Certified Nurse Aide (CNA) 1, and CNA3, revealed reference checks were not completed.During an interview on 04/17/26 at 3:42 PM, the HRD stated the facility did not complete reference checks and only performed employment verification checks through the company that performed the background checks. The HRD further stated that the corporate office had directed the facility to resume completing reference checks.Review of the facility's policy titled, Resident Abuse Prevention Program provided by the facility, dated 12/15/04, indicated The community will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Criminal History of Nurse Aides and Other Unlicensed Employees, or with a finding of abuse listed on the Nurse Aide Registry or criminal history background check. Prior to a new employee starting a work schedule, this community will: Initiate a reference check from previous employer(s), in accordance with community policy; obtain a copy of the state license of any individual being hired for a positionrequiring a professional license; if applicant is a nursing assistant, obtain a copy of the person's state nurse aide registry report from the state department; obtain a limited criminal history for nurse aides and other unlicensed employees.Review of the facility's policy titled, Hiring Process, provided by the facility, revised 11/14, indicated Once a hiring official has selected an applicant and notified Human Resource staffto begin hiring process, the job offer will only be extended after clearance from Human Resources based on several factors to include, but not limited to: acceptable references, review of criminal history; licensure/certification verification, and fingerprint records check as required for position. Final clearance to begin employment and start date will be determined after receiving negative drug screen results, completion of step one of TB test, and general medical evaluation from Occupational Health is received. Human Resources will notify the hiring official when all required documentation is complete.

Based on interviews, record review, and policy review, the facility failed to ensure grievances were promptly resolved for five residents (Resident (R) 9) R23, R35, R50, and R61 of 22 sample residents. Specifically, the facility failed to date, summarize findings, and document corrective action taken as a result of the grievance. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. 1.Review of R23's ) revealed a quarterly Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/13/26 revealed R23's admission date was 08/26/25. R23 had a diagnosis that included kidney insufficiency. R23 had a Brief Interview for Mental Status (BIMS)score of 14 out of 15 which indicated no cognitive impairment. 2.Review of R61's EMR revealed a quarterly ''MDS'' assessment, located under the ''MDS'' tab, with an ARD of 03/23/26 revealed R61's admission date was 12/17/25. R61 had a BIMS score of 9 which indicated moderate cognitive impairment. Active diagnoses included cancer, heart failure, stroke, and depression. 3.Review of R50's EMR revealed a quarterly ''MDS'' assessment, located under the ''MDS'' tab, with an ARD of 03/04/26 revealed R50's admission date was 12/29/21. R50 had a BIMS score of 13 which indicated no cognitive impairment. Active diagnoses included coronary artery disease, high blood pressure, diabetes, anxiety disorder, depression, and asthma. 4.Review of R35's EMR revealed a quarterly ''MDS'' assessment, located under the ''MDS'' tab, with an ARD of 01/13/26 revealed R35's admission date was 04/18/24. R35 had a BIMS score of 10 which indicated moderate cognitive impairment. Active diagnoses included chronic kidney disease, heart disease, and stroke. Review of the Resident Council Concerns dated June 25, 2025, revealed a Summary of Resident Concern. There was no documentation of Departmental Signature, or the Date Concern Returned to Administrator. No response from the complainant was documented.Review of the facility Resident Grievance Log for April 2025 through April 14th, 2026, revealed no documentation of any grievances filed on behalf of R61 or R50. Review of the Grievance Concern Form, provided by the facility, revealed six grievances had been filed on behalf of R35 on 09/7/2025, 02/21/2026, 03/19/2026, 03/22/2026, 03/30/2026, and 04/5/2026. The Name of Person Notified of Resolution listed at the end of the form was listed as R35's family member. The form was marked satisfied with no documentation of what was discussed with the family member or what the family member's response was. During an interview on 04/16/26 at 3:45 PM, R61's family member stated she had expressed her concerns to the facility staff numerous times, but there had been no change in staffing. R61's POA stated R61 was dependent upon staff and there were times when R61 was not receiving the care he needed. The POA stated her grievances had not been addressed or resolved. Review of the Grievance Concern Form, provided by the facility, revealed six grievances had been filed on behalf of R35 on 09/7/2025, 02/21/2026, 03/19/2026, 03/22/2026, 03/30/2026, and 04/5/2026. The Name of Person Notified of Resolution listed at the end of the form was listed as R35's family member. The form was marked satisfied with no documentation of what was discussed with the family member or what the family member's response was. During an interview on 04/17/26 at 12:03 PM, R35's family member stated he had reported he had filed several grievances regarding R35's care. R35's POA stated he had frequently been told by the Administrator he would get back to him, but he never did. During an interview on 04/17/26 at 5:02 PM, the Social Services Director (SSD) stated the documentation should be more in-depth and should include specific concerns, and how they determined the reporting party was satisfied for R35. The SSD revealed verbal complaints should be filed and addressed. During an interview on 04/17/26 at 11:42 AM, the Administrator confirmed follow-up for resident council concerns had been inconsistent.Review of the facility's policy titled, Grievance Complaints & Missing Property with a revision date of 01/11/19, revealed, It is the policy of our facility to support and assist the residents, representatives, interested family members or resident advocate in their right to file a grievance without discrimination or reprisal and without fear of reprisal.

Based on record review, interview, and facility policy review, the facility failed to ensure the comprehensive assessment accurately reflected a discontinued antipsychotic medication for one (Resident (R) 22) of five residents reviewed for unnecessary medications in the sample of 22 residents. This failure had the potential to lead to a lack of alternative interventions. Review of R22's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R22 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia with behavioral disturbance.Review of R22's monthly Pharmacy Review provided by the facility revealed a pharmacy recommendation to discontinue quetiapine 25 milligrams (mg) one tablet by mouth daily starting on 03/05/26.Review of R22's Medication Administration Record located under the Orders tab of the EMR revealed Seroquel oral tablet 25 milligrams (mg) (quetiapine fumarate) give one tablet by mouth in the evening related to dementia with behavioral disturbance discontinued on 03/05/26 with the last dose being administered on 03/04/26.Review of R22's Care Plan located under the Care Plan tab of the EMR revealed R22 had her Seroquel antipsychotic medication discontinued starting 03/05/26.Review of R22's annual Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/12/26 indicated the resident received antipsychotics.During an interview on 04/17/26 at 3:22 PM, the MDS Coordinator confirmed the MDS has a seven day look back period and the antipsychotic medication should not have been coded on the MDS for R22 as the medication was discontinued 8 days prior.Review of the facility's policy titled, Comprehensive Assessments with a revision date of March 2022 indicated, Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.

Based on record review, interview, and review of facility's policy, the facility failed to convey information to hospital at the time of transfer, failed to notify resident and resident representative in writing of the reason for the transfer/discharge to the hospital, and failed to notify the resident/resident representative of the facility policy for bed hold including reserve bed payment. one of three residents (Resident (R) 7) reviewed for hospitalization out of 22 sampled residents. This failure creates the potential for residents and responsible parties to be misinformed of the transfer out of the facility and to not have the information needed to safeguard their return to the facility. Review of R7's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses that included diastolic (congestive) heart failure (CHF), atrial fibrillation, presence of cardiac pacemaker, and anxiety disorder. Review of R7's annual Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 02/17/26 indicated R7 was coded as having a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R7 was severely cognitively impaired.Review of R7's Progress Note, dated 02/09/26 and located under the Prog Notes tab of the EMR, revealed R7 was sent to the hospital for respiratory distress. Review of R7's entire medical record revealed no documented evidence that the facility conveyed information to hospital at the time of transfer, notified R7 or the resident representative in writing of the reason for the transfer/discharge to the hospital, and failed to notify the resident/resident representative of the facility policy for bed hold including reserve bed payment.During an interview on 04/17/26 at 7:16 PM, the Director of Nursing (DON) indicated that written notification of transfer to the hospital, written notification for the reason of transfer to R7 and/or their responsible party, and bed hold policy notification were not issued when R7 was emergently transferred to the hospital. Review of the facility's policy titled, Transfer or Discharge, dated March 2025, indicated When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: the basis for the transfer or discharge; that an appropriate notice was provided to the resident and/or legal representative; the date and time of the transfer or discharge; the new location of the resident; . a summary of the resident's overall medical, physical, and mental condition; . The policy did not specify information regarding bed hold policy notification.

Based on record review, interview, and facility policy review, the facility failed to ensure the Discharge Return Anticipated Minimum Data Set (MDS) was completed for one of three residents (Resident (R) 7) reviewed for hospitalization out of a total sample of 22 residents. This had the potential to lead to inaccurate goals of care, including functional and health status and strengths and needs of the resident. Findings include:Review of medical record 02/9/26 no evidence of documented transfer notification; einteract transfer or bed hold. 02/9/26 Discharge MDS marked out in error - not completed; 02/10/26 Entry MDS marked out in error - not completeAn interview on 04/17/2026 at 7:16 PM with the Director of Nursing (DON) revealed she was unable to locate transfer notice to hospital, transfer notification to resident/resident representative or bed hold notice. The DON stated a notice of transfer is required to be sent with the resident to the hospital, written notice to the resident representative, and bed hold notice is required to be sent. DON confirmed 2/9/26 Discharge Return Anticipated MDS should have been completed.

Based on record review, interview, and facility policy, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment prior to initiating psychotropic medication for one (Resident (R) 42) of five residents reviewed for unnecessary medications out of a total sample of 22 residents. This failure increased the risk of residents not knowing the potential side effects of the medications. 1. Review of R42's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R42 was admitted to the facility on [DATE] with diagnoses that included depression, dementia, and anxiety disorder. Review of R42's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/26, located under the MDS tab of the EMR, revealed R42 was unable to complete a Brief Interview for Mental Status (BIMS) and was assessed by staff as severely cognitively impaired. The MDS revealed R42 took antianxiety medications.Review of R42's Medication Administration Record (MAR) dated January 2026 and Physician Orders located under the Orders tab of the EMR, revealed R42 received lorazepam (Ativan, an anxiolytic medication) 0.5 milligrams (mg) every eight hours as needed for anxiety, which originated on 01/16/26.Review of R42's medical records revealed no documentation that she or the resident's representative had been provided information in advance of receiving the medication for the risks and benefits of the prescribed medications, the treatment alternatives, or other options, and consented to the medications.During an interview on 04/17/26 at 5:34 PM, the Director of Nursing (DON) stated Psychotropic medications need to have informed consent prior to administration including upon admission. Nursing staff are responsible for obtaining consent. The DON was unable to provide documentation of consent prior to administration of lorazepam on 01/16/26.Review of the facility's policy titled, Psychotropic Medication use, dated February 2025, indicated Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/resident representative prior to obtaining documented consent or refusal: non-pharmacological alternatives; the indications and rationale for the recommendation; the potential risks and benefits (including possible side effects, adverse consequences, and black boxwarnings); and the resident's/representative's right to accept or decline the treatment.

Based on observations, interviews, and record reviews, the facility failed to ensure personal resident refrigerators were maintained to prevent potential food borne illness for two residents of two sampled residents (Resident (R)33) and R50) who owned a refrigerator. This failure had the potential to cause the residents to eat spoiled food which could cause a decline in the residents' overall health. Findings include:1.Review of R33's quarterly ''Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab of the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/03/26 revealed R33 admission date was 12/29/21. R33 had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severe cognitive impairment. R33 had a diagnosis that included high blood pressure.During an observation and interview on 04/14/26 at 2:56 PM, R33 had a personal refrigerator near the door in her room. On the outside of the refrigerator door, a Refrigerator Temperature Log was attached to the door. There were no temperatures recorded on 04/11/26 or 04/12/26. The temperature on the thermometer in the refrigerator read 46 degrees Fahrenheit (F). Inside the refrigerator a melamine cup was observed with peaches. On top of the peaches was thick yellow, white, and black fuzzy material that appeared to be mold. The cup had a lid on it that did not have a date marked. The Maintenance Director (MD) stated that resident's personal refrigerator temperatures should be checked and recorded every day. The MD confirmed the peaches in R33's refrigerator had mold on them.2.Review of R50's quarterly ''MDS'' assessment, located under the ''MDS'' tab of the EMR, with an ARD of 03/04/26 revealed R50's admission date was 12/29/21. R50 had a BIMS score of 13 out of 15 which indicated no cognitive impairment. Active diagnoses included coronary artery disease, high blood pressure, diabetes, anxiety disorder, depression, and asthma. During an observation on 04/14/26 at 3:13 PM, of R50's personal refrigerator located near the door revealed temperatures were not recorded on the Refrigerator Temperature Log on the days of 04/03/26, 04/05/26, 04/11/26, and 04/12/26. During an interview on 04/14/2026 at 3:16 PM, Licensed Practical Nurse (LPN) 2 stated the peaches that were in R33's refrigerator had a thick yellow, white, and black fuzzy material that appeared to be mold. During an interview on 4/14/2026 at 3:17 PM, Registered Nurse (RN) 2 confirmed the peaches in R33's refrigerator had peaches with thick yellow, white, and black fuzzy material that appeared to be mold and needed to be discarded.During an interview on 04/14/26 at 3:41 PM, the Administrator stated the residents' personal refrigerators were to be checked daily during rounds, by assigned staff. He stated their checks should include the temperature of the refrigerator and checking for outdated or spoiled food. The Administrator revealed the expectation was that resident refrigerators should be checked daily by the unit supervisor and temperatures were to be recorded and outdated/spoiled food should be discarded. Review of the facility's policy titled, Use of Personal Refrigerators, with an effective date of 03/19/26, revealed Personal refrigerators must maintain temperatures at or below 41 degrees F .Temperature monitoring must be performed daily. Logs must include date, time, recorded temperature, staff initials, and corrective actions if applicable. Expired, spoiled, or improperly stored items would be removed by staff .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for oxygen was obtained prior to administering oxygen; ensure appropriate oxygen signage was posted on the resident's door; and ensure respiratory supplies were dated and stored in a sanitary manner in accordance with professional standards for one of one residents (Resident (R) 68) reviewed for respiratory care out of a sample of 22 residents. This failure had the potential to compromise infection control and increase the risk of infection transmission within the facility. Cross Reference F658Findings include:Review of R68's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R68 was admitted on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit.Review of R68's Care Plan located under the Care Plan tab of the EMR dated 04/07/26 revealed the resident was not care planned for oxygen.Review of Progress Notes located under the Progress Notes tab of the EMR revealed on 04/07/26 at 3:19 PM; 04/07/26 at 3:34 PM; 4/15/26 at 4:00 PM that R68 was administered oxygen.Review of R68's Order Summary Report located under the Orders tab of the EMR dated 04/14/26 revealed there is no physician's order for oxygen.During an observation on 04/14/26 at 10:51 AM, R68 was in her room with oxygen concentrator present and running at five liters per minute (LPM) through nasal cannula. Humidification present with no date. No storage bag present and oxygen tubing is not dated.During an interview on 04/14/26 at 2:13 PM, R68 said she is on oxygen because without it her oxygen level bottoms out.During an observation on 04/14/26 at 2:21 PM, R68 was in her room with oxygen concentrator present and running at five LPM through nasal cannula. Humidification present with no date. No storage bag present and oxygen tubing is not dated.During an observation on 04/15/26 at 12:58 PM, R68 was in her room with oxygen concentrator present in room running at seven LPM through nasal cannula. Humidification present with no date. No storage bag present and oxygen tubing is not dated. No oxygen sign was present outside door.During an observation on 04/16/26 at 9:07 AM, R68 was in her room with oxygen concentrator present in room running at seven LPM through nasal cannula. Humidification present with no date. No storage bag present and oxygen tubing is not dated. No oxygen sign was present outside door.During an interview on 04/16/26 at 9:10 AM, Registered Nurse (RN)2 at R68's bedside revealed the resident was currently receiving eight liters of oxygen through nasal cannula per the physician order, humidification and tubing were not dated and should be for infection control purposes, there should be a storage bag present for infection control purposes when the resident has her oxygen removed. RN2 confirmed there is no oxygen sign outside R68's door and that it is to be present to let people know there is no smoking. RN2 confirmed, after looking in the EMR at the physician's orders for R68, that there was no physician's order for oxygen.During an interview on 04/16/26 at 9:18 AM, the Director of Nursing (DON) while at R68's bedside confirmed the resident was currently receiving seven liters of oxygen through nasal cannula, humidification and tubing were not dated and should be for infection control purposes, there should be a storage bag present for infection control purposes when the resident has her oxygen removed. The DON confirmed there is no oxygen sign outside R68's door and that it is to be present to let people know the resident is on oxygen. DON confirmed, after looking in the EMR at the physician orders for R68, that there was no physician's order for oxygen.Review of R68's Medication Administration Record (MAR) revealed the resident did not have an order for oxygen until 04/16/26.During an interview on 04/17/26 at 2:03 PM, RN3 revealed the admission process is dependent on where a resident is admitted from. RN3 also revealed when a resident admits with hospice they does an assessment, gives orders, and the facility puts the orders in electronic health record. RN3 revealed she would look at the physician's order when starting oxygen on a resident. RN3 also revealed the hospice nurse told her how many liters to put the resident on as hospice provided the oxygen concentrator with higher liters. RN3 revealed she did not look at the physician orders that she was told verbally by hospice how many liters to place R68 on. RN3 revealed she would look at the MAR to know how many liters R68 was to remain on or if there were any changes in oxygen administration. During an interview on 04/17/26 at 2:22 PM, ADON r confirmed there was no order for oxygen in the hospital discharge paperwork. ADON revealed the hospice nurse was in the facility when R68 arrived. ADON confirmed that either the nurse, DON or herself put in hospice orders once they are faxed to the facility. ADON revealed the way they know if a resident is to be placed on oxygen is through the physician orders and that ultimately, they follow they orders placed in the EMR. ADON confirmed there was no order in the EMR until 04/16/26 due to it not being signed.Review of the facility's policy titled, Oxygen Administration with a revision date of October 2010 revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. 'Preparation:' 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 'Equipment and Supplies:' The following equipment and supplies will be necessary when performing this procedure. 4. No smoking/ oxygen is use signs. 'Steps in the Procedure'. 2. Place an Oxygen in Use sign on the outside of the room entrance door.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Administering Oral Medications, the facility failed to ensure medications were accurately labeled for one out of three Residents (R) (R55) observed during medication administration. Findings include: Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, revealed under Purpose, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Under Steps in the Procedure, . 6. Check the label on the medication and confirm the medication name and dose with the MAR [Medication Administration Record]. Review of the Admission Record revealed R55 had a medical history that included diagnoses of essential hypertension, atrial fibrillation, and heart disease. Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/6/2025, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of R55's Care Plan included a problem, initiated 2/4/2025, that indicated the resident had hypertension. Interventions directed staff to give antihypertensive medications as ordered and monitor for effectiveness and side effects such as orthostatic hypotension and increased heart rate (tachycardia). Review of R55's Order Summary Report with active orders as of 2/19/2025 indicated the resident had the following physician's orders: - amlodipine besylate-valsartan oral tablet 5-320 milligrams (mg), one tablet by mouth once daily for hypertension (ordered 12/31/2024 to start 1/1/2025). - Cardizem extended-release 24-hour coated beads 180 mg, one tablet by mouth once daily for atrial fibrillation (ordered 12/31/2024 to start 1/1/2025). During an observation of a medication administration pass on 2/18/2025 at 8:27 AM, Registered Nurse (RN) #7 checked Resident #55's blood pressure and pulse. The blood pressure result was 107/61 and the pulse was 48 beats per minute. RN #7 pulled R55's prepackaged medications from the cart, opened the packets of medication, and poured them all of them into a medication cup together. After entering the resident's room, RN #7 decided to hold the amlodipine besylate-valsartan 5-320 mg and the Cardizem extended-release 180 mg, due to the resident's blood pressure reading. Returning to the medication cart, she attempted to remove the amlodipine besylate-valsartan 5-320 mg tablet and the Cardizem extended-release 180 mg tablet from the medication cup and stated she needed to pull a strip of tomorrow's medications from the cart to see which pill the Cardizem was, because the descriptions from the pharmacy on the medication packets did not always match the medications that were in the packages. She stated sometimes the manufacturers changed the appearance of the medications, and the pharmacy did not update the medication packets to match what the medications looked like. She indicated this made it difficult for the nurses to know which medications they were giving without looking them up on their phones. RN #7 removed the two medications from the cup and destroyed them. During an interview on 2/19/2025 at 10:05 AM, the Director of Nursing (DON) stated the nurses had sealers so that a tablet could be sealed off in a corner of the packets and not come out of the packet with the rest of the medications. She stated being able to seal off a medication would require the description on the outside of the packet to be correct. The DON stated the pharmacist was currently at the facility and would look at R55's medications with the surveyor. During an interview on 2/19/2025 at 10:17 AM, the Pharmacist was observed reviewing R55's medication package for the morning medication pass. She stated the amlodipine besylate-valsartan had the wrong description on the outside of the packet. She stated the medication in the package was large and brown with an L-299 on it, and the description on the outside of the packet indicated it was white and oval with P-576 on the tablet. The pharmacist stated it was a pharmacy error and that she would need to take it to her supervisors to find out what had happened. She stated the error should have been caught in the pharmacy's quality assurance (QA) process and should not have made it to the facility. She indicated at times, the manufacturers changed the appearance of a medication, but there had to be a way to ensure the description of the medication was changed in the system as well. She stated when there were medication description errors, a resident could receive a medication they were not supposed to get, since the nurse could not verify the medication. Copies of the front and back of R55's medication packaging and the actual medications inside were provided for review. The medications were lined up inside the packaging according to a list on the front of the package to show the discrepancy between the medication description and the appearance of the medication inside. The packaging indicated the amlodipine besylate-valsartan description was OVL/WHT/P-576 [oval/white/P-576]. The medication inside was a dark, football-shaped medication with L-299 stamped on the tablet. During a subsequent interview on 2/19/2025 at 11:15 AM, the pharmacist stated she had talked to her supervisor about the problem with the identifier description not matching the pills inside of the packet. She stated she was given a sticker to put on R55's medication cycle going forward that identified the amlodipine besylate-valsartan's changed description. The pharmacist stated, We are going to have to look at the process going forward and have some things to change so that this does not happen again to anyone else and cause a significant medication error. During an interview on 2/20/2025 at 1:30 PM, the DON stated her expectation was for the nurses to follow the policy for passing medications. During an interview on 2/20/2025 at 1:45 PM, the Administrator stated her expectation was for the nurses to pass medication per policy and per regulation.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Medication Holds and Administering Oral Medications, the facility failed to ensure the medication error rate was less than 5% for two out of Residents (R) (R55 and R29) of three residents observed during medication administration. Observation of medication administration revealed 4 medication errors out of 31 opportunities, which resulted in a medication error rate of 12.9 %. Findings include: Review of the facility's policy titled, Medication Holds, revised 4/2007, revealed under Policy Statement, Temporary medication holds may be ordered by the resident's attending physician. Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, revealed under Purpose, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy revealed under Steps in the Procedure, . 9. Prepare the correct dose of medication: Remove the cap from the bottle and place cap upside down on the work surface. Hold the medication cup at eye level and use your thumb to mark the desired level on the cup. Fill to the bottom of the meniscus at the desired level. Place cup on a level surface and read the poured amount at eye level to check accuracy. 1. Review of the Admission Record revealed R55 had a medical history that included diagnoses of essential hypertension, atrial fibrillation, and heart disease. Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/6/2025, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of R55's Care Plan included a problem, initiated 2/4/2025, that indicated the resident had hypertension. Interventions directed staff to give antihypertensive medications as ordered and monitor for effectiveness and side effects such as orthostatic hypotension and increased heart rate (tachycardia). Review of R55's Order Summary Report with active orders as of 2/19/2025 indicated the resident had the following physician's orders: - amlodipine besylate-valsartan oral tablet 5-320 milligrams (mg), one tablet by mouth once daily for hypertension (ordered 12/31/2024 to start 1/1/2025). - Cardizem extended-release 24-hour coated beads 180 mg, one tablet by mouth once daily for atrial fibrillation (ordered 12/31/2024 to start 1/1/2025). Neither order included parameters for withholding the medication. During an observation of a medication administration pass on 2/18/2025 at 8:27 AM, Registered Nurse (RN) #7 checked R55's blood pressure and pulse. The blood pressure result was 107/61 and the pulse was 48 beats per minute. RN #7 pulled R55's prepackaged medications from the cart, opened the packets of medication, and poured them all of them into a medication cup together. After entering the resident's room, RN #7 decided to hold the amlodipine besylate-valsartan 5-320 mg and the Cardizem extended-release 180 mg, due to the resident's blood pressure reading. Returning to the medication cart, she removed the amlodipine besylate-valsartan and the Cardizem from the medication cup. She documented on the Medication Administration Record (MAR) that she was holding the medications, then destroyed the medications in a solution on the medication cart. RN #7 then returned to R55's room and administered the remaining medications to the resident with a glass of water. Further review of R55's medical record revealed the physician's orders for amlodipine besylate-valsartan 5-320 mg and Cardizem extended-release 180 mg did not include parameters for withholding the medications. Additionally, there was no documentation as of 2/19/2025 at 9:19 AM to indicate RN #7 contacted the physician to obtain an order to withhold the medications on 2/18/2025. This resulted in two medication errors. During an interview on 2/19/2025 at 9:44 AM, RN #7 stated, The ability to hold a medication is based on the type of medication it is and nursing judgement. She stated she did not notify the physician about holding a medication until there was a pattern of like three days. RN #7 stated she held the blood pressure medications for R55's because she knew the resident and how their blood pressure changed. She stated the facility did not have standing orders for parameters on when to hold medications or when to notify the physician. During an interview on 2/20/2025 at 1:30 PM, the Director of Nursing (DON) stated her expectation was for the nurses to follow the policy for passing medications and to follow through with physician notification if they were going to hold a medication. During an interview on 2/20/2025 at 9:10 AM, the Medical Director (MD) stated he would expect a nurse to hold a blood pressure medication and notify him each time it was necessary and, if there was a pattern, he would look at altering the medication regimen. 2. Review of the Admission Record revealed the facility admitted R29 on 1/10/2020. According to the Admission Record, the resident had a medical history that included diagnoses of anxiety and cognitive communication deficit. Review of the Significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/4/2024, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident required a wheelchair for locomotion and total assistance with all activities of daily living (ADLs). Review of R29's Care Plan included a problem, initiated 12/20/2021, that indicated the resident had Crohn's disease with an alteration in gastrointestinal status. Interventions directed staff to give medications as ordered. Review of R29's Order Summary Report with active orders as of 2/19/2025 revealed the following physician's orders: - cholecalciferol tablet 1000 units, one tablet by mouth once daily for supplement (ordered 01/27/2025). - polyethylene glycol 3350 kit, 17 grams by mouth once daily related to constipation (ordered 6/1/2021). During an observation of medication administration on 2/18/2025 at 8:54 AM, RN #7 prepared R29's medications. She poured the polyethylene glycol powder into the cap of the bottle and did not measure it on a flat surface before pouring it into a cup of water and stirring it up. As RN #7 finished preparing the medications, the resident's significant other walked by, and the nurse reminded them to bring in more calcium 1000-unit tablets because they were out. She stated there was none to give for this medication pass. The nurse counted five tablets and one gel cap in the medication cup prior to administration, for a total of six medications. According to R29's MAR, there should have been six tablets and one gel cap in the medication cup. The ordered cholecalciferol tablet (calcium 1000-unit tablet) was omitted. During an interview on 2/19/2025 at 10:05 AM, the DON stated medications that were poured and needed to be measured should be prepared on a flat surface and at eye level to make sure the level of medication poured was accurate. During a subsequent interview on 2/20/2025 at 1:30 PM, the DON stated she expected the nurses to follow the policy for passing medications and for the medication error rate to be below the percentage necessary to keep from getting a citation. During an interview on 2/20/2025 at 1:45 PM, the Administrator stated her expectation was for the nurses to pass medications per policy and regulation.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Dignity, the facility failed to treat residents with dignity for one out of three Residents (R) (R8) observed during dining and for one out of three Residents (R) (262) observed during medication administration. Specifically, the facility failed to ensure R8 received a meal tray at mealtime due to a lack of sufficient dining table space causing R8 to observe other residents eating their meals while waiting for a space to become available and assistance. In addition, the facility failed to ensure R262's blood glucose testing procedure was completed in a private area to protect the resident's dignity. Findings include: Review of the facility's policy titled, Dignity, revised 2/2021, under the Policy Statement revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-bring, level of satisfaction with life, and feelings of self-worth and self-esteem. Under the section titled Policy Interpretation and Implementation revealed, 1. Residents are treated with dignity and respect at all times, and 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: 5e. provided with a dignified dining experience 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1.Reveiw of the Admission Record revealed R8 admitted with diagnoses that included but not limited to diagnoses of mild cognitive impairment, memory deficit following other cerebrovascular disease, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2024, Section C (Cognitive Patterns) revealed, R8 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment of mental status (SAMS); Section G (Functional Status) revealed, R8 was dependent on staff for eating and required the use of a wheelchair propelled by staff for locomotion. Review of R8's Care Plan included a problem, initiated 1/17/2022, that indicated the resident was malnourished due to having a low body mass index (BMI) for their advanced age, cognitive impairment, limited mobility, and was on hospice care. An intervention directed staff to assist the resident with meals as needed (initiated 1/17/2022). Review of the Dietary Progress Note dated 12/6/2024 at 9:22 am revealed R8 had good food intake, consuming approximately 90 percent of most meals, and was fed by staff. Review of R8's Order Summary Report with active orders as of 2/18/2025 revealed a physician's order dated 2/18/2022 for a regular soft diet with bite-sized, Level 6 dysphagia/chopped texture and regular consistency liquids. Review of R8's Kardex, with care instructions as of 2/18/2025, directed staff to assist the resident with meals as needed. During a dining observation on 2/17/2025 at 11:48 am, R8 was noted sitting off to the side of the secure unit dining room during mealtime, observing other residents eating their lunch. Four staff members could be seen on the unit assisting residents to eat. While observing other residents eating their meals over the next 31 minutes, R8 was attempting to get staff's attention by clapping and verbalizing. At 12:19 pm, the Staffing Coordinator arrived in the dining room, pulled a bedside table next to R8's wheelchair, and began to feed the resident. During an interview on 2/19/2025 at 2:12 pm, the Staffing Coordinator stated he was a Certified Nurse Aide (CNA) and only went back to feed on the secure unit when he was needed. He stated he did not go back there every day and had been asked to go and assist the staff to feed residents on Monday (2/24/2025). During an interview on 2/19/2025 at 2:29 pm, Licensed Practical Nurse (LPN) #4 stated she had worked at the facility for three years, and there were fourteen residents currently residing on the secure unit, including six feeders. She indicated that, depending on how much help was available, with one staff person for each resident, there were three or four residents who had to wait to be moved to the dining table once staff was finished assisting someone else. She stated the residents sat over to the side of the dining room until they could be moved to the table. She also indicated staff were not allowed to assist more than one resident at a time with eating, so for those residents who had to wait, there was a hot box where their food was kept warm, and their beverages were kept cold in the refrigerator until staff were available to feed them. LPN #4 also stated this process happened every day, for every meal, as there was not enough staff or room to provide one-to-one feeding for all six feeders. During an interview on 2/19/2025 at 2:15 pm, CNA #5 stated when staff were in the dining room assisting residents, they were only allowed to feed one resident at a time. She indicated if she saw that there was a resident sitting off to the side without a meal, she would excuse herself briefly from the table and inquire where the other resident's meal was and would get them their food, even if the resident who was waiting needed to be assisted as well. She stated she would put their food in front of the resident and give them some verbal cues to get them started until she could get someone to assist them or finish what she was doing so that she could help them herself. During an interview on 2/19/2025 at 2:55 pm, CNA #6 stated staff in the dining room were only allowed to feed one resident at a time due to the choking hazard. She stated staff needed to be paying attention to the resident they were helping. She indicated if she saw that a resident was without food and not sitting at a table, she would find the nurse and ask why the resident was not eating and would try to find someone to assist the resident until she was available to help them herself. She stated, No one should sit there and watch everyone else eat. During an interview on 2/20/2025 at 1:39 pm, the Director of Nursing (DON) stated she expected residents to be treated with dignity at all times, including during the dining process. She stated the facility would address the reason residents were sitting to the side and watching others eat and, That is not a right process, and we will make it right. During an interview on 2/20/2025 at 1:46 pm, the Administrator stated her expectation was that everyone would have a specific time to eat, and no one would be secluded and have to sit and watch others eat. She stated she expected residents to be treated with dignity during the dining process and at all times. 2. Review of the Admission Record revealed R262 admitted with diagnosis that included but not limited to diabetes mellitus without complications. Review of the Admission Minimum Data Set (MDS) was not yet completed and available for review at the time of the survey. Review of R262's Care Plan included a problem, initiated 2/17/2025, that indicated the resident had a diagnosis of diabetes mellitus. Interventions directed staff to check blood glucose levels per physician's orders (initiated 2/18/2025). Review of R262's Order Summary Report with active orders as of 2/19/2025 revealed a physician's order dated 1/31/2025 to check the resident's blood glucose two times a day. During an observation of the medication administration pass on 2/18/2025 at 9:08 am, Registered Nurse (RN) #7 placed R262's morning medications into a medication cup and gathered blood glucose testing supplies and a glass of water for the resident. R262 was ambulating in the hallway with a therapist to the therapy gym. RN #7 followed the resident and therapist into the therapy gym and, after R262 was seated on a stationary bike, RN #7 handed the resident the medication cup and glass of water. As the resident was swallowing the medications, RN #7 grabbed a bedside table in the therapy gym and placed the blood glucose testing supplies on the table. Once R262 finished taking the oral medications, the nurse performed a fingerstick blood glucose test, obtaining a blood sample from the resident's finger, then told the resident the result was 191 in the presence of other residents and staff in the therapy gym. During an interview on 2/19/2025 at 2:29 pm, LPN #4 stated the place to obtain a blood sugar was in the resident's room, privately. She stated if the blood sugar testing occurred in the dining room or therapy gym, this would be a privacy issue and a violation of a basic resident right. During an interview on 2/19/2025 at 2:59 pm, RN #8 stated the appropriate place to obtain a blood sugar was in the privacy of the resident's room. She stated the only time it would be appropriate to obtain a blood sugar in a public place like the dining room or the therapy gym was in the case of an emergency. During an interview on 2/19/2025 at 3:10 pm, LPN #9 stated the appropriate place to obtain a blood sugar was in the resident's room. During an interview on 2/19/2025 at 10:05 am, the Director of Nursing (DON) stated the appropriate place to check a resident's blood glucose was in the resident's room, not in a public area like the therapy gym. During a follow-up interview on 2/20/2025 at 1:30 pm, the DON stated her expectation was for the nurses to follow facility policies for passing medications and for dignity issues related to appropriate places to do blood sugar checks. During an interview on 2/20/2025 at 9:10 am, the Administrator stated her expectation was that the nurses pass medications per policy and ensure the dignity of the facility's residents in the process.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control Program, the facility failed to ensure infection control practices to prevent the potential spread of infection were maintained during medication administration for residents receiving medications from one of four medication carts observed. The failed practice affected one out of three Residents (R) (R55) observed during medication pass and one out of one (R262) observed receiving a blood glucose check. Specifically, the nurse attempted to remove medications from a medication cup with an ungloved fingernail for R55, placed a glucometer on a bedside table without disinfecting the table or placing a barrier for R262, failed to promptly replace an overflowing sharps container on the medication cart, and had an open personal beverage sitting on top of the cart uncovered throughout the medication pass. These failures had the potential of exposing residents to infections. Findings include: A facility policy titled, Infection Prevention and Control Program, revised 12/2023, indicated under Policy Statement, An infection prevention and control program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Section 7. indicated, Important facets of infection prevention include: .3. educating staff and ensuring that they adhere to proper techniques and procedures. 1. During an observation of medication administration on 2/18/2025 at 8:20 AM, Registered Nurse (RN) #7 was preparing to pass medications. She had an open can of flavored seltzer water sitting on top of the cart uncovered in an ice bath for the duration of the medication pass. The sharps container attached to the right side of the cart was filled past the designated full line, with lancets and needles visible above the protective flap. During an observation of medication administration on 2/18/2025 at 9:08 AM, RN #7 performed a blood glucose test on R262, then returned to the medication cart and disposed of the lancet in the sharps container, stating her sharps container was way too full and should have been changed out. During an observation of the medication cart on 2/19/2025 at 9:52 AM, the sharps container remained overfilled and had not been changed out, even after being acknowledged by RN #7 at 9:08 AM. During an interview on 2/19/2025 at 10:05 AM, the Director of Nursing (DON) was informed of the surveyor's observations of the sharps container on the medication cart being overfilled. During an observation of the medication cart on 2/19/2025 at 3:07 PM, the sharps container remained overfilled. During an observation of the medication cart on 2/20/2025 at 3:00 PM, the sharps container remained overfilled. During an interview on 2/20/2025 at 1:30 PM, the DON stated her expectation was for the nurses to follow the policy for passing medications, including infection control practices. During an interview on 2/20/2025 at 1:45 PM, the Administrator stated her expectation was that the nurses pass medications per policy and per regulation while following infection control practices. During an interview on 2/20/2025 at 9:10 AM, the Medical Director (MD) stated he was made aware of multiple infection control issues during the medication pass that were not acceptable, and the facility would have to in-service the nurses on those items. 2. Review of R55's Order Summary Report with active orders as of 2/19/2025 indicated the resident had the following physician's orders: - amlodipine besylate-valsartan oral tablet 5-320 milligrams (mg), one tablet by mouth once daily for hypertension (ordered 12/31/2024 to start 1/1/2025). - Cardizem extended-release 24-hour coated beads 180 mg, one tablet by mouth once daily for atrial fibrillation (ordered 12/31/2024 to start 1/1/2025). During an observation of medication administration on 2/18/2025 at 8:27 AM, RN #7 decided to withhold two of R55's medications (amlodipine-besylate valsartan and Cardizem) after placing them in a medication cup with the resident's other scheduled medications. At the resident's bedside, without gloves on, RN #7 began using her fingernail to dig around in the medication cup to retrieve the two medications. She was able to recognize one of the medications and had to return to the cart to read the description of each medication on the packaging to identify the second medication to be removed. RN #7 removed the second blood pressure medication with her bare hand as well, destroyed the two medications, and then administered the remaining medications to R55. During an interview on 2/19/2025 at 2:29 PM, Licensed Practical Nurse (LPN) #4 stated if she needed to remove a medication from a medication cup with more than one medication in it, she would put on a pair of gloves, remove the medication, and destroy it. During an interview on 2/19/2025 at 2:59 PM, RN #8 stated if she needed to remove a pill from a medication cup with multiple pills in it, she would put on a pair of gloves, identify the pill, and remove it from the cup with a gloved finger, or she would use a medicine spoon to retrieve it and then destroy the medication. During an interview on 2/19/2025 at 3:10 PM, LPN #9 stated if she needed to remove a pill from a medication cup with multiple pills in it, she would use a medicine spoon to retrieve it and then destroy the medication. 3. Review of R262's Order Summary Report, dated 2/19/2025, revealed an order to check the resident's blood glucose twice daily. During an observation of medication administration on 2/18/2025 at 9:08 AM, RN #7 prepared R262's morning medications and gathered the blood glucose testing supplies and a glass of water. R262 was ambulating in the hallway with a therapist to the therapy gym. RN #7 followed the resident and therapist into the therapy gym. After R262 was seated on a stationary bike, RN #7 grabbed a bedside table in the therapy gym and, without disinfecting it or placing a barrier on the table, placed the glucometer directly on the tabletop, then proceeded with the blood glucose test. The nurse disinfected the glucometer upon returning to the cart.

Based on observation, staff interviews, record review, and review of the facility's policy titled Administering Oral Medications, the facility failed to ensure care and services were provided in accordance with accepted professional standards for one out of three Residents (R) (R55) observed during medication administration. Specifically, Registered Nurse (RN) (RN#7) withheld R55's physician-ordered medications without consulting with the physician for an order to do so. Findings include: Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, under the section titled Purpose revealed, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy did not address withholding ordered medications. Review of the facility's policy titled, Medication Holds revised 4/2007, under the Policy Statement revealed, Temporary medication holds may be ordered by the resident's attending physician. Review of the Admission Record revealed, R55 admitted to the facility with diagnoses that included but not limited to essential (primary) hypertension, unspecified atrial fibrillation, and unspecified heart disease. Review of R55's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/6/2025, revealed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of R55's Care Plan included a problem, initiated 2/4/2025, that indicated the resident had hypertension. Interventions directed staff to give antihypertensive medications as ordered and monitor for effectiveness and side effects such as orthostatic hypotension and increased heart rate (tachycardia). Review of R55's Order Summary Report with active orders as of 2/19/2025 indicated the resident had the following physician's orders: - amlodipine besylate-valsartan oral tablet 5-320 milligrams (mg), one tablet by mouth once daily for hypertension (ordered 12/31/2024 to start 1/1/2025). - Cardizem extended-release 24-hour coated beads 180 mg, one tablet by mouth once daily for atrial fibrillation (ordered 12/31/2024 to start 1/1/2025). Neither order included parameters for withholding the medication. During an observation of a medication administration pass on 2/18/2025 at 8:27 am, Registered Nurse (RN) #7 checked Resident #55's blood pressure and pulse. The blood pressure result was 107/61 and the pulse was 48 beats per minute. RN #7 decided to hold the amlodipine besylate-valsartan 5-320 mg and the Cardizem extended-release 180 mg, due to the resident's blood pressure reading. She documented on the Medication Administration Record (MAR) that she was holding the medications and destroyed the medications in solution on the medication cart. RN #7 then returned to R55's room and administered the remaining medications to the resident with a glass of water. Review of R55's Medication Administration Record for February 2025 revealed RN #7 had documented her initials and, 04 for the Cardizem and amlodipine besylate-valsartan. The Chart Codes on the MAR revealed 04 indicated, vital sign outside of parameter. Review of R55's Progress Notes revealed that as of 2/19/2025 at 9:19 am, RN #7 had not documented notifying the resident's physician of the decision to withhold the resident's ordered medications or to obtain orders for parameters for withholding the medications. During an interview on 2/19/2025 at 9:44 am, RN #7 stated she did not notify the physician about withholding a medication until there was a pattern of like three days. She stated she withheld the medications for R55 because she knew the resident and how the resident's blood pressure changed, but she did not call the physician. During an interview on 2/19/2025 at 2:29 pm, Licensed Practical Nurse (LPN) #4 stated all orders for blood pressure medications should include parameters for withholding the medication. She indicated if there were no parameters, she would contact the physician before administering the medication to discuss whether or not to withhold it. During an interview on 2/19/2025 at 2:59 pm, RN #8 stated if there were no parameters for withholding a medication in the order, she would use her nursing judgement to hold the medication, would document it on the electronic MAR (eMAR), and would call the physician to notify them of the rationale for holding the medication and to ask for parameters to add to the order for the future. During an interview on 2/19/2025 at 3:10 pm, LPN #9 stated if there were no parameters in a blood pressure medication order, she would use nursing judgement to hold the medication, would document it on the eMAR, and then would call the physician to notify them and ask for parameters. During an interview on 2/19/2025 at 10:05 am, the Director of Nursing (DON) stated the nurses used nursing judgement for withholding blood pressure medications and would obtain parameters from the physician on as-needed (PRN) blood pressure medications. She stated the facility's policies did not specify what blood pressure parameters to use, but she would consider a systolic blood pressure less than 90 or a diastolic blood pressure less than 50 to be low. She stated, Every nurse could have a different idea of what is low, I guess. During a subsequent interview on 2/20/2025 at 1:30 pm, the DON stated her expectation was for the nurses to follow the policy for passing medications and to follow through with physician notification if they were going to hold a medication. During an interview on 2/20/2025 at 1:45 pm, the Administrator stated her expectation was for the nurses to pass medication per policy and per regulation. During an interview on 2/20/2025 at 9:10 am, the Medical Director (MD) stated his opinion on blood pressure parameters was that it should be determined on an individual basis and with nursing judgment. He stated he preferred that blood pressure medications have parameters that are set based on the induvial resident and not a standing order. He indicated he would expect a nurse to hold a blood pressure medication and notify him each time it was necessary and, if there was a pattern, he would look at altering the medication regimen.

Based on staff interviews, record reviews, and review of the facility's policy titled, Accepting Delivery of Medications, the facility failed to administer medications per physician's orders for one resident (R) (R4). Specifically, the facility failed to ensure that R4 received baclofen (muscle relaxant) and vitamin B12 (water-soluble vitamin) as ordered by the physician. Findings include: Review of the facility's policy titled Accepting Delivery of Medications, dated February 2021, under subtitle, Policy heading revealed 1. All staff should follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the pharmacist and Director of Nursing. Review of R4's Admission Record located in the Electronic Medical Record (EMR) under the Profile tab revealed R4 was admitted with a primary diagnosis of cerebral infraction due to unspecified occlusion or stenosis of unspecified vertebral artery. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/5/2023 revealed for Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of five (5) indicating severe cognitive impairment; Section I- Active diagnoses included cerebrovascular accident. Review of R4's comprehensive care plan located in the EMR under the Care Plan tab, dated 9/15/2023 included CVA: Resident had a Cerebrovascular Accident and/or other neurological disorders. During a telephone interview on 11/15/2023 at 2:24 pm with the Family of R4 revealed R4 had an outpatient follow-up appointment with the neurologist on 7/20/2023. She further stated that R4 was prescribed medications during this visit, however, she did not receive them at the facility until several weeks later. R4's Family further stated when she asked the nurse about the medications, she was told R4 did not have any new medications. R4's Family stated she had to call the pharmacy herself and learned that facility received the medications the same day of R4's appointment on 7/20/2023. During a telephone interview on 11/15/2023 at 2:50 pm with the Pharmacist at the pharmacy utilized by the facility revealed the pharmacy received two electronic prescriptions from the neurologist on 7/20/2023. The Pharmacist further stated that the prescriptions were filled, and the medications were sent to the facility on [DATE]. The Pharmacist further stated that a Licensed Practical Nurse (LPN) signed for the medications at 9:54 pm. The Pharmacist stated that when the electronic prescriptions for the facility were received, a copy of the order was faxed to the facility prior to the delivery of the medications. Review of the Packing Slip Proof of Delivery document revealed seven baclofen 5 milligram (mg) tablets and 14 vitamin B12 1000 microgram (mcg) tablets were delivered to the facility for R4 on 7/20/2023 at 9:54 pm and a facility representative (LPN) signed for the medications. Review of R4's active orders as of 10/6/2023 revealed an order for baclofen 5mg tablet, give 0.5 tablet by mouth at bedtime for muscle pain with an order and start date of 7/26/2023. There was also an order for vitamin B12 extended release 1000 mcg, give one (1) tablet by mouth one time a day for supplement with an order date of 7/26/2023 and a start date of 7/27/2023. Review R4's Electronic Medication Record (eMAR) for July 2023 revealed the first dose of baclofen was not documented as administered until 7/26/2023 at 9 pm and the first [NAME] of vitamin B12 1000 mcg was documented as administered on 7/27/2023. These medications were not administered until six (6) days after they were ordered by the physician and received from the pharmacy. Record review of Progress Note dated 7/25/2023 revealed, Writer left message for Ga House Calls (Nurse Practitioner), requesting order for baclofen. Medication on hand but requires an order. Record review of a Progress Note dated 7/27/2023 revealed, Resident started on baclofen tonight, tolerated well. No adverse reactions noted. During an interview on 11/16/2023 at 10:13 am with LPN BB revealed she usually worked night shift when medications were delivered from the pharmacy. LPN BB stated that upon delivery of the medications, she was required to check and collaborate the orders with the resident's record for accuracy prior to placing the medications on the cart. She stated if there was a new medication that came in that's not listed on a resident's mediation administration record, she would either call the physician or DON for further directives. LPN BB stated that this process of order clarification is usually corrected within 24 hours. During an interview on 11/16/2023 at 10:29 am with the Assistant Director of Nursing (ADON) CC revealed that there were outside providers who send new prescriptions into the pharmacy electronically. She further stated that when this happens, the pharmacy is supposed to fax over a copy of the new order but that does not always happen. ADON CC further stated the nurse usually leaves the nursing administration team a note informing them of new medications delivered from the pharmacy not listed on the eMAR. During an interview on 11/16/2023 at 11:11 am with Registered Nurse (RN) EE revealed she has had new medications on the cart without orders in the record. RN EE further stated when that happens, she is required to report the issue to the Nurse Practitioner or the Physician to research or clarify the medication prior to administering the first dose. RN EE further stated that issues like this are generally taken care of on the same day and should not take a week. During an interview on 11/16/2023 at 11:47 am with Receptionist DD revealed that she had been in the receptionist position for only one month. She further stated that 99 percent of the time, she received the packet upon residents return from outside appointments. She also stated that she is required to deliver that packet to the nurses or the Director of Nursing (DON). Receptionist DD also stated that all orders faxed to the facility from the pharmacy are forwarded to the nurses upon receipt. During an interview on 11/16/2023 at 11:49 am with DON revealed the facility did not receive the fax pertaining to R4's new orders on 7/20/2023. DON stated the fax sent by the pharmacy failed. DON stated when the medications arrived at the facility an Agency nurse was working, and she just placed the medications on the cart. DON stated after learning of the medications and researching the orders, she entered the medications into the eMAR. DON stated that the nurse should have notified the nursing administration team if the medication was not on the resident's record.

46691 Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Drugs, the facility failed to assess six of 28 residents (R) R#33, R#53, R#55, R#54, R#20, and R#2 reviewed for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility policy titled Self-Administration of Drugs effective date 12/22/2014 revealed: Intent statement: It is the intent of this facility to permit residents to self-administer their drugs and medications unless such practice for the resident is deemed unsafe. 1. The care planning team should assess each resident's mental, physical, and visual ability to determine if the resident is capable of self-administration of drugs and medications. 2. Should the care planning team determine that the resident is unable to carry out this responsibility (because it would be dangerous to himself/or herself, or to others), the resident should not be permitted to self-administer his or her drugs or medications. 3. Should the care planning team determine that the resident is able to carry out this responsibility; the team should ask the resident, during his or her assessment conference, if he or she would prefer to administer his or her own drugs and medications. 4. Should the resident wish to self-administer his or her own drugs or medications, the resident should be permitted to do so. Drugs and medications should be stored in a safe and secure place designated by the Director of Nursing Services. 5. Appropriate documentation as to whether or not the resident made a choice about self-administration of drugs should be filed in the resident's medical record. 1.Record review of the electronic medical record (EMR) for R#33 revealed diagnosis including but not limited to depressive disorder, rheumatoid arthritis, anxiety disorder and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) score of 13, indicating R#33 was cognitively intact; Section G-Functional Status: required supervision with activities of daily living (ADLS); Section N-Medications: received an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: Tolnaftate Powder one (1) percent (%) apply to sacrum, buttocks, gluteal topically every shift for diaper dermatitis, start date 10/05/2021; Systane Ultra Solution 0.4-0.3 % (Polyethyl Glycol-Propyl Glycol) instill one drop in both eyes one time a day related to dry eye syndrome or bilateral lacrimal glands, start date 10/5/2021 and nystatin external powder 100,000 UNIT/(grams) GM (nystatin topical) apply to groin area/inner thighs topically two times a day for candida intertrigo start date 9/02/2023. Observation on 9/15/2023 9:15 am revealed R#33 lying in bed awake with multiple medications on the bedside table that includes 1 bottle of Thera Breath Dentist Formulated Fresh Breath Oral Rinse, 1 bottle of Dermal Wound Cleanser, 1 bottle Nystatin Topical Powder 100,000 units per gram, 1 bottle Tolnaftate Powder 1%, 1 container of Triamcinolone Acetonide Cream 0.1%, and 1 bottle of Systane lubricant eye gel. Observation on 9/15/2023 at 10:02 am revealed Licensed Practical Nurse (LPN) DD in resident room to administer morning medications. LPN DD exited the room. The surveyor re-entered R#33's room afterward, medications remained on the bedside dresser. Observation on 9/15/2023 at 12:14 pm revealed medications remain on bedside dresser. During an interview on 9/15/2023 at 12:29 pm with LPN, Assistant Director of Nursing (ADON) CC revealed there currently are no residents residing at the facility who have been assessed to self-administer medications. LPN, ADON CC further stated there should not be any medications in residents' rooms. LPN, ADON CC verified medications on R#33's beside table and stated resident's wife must have brought the medications to the facility. LPN, ADON CC removed the medications from the resident's room at that time. During an interview on 9/15/2023 at 12:42 pm with LPN DD revealed that he is an Agency Nurse. LPN DD stated that there should not be any medications in R#33's room. LPN DD further stated that he did not notice any medications on resident's bedside dresser and if there were medications there, he did not place them there and it had to have been there before he reported to work today. 2. Record review of the EMR for R#53 revealed diagnosis including but not limited to cognitive communication deficit, anxiety and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance. Review of Quarterly MDS assessment dated [DATE] revealed: Section C-Cognitive Patterns: BIMS score of 99, indicating R#53 was cognitively not able to complete the assessment; Section G-Functional Status: R#53 required extensive to total assistance with ADLs. Review of the physician's orders revealed medication orders to include Left heel- cleanse open area to the left heel with soap and water, apply Medi honey to the open area, and secure with border dressing; Please lotion feet before dressing is applied. Review of the clinical records revealed there was no assessment for self-administration of medication. Observation on 9/15/2023 at 9:06 am revealed R#53 observed lying in bed with a tube of Medi Honey (wound medication) in a tray on the bedside dresser. Further observation on 9/15/2023 at 11:55 am revealed R#53 sitting in a wheelchair in room with the tube of Medi Honey that remained on the bedside dresser. During observational rounds, an interview was conducted on 9/15/2023 at 12:29 pm with LPN, ADON CC verified the wound medication in R#53's room. LPN, ADON CC stated R#53 receives wound care services from a third-party company, which is the reason the medication is in the resident's room. LPN, ADON CC agreed that the Medi Honey is a medication and should not have been in the resident's room. LPN, ADON CC removed the medication from the resident's room at that time. During an interview on 9/16/2023 at 11:17 am with Wound Nurse revealed that she is new to the facility. Wound Nurse further stated that the facility's process was to have the wound supplies and medication in each residents' rooms. She further stated not all the residents had their wound medications in their rooms but residents who attend the wound clinic, the medications are stored in residents' rooms. 3. Record review of the Significant change MDS assessment for R#55 dated 7/7/2023 revealed Section C-Cognitive Patterns: BIMS score of 13, indicating R#55 was cognitively intact; Section G-Functional Status: R#55 required assistance with ADLS. Review of the physician's orders revealed medication orders to include: OcuSoft Eyelid Cleansing External Pad (Eyelid Cleansers). Instill 1 application in both eyes one time a day for lid hygiene clean both upper and lower eyelids once daily, Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium instill 1 drop in both eyes four times a day for after cleansing eyelids, Opcon-A Ophthalmic Solution 0.027-0.315 % (Naphazoline w/ Pheniramine) instill 1 drop in left eye every four (4) hours as needed for allergic conjunctivitis, and Nystatin Cream 100,000g apply to groin daily to affected area every shift for excoriation. There was not a physician's order for the Visine Dry Eye Relief Eye solution which was observed in resident's room. Review of the clinical record revealed there was no assessment for self-administration of medications. Observation on 9/15/2023 at 9:24 am revealed R#55 lying in bed with Refresh eye solution, Opcon-A eye allergy relief eye solution, Visine Dry Eye Relief, OcuSoft Eyelid Cleansing External Pad (Eyelid Cleansers) - 3 packets, and a container containing Nystatin cream located on resident's dresser. Observation on 9/15/2023 at 11:04 am and 12:17 pm revealed medications remained on the dresser. During observational rounds, an interview was conducted on 9/15/2023 at 12:29 pm with LPN, ADON CC verified the medications in R#55's room, stated it should not be there, and removed medications from room. R#55's private sitter informed LPN, ADON CC and surveyor, R#55's eye medications have always been located on top of his dresser. She further stated that the nurse came into his room earlier this morning, administered the eye medications and placed back on the dresser. During an interview on 9/15/2023 at 12:34 pm with Registered Nurse (RN) FF revealed that she administered R#55's eye drops this morning but retrieved and returned the eye medications from the medication cart. RN FF further stated that she did not notice and was unaware of medications being in resident's room. 4. Record review of the EMR for R#54 revealed diagnosis including but not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, muscle weakness (generalized), seizures, major depressive disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Section C-Cognitive Patterns: BIMS score of 13, indicating R#54 was cognitively intact; Section G-Functional Status: R#54 required extensive assistance with ADLS. Section N-Medications: indicated an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: cyanocobalamin tablet 1000 microgram (MCG) give 1 tablet by mouth one time a day for vitamin B12 deficiency for three (3) Months, oxycodone HCl Oral Tablet 15 MG give 0.5 tablet by mouth six times a day for pain; Keppra oral tablet 750 MG (Levetiracetam) give 1 tablet by mouth one time a day for seizure; Verapamil HCl ER Oral Tablet Extended Release 180 MG (Verapamil HCl) Give 1 tablet by mouth one time a day for HTN; Sertraline HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression; Oyster-Cal 500 Tablet (Calcium) Give 1 tablet by mouth one time a day for Vit D deficiency; Multivital-M Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement; Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth three times a day for diabetes mellitus (DM); Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day for hypertension (HTN); Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation. Review of the clinical record revealed there was no assessment for medication self-administration. Observation on 9/15/2023 at 9:32 am revealed R#53 lying in bed with a clear plastic cup of medications and a cup of water on her bedside table. R#54 informed surveyor that the nurse left her medications there for her to take later because she only wanted to take her pain medication at the time. R#54 further stated, it can stay there, I will take it later. Observation on 9/15/2023 at 9:41 am revealed medications remained on R#54's bedside table while LPN DD was at the medication cart on the hall administering morning medications. Observation on 9/15/2023 at 9:59 am revealed LPN DD entered R#54's room and later exited. A surveyor entered the room and noted medications were not on the table at this time. R#54 informed surveyor that she had just taken the medications. During an interview on 9/15/2023 at 12:44 pm with LPN DD and LPN, ADON CC, LPN DD acknowledged leaving the medications with R#54. LPN further stated I saw you watching me, I guess that was a problem with leaving the medications since you are asking me about it. I probably should have taken the meds out and took them back in to her later. During an interview on 9/15/2023 at 12:47 pm with DON, she stated that there are not any residents in the facility who have been assessed to be allowed to self-administer medications. She further stated that an assessment is required for residents to self-medicate and if deemed appropriated to self-medicate the medications are stored in a lock container in residents' room. Therefore, medications should never be left at a residents' bedside. 5. Observation and interview with R#20 on 9/15/2023 at 9:08 am revealed one Ventolin HFA (high flow aerosol) (a medication used to treat used to treat or prevent bronchospasm) inhalation aerosol solution 108 (90 Base) microgram per actuation on the over bed table. R#20 stated she always had it at her bedside, and she used two puffs every day at noon and as needed at other times. She stated she did not report the use to the nurse nor document the use. Observations on 9/15/2023 at 11:25 am and 9/15/2023 at 12:49 pm revealed the Ventolin HFA inhaler remained on R#20's over bed table. Review of the Quarterly MDS dated [DATE] revealed: Sections C-Cognitive Patterns revealed R#20 had a BIMS of 15 (meaning she was cognitively intact); Section G-Functional Status revealed she required extensive to total assistance for ADLs. Review of the physicians' orders included an order dated 3/3/2023 for Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) mcg/act 2 puffs inhaled orally every 4 hours as needed for wheezing or shortness of breath. Review of the diagnoses included obstructive sleep apnea and mild persistent asthma. Review of the care plan revealed interventions for the diagnosis of asthma that included giving medications as ordered and monitoring and document side effects and effectiveness. There was not a care plan for self-administration of medication. Review of the assessments revealed there was not an assessment for self-administration of medication. Review of the MARS dated 9/2023, 8/2023, 7/2023 revealed the Ventolin HFA Inhalation Aerosol was administered two times from 9/1/2023 to 9/15/2023; was not administered in 8/2023; was not administered in 7/2023. Interview on 9/15/2023 at 12:51 pm with RN FF revealed there were no residents on Magnolia North that were assessed for self-administration of medications and that medications should not be left in the resident rooms. She stated that Ventolin HFA inhaler was considered a medication. She verified R#20 had a physician's order for Albuterol Inhaler to be used every four hours as needed and she verified there was not a Ventolin HFA inhaler in the medication cart for R#20. Observation of R#20's room with RN FF verified the Ventolin HFA inhaler was located on the resident's overbed table at her bedside. RN FF educated R#20 about the use of the inhaler and removed the inhaler from the room and placed it on the medication cart. Interview on 9/15/2023 at 12:29 pm with the LPN, ADON CC stated that there were currently no residents residing at the facility who have been assessed to self-administer medications. She further stated therefore no medications should be in residents' rooms. Interview on 9/15/2023 at 12:47 pm with DON stated that there were not any residents in the facility who have been assessed to be allowed to self-administer medications. She further stated that an assessment is required for residents to self-medicate and if deemed appropriated to self-medicate the medications are stored in a lock container in residents' room. Therefore, medications should not be ever left at residents' bedside. 6. Observations on 9/15/2023 at 10:18 am and 9/15/2023 at 12:25 pm revealed R#2 lying in bed with eyes closed with even and unlabored breathing. Observation of the room revealed one hard plastic open carrier with a handle to be sitting in an area under the window and to contain various wound care supplies including one 30g (gram) tube of Santyl ointment (a prescription medication used to help the healing of burns and skin ulcers) and one 16 oz (ounce) container of Dakin Solutions (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns). Interview on 9/15/2023 at 12:25 pm with the LPN, ADON CC stated wound care supplies and medications were kept in resident rooms. Observation of the medications in R#2's room with the LPN, ADON CC verified the Santyl ointment and Dakin Solution were in R#2's room and located on a sitting area under the window area. Review of the Significant Change MDS dated [DATE] revealed: Sections C-Cognitive Patterns R#2 had a BIMS score of 14 (meaning was cognitively intact); Section G-Functional Status revealed R#2 required extensive assist to total assist for ADLs: Section M-Skin Conditions revealed R#2 had one stage four pressure ulcer and two unstageable pressure ulcers. Review of the physician's orders included orders dated 9/13/2023 revealed: Dakins (1/2 strength) External Solution Apply to sacrum topically one time a day for wound; 9/4/2023: Right buttock and Sacrum. Wash area with 1/4 Dakins, pat dry, apply skin prep to peri wound. Apply Santyl to slough. Pack with calcium alginate, cover with 4x4 gauze and ABD pad one time a day; 8/8/2023: Right heel. Apply Santyl to slough. Calcium alginate to open area. Betadine to eschar, cover with 4x4 gauze, wrap with kerlix in the morning. Review of diagnoses included a diagnosis of pressure ulcer. Review of the care plan revealed interventions for pressure ulcers to include treatment to wound as ordered. Review of the MARS dated 9/2023 revealed documentation that the physician order of wound care was documented as performed daily on 9/1/2023 through 9/15/2023. Interview on 9/15/2023 at 12:25 pm with the LPN, ADON CC stated wound care supplies and medications were kept in the residents' room and she verified the Santyl ointment and Dakins Solution was kept in R#2 room with the wound care supplies. Observation of the supplies and medications in R#2's room with LPN, ADON CC verified the Santyl ointment and Dakins Solution in R#2's room and located on a sitting area under the window area.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Planning - Comprehensive Preliminary, the facility failed to implement a care plan intervention for one of four residents (R) (R2) reviewed with an urinary catheter. Specifically, the facility failed to ensure the resident's urinary catheter drainage bag was placed in a privacy bag as instructed on the care plan. The sample size was 28 residents. Findings include: Review of the facility policy titled Care Planning - Comprehensive Preliminary with an effective date of 12/18/2014 revealed the intent was for the facility to develop and maintain an individualized plan of care for each resident. The Procedural Guidelines section revealed: 3. The care plan is available for use by all personnel providing care/services to/for the resident. It includes but is not limited to: A. Incorporate identified problem areas; B. Incorporate risk factors(s) associated with the identified problem (s). Observations on 9/15/2023 at 10:18 am, 9/15/2023 at 12:21 pm, and 9/16/2023 at 9:30 am of R2 revealed her to be in bed, the door to her room opened, and a urinary catheter drainage bag visible from the hallway The urinary catheter drainage bag was not in a privacy bag, allowing staff, other residents, and visitors to observe her urine. Review of R2 clinical records revealed diagnoses but not limited to neuromuscular dysfunction of bladder and urinary retention. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section H-Bladder and Bowel indicated R2 indicated use of an indwelling urinary catheter. Review of the physician's orders dated 9/17/2021 revealed Foley Catheter - 18French with 10 cubic centimeters (cc) bulb related to neuromuscular dysfunction of bladder. Review of the care plan revealed R2 had an indwelling urinary catheter with an intervention for a privacy bag at all times. Interview on 9/16/2023 at 9:45 am with Certified Nursing Assistant (CNA) JJ revealed she had worked at the facility for six months. She stated the urinary catheter drainage bags should be placed into a privacy bag when the resident was out of their room and if a resident requested one to be placed while in the room. Interview on 9/16/2023 at 9:50 am with Licensed Practical Nurse (LPN) EE revealed she had worked at the facility for six years. Observation of R2 from the hallway with LPN EE verified R2's urinary drainage bag was secured to the bed frame on the side of the bed next to the floor, not in a privacy bag, and R2's urine was visible from the hallway. Interview on 9/17/2023 at 12:35 pm with the Director of Nursing (DON) revealed her expectation was for nursing staff to follow the individualized care plan for R2. She verified R2 had a care plan intervention to have a privacy bag at all times for the urinary drainage bag. She stated the intervention should be worded differently. Cross reference F550

Based on resident and staff interviews, record review and review of the facility policy titled Hemodialysis Access Care, the facility failed to ensure communication between the facility and the dialysis center was documented after each dialysis treatment for one of one resident (R) (R 20) reviewed for dialysis care. The sample size was 28 residents. Findings include: Review of the policy titled Hemodialysis Access Care with a revision date of September 2010 revealed in section subtitled Documentation stated: The general medical nurse should document in the residents' medical record every shift as follows: 3. If dialysis was done during shift; 4. Any part of report from dialysis nurse post-dialysis being given. Interview on 9/15/2023 at 10:08 am with R20 revealed she went to off-site dialysis treatment three times per week. Interview on 9/15/2023 at 2:30 pm with R20 revealed she had an off-site dialysis treatment on this date. Review of electronic medical record (EMR) revealed R20 diagnoses included but not limited to end stage renal disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C- Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact; Section O- Special Treatments and Programs revealed she received dialysis. Review of the physicians' orders dated 9/8/2023 revealed R2 to receive dialysis on (Tuesday, Thursday, Saturday); send Dialysis Communication Form with resident. Interview on 9/16/2023 at 9:55 am with Licensed Practical Nurse (LPN) EE revealed R20 went to dialysis three days a week. She stated she was unsure if communication forms were completed with each dialysis treatment and further stated R20 goes to dialysis during night shifts hours. She further stated the resident did not return with a communication form when she was on shift this date and she did not contact the dialysis center for a report of resident's condition. Interview on 9/16/2023 at 4:00 pm with the Administrator and the Director of Nursing (DON) revealed they were unsure if a communication form was completed and returned at each dialysis treatment. The DON stated she would provide dialysis communication forms if there were any. The DON did not provide the communication forms between the dialysis center and nursing staff as requested. Interview on 9/17/2023 at 9:30 am with LPN EE stated she had not observed a dialysis communication document for R20. She further stated when a resident returned from dialysis she assessed for vital signs, accessed the access site, and general condition of resident and documented in the progress notes and on the Medication Administration Record (MARS). Review of the nursing progress notes did not reveal nursing communication with the dialysis center. Interview on 9/17/2023 at 10:00 am with the DON revealed R20 was the facility's first dialysis resident in a while. She stated a dialysis communication document should be completed by the nurse prior to transport to the dialysis facility that includes vital signs, and the form should be completed by the dialysis center and returned with the resident that include vital signs and access site condition. She further revealed the communication document should be scanned into the EMR. She revealed if the communication document was not returned to the facility, the nurse should contact the dialysis center for a report of the resident condition and document that telephone communication in the nursing progress notes. DON verified there was no post dialysis communication documentation in the EMR for R20.

Based on observations, staff and resident interviews, record review, and a review of the facility's policies titled, Administering Medications through a Small Volume (Handheld) Nebulizer, and Oxygen Therapy - Mask And Nasal Cannula the facility failed to ensure oxygen equipment was properly stored while not in use and failed to properly administer and assess resident after nebulizer treatment for four (4) residents (R) (R33, R52,R20, and R26) receiving treatment for respiratory care. The deficient practice had the potential to increase the risk of respiratory complications and infection. The sample size was 28. Findings include: Review of policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds. 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment. 20. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline or if the resident complains of nausea or vomits. 21. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup. 22. Encourage the resident to cough and expectorate as needed. 23. Administer therapy until medication is gone. 26. Obtain post-treatment pulse, respiratory rate, and lung sounds. 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. wash pieces with warm soapy water; b. rinse with hot water; c. place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; d. rinse all pieces with sterile water (NOT tap, bottled, or distilled), and e. allow to air dry on a paper towel. 29. When equipment is completely dry, store in a plastic bag with resident's name and the date on it. Review of policy titled Oxygen Therapy - Mask and Nasal Cannula effective date 12/30/2014, Intent: It is the intent of the facility that that oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Procedural Guidelines: 4. When cannula becomes soiled with secretions, it needs to be changed. When masks and cannulas are not in use, store covered as designated by the facility. 1.Review of the clinical record for R33 diagnoses included but not limited to chronic cough, chronic obstructive pulmonary disease, and panlobular emphysema. Review of the September 2023 Physician Orders for R33 revealed an order dated 8/9/2023 for ipratropium-albuterol 0.5-2.5 mg(milligrams) /3ml (milliliters) SOLN (solution) inhale 1 (one) vial orally three (3) times a day for scheduled due to chronic cough related to chronic obstructive pulmonary disease. Observation on 9/15/2023 at 9:15 a.m., 10:02 a.m., and 12:14 p.m. of R33's room revealed a nebulizer mask on the bedside dresser along the side of the bed with the mask lying on the table and not properly bagged while not in use. Observation on 9/15/2023 at 12:29 p.m. while rounding with the Assistant Director of Nursing (ADON) CC revealed she removed medications from R#33's bedside dresser but did not address or remove the nebulizer that was not properly stored and not in use at this time. Interview on 9/16/2023 at 10:31 a.m. with Registered Nurse (RN) BB stated R33 received 2 nebulizer treatments that morning. RN BB further stated that after she administered the first treatment, R33's breakfast had arrived, so she wiped the nebulizer out and placed it on the dresser. She stated that she did not bag the nebulizer because she had to administer another treatment after the resident completed his meal. RN BB stated she was aware nebulizers should be rinsed, dried, and stored in a bag after use and not only placing it on the dresser. 2. Review of the clinical record for R52 diagnoses included but not limited to chronic obstructive pulmonary disease, panlobular emphysema, bronchiectasis, and chronic respiratory failure with hypoxia. Review of the September 2023 Physician Orders for R52 revealed an order dated 7/17/2023 for oxygen 2-5 (two to five) liters per minute (LPM) via nasal cannula (NC) every shift. Observations on 9/15/2023 at 9:06 a.m. revealed resident R52 sitting up on the side of the bed. The oxygen concentrator was off with the nasal cannula across it and not properly stored while not in use. There was a nasal cannula attached to the oxygen cylinder on the back of R52's wheelchair that was not properly stored while not in use. Observation 9/16/2023 at 8:50 a.m. revealed R52 receiving oxygen at 2 LPM via NC attached to the oxygen concentrator. The nasal cannula attached to the oxygen cylinder on the back of R52's wheelchair remained not properly stored while not in use. Observation on 9/16/2023 at 11:10 a.m. while rounding with ADON CC verified oxygen tubing attached to the oxygen cylinder on the back of the wheelchair was not properly stored while not in use. ADON CC stated R52's use the oxygen on the back of her wheelchair when her family they take her outside for fresh air. Interview on 9/16/2023 at 12:09 p.m. with the Director of nursing (DON) and the Assistant Director of Nursing (ADON) revealed respiratory mask and mouthpieces should be placed in a mesh bag when not in use. She stated that all staff are responsible for ensuring compliance with this process. 46691 3. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Sections C -Cognitive Patterns: revealed R20 had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact; Section G-Functional Status: indicated she required extensive to total assistance for activities of daily living (ADLs). Review of the physician's orders dated 9/8/2023 revealed: Wash headgear/straps in warm, soapy water and air dry, Wash tubing with warm, soapy water and air dry, Cover with mesh bag for storage when not in use; 8/3/2023: Albuterol Sulfate Nebulization Solution (a medication used to treat wheezing and shortness of breath) 2.5 mg (milligrams) per 3 ml (milliliters) 0.083% one vial inhale orally via nebulizer every 8 (eight) hours as needed for shortness of breath; 6/22/2023: BiPap at bedtime with a full-face mask. Review of the diagnoses included but not limited to obstructive sleep apnea and mild persistent asthma. Review of the care plan revealed interventions for BiPap therapy for obstructive sleep apnea and asthma including to give nebulizer treatments as ordered. Review of the Medication Administration Record (MAR) dated 9/2023, 8/2023, 7/2023 revealed the Albuterol Sulfate Nebulization Solution was administered via nebulizer as ordered. Review of the Treatment Administration Record (TAR) dated 9/2023 revealed there was no documentation for the storage of the BiPap headgear/straps when not in use. Observation and interview on 9/15/2023 at 9:08 a.m. with R20 revealed one bilevel positive airway pressure (BiPap) machine on the bedside table with the mask lying on top of the machine and one nebulizer machine with the mask lying on top of the machine, both masks were not in a protective bag and exposed to the environment. R20 stated she used the nebulizer more than one time per day and the BiPap every night. She stated she required assistance with the use of both. She stated she was unaware of how often the masks were cleaned and further stated the masks had not been placed into protective bags. Observations on 9/15/2023 at 11:25 a.m. and 9/16/2023 at 12:15 p.m. revealed the bi-pap mask and nebulizer mask remained lying on top of the machines, uncovered, and exposed to the environment. Interview on 9/16/2023 at 9:45 a.m. with Certified Nursing Assistant (CNA) JJ revealed the nurses were responsible for providing respiratory-related care and the CNAs did not perform any tasks related to respiratory treatments. She stated R20 required extensive assistance with ADLs and would not be physically able to use the Bi-Pap or nebulizer unassisted. Observation and Interview on 9/16/2023 at 3:03 p.m. of R20 room with Licensed Practical Nurse (LPN) EE verified the Bi-Pap mask and the nebulizer mouthpiece was lying on top of the machines on the bedside table, un-bagged and exposed to the environment. LPN EE revealed the night shift nurse was responsible for placement and removal of Bi-Pap masks and should have placed the mask into a protective bag at removal and further revealed all nurses were responsible for ensuring respiratory face masks and nebulizer mouth pieces were placed in a protective bag when not in use. She stated respiratory masks and mouth pieces should be placed in protective bags when not in use to prevent the spread of illness. She stated she would place the mask and mouthpiece into protective bags. 4. Review of the physician's orders for R26 dated 5/11/2023 revealed: Xopenex Inhalation Nebulization Solution 0.63mg per 3ml one application inhale orally via nebulizer every 6 (six) hours as needed for asthma, wheezing, or shortness of breath. Review of diagnoses included but not limited to severe persistent asthma with (acute) exacerbation. Review of records revealed there was not a care plan area for the use of nebulizer treatments. Review of the MARS dated 9/2023, 8/2023, 7/2023 revealed R26 received Xopenex Inhalation Nebulization Solution 0.63mg per 3 (three) ml one application inhaled orally via nebulizer as ordered. Observation on 9/16/2023 at 12:00 p.m. of Medication pass with Registered Nurse (RN) BB, revealed R26 was administered Xopenex Inhalation Nebulization Solution 0.63mg per 3ml (a medication used to treat wheezing and shortness of breath) one unit via handheld nebulizer. RN BB prepared the medication, handed the handheld nebulizer mouthpiece to the resident, and exited R26's room. She did not obtain a baseline pulse, respiratory rate, or lung sound. At 12:10 p.m., she entered R26's room, turned off the machine and obtained the handheld nebulizer mouthpiece from the resident and cleaned the mouthpiece. She did not remain with the resident for the treatment or monitor the resident for side effects from the medication. Interview on 9/16/2023 at 12:15 p.m. with Registered Nurse (RN) BB revealed she had worked at the facility for one and one-half years and had not received recent education on administering medications via a nebulizer. She was unsure if she had received education on administration of nebulizer medications upon hire. She confirmed she should have assessed the resident's pulse rate, respiratory status and lung sounds before and after the nebulizer treatment and should have stayed with the resident during the treatment. She stated she was aware the medication could have adverse effects on a resident and confirmed the resident should be monitored during the treatment. Interview on 9/17/2023 at 9:15 a.m. with LPN EE stated she had received education on administration of medications via nebulizer within the last year and could not remember the date. She stated when she administered the medication via nebulizer, she prepared the medication and handed the mouthpiece to the resident, left the room, and returned every few minutes to check on the resident. She did not state that she would check the resident's vital signs or lung sounds prior to or during administering the nebulizer treatment. Interview on 9/17/2023 at 9:25 a.m. with RN GG stated she had not received education on administration of medications via nebulizer from the facility. She stated when she administered the medication via nebulizer, she prepared the medication and handed the mouthpiece to the resident if the resident could hold the mouthpiece, left the room, and checked on the resident every few minutes until the medication cup was empty. She did not state she would check the resident's vital signs or lung sounds prior to or during the nebulizer treatment. Interview on 9/17/2023 at 10:15 a.m. with the DON stated nurses should administer medications according to the physician orders. She stated when administering medications via a nebulizer, the nurse should verify the physician order, administer the medication by placing the medication in the medication cup of the nebulizer set-up, turn the machine on, hand the mouthpiece to the resident, leave the room, return to check on the resident in about 15 to 20 minutes. She did not state the nurse should assess the resident's lung sounds or vital signs at any time during the administration of the nebulizer treatment. She then stated she was aware of the procedure for administration of medications via a nebulizer and stated the nurse should assess lung sounds and vital signs prior to the treatment. She stated she was unsure if education had been provided to nursing staff about the administration of medication via a nebulizer in the past year. Interview on 9/17/2023 at 11:40 a.m. with the Medical Director revealed his expectations for staff administering medications via a nebulizer to assess the resident's lung sounds prior to and after each treatment and for vital signs to be assessed if the resident was in distress.

Based on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) R45 reviewed for medication management. This failure had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. The sample size was 28 residents. Findings include: Review of clinical records revealed R45 had diagnoses of but not limited to Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder. Review of R45 Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of the physician orders for R45 dated September 2023 revealed an order for lorazepam 0.5 milligram (mg) by mouth every four (4) hours as needed for agitation or anxiety related to anxiety disorder. The original order dated was 8/1/2023. Review of care plans for R45 revealed the following: Psychotropic Medication: R45 is at risk for side effects from psychotropic medication. Psychotropic medication ordered: hypnotics and antianxiety meds. Interview with Licensed Practical Nurse (LPN) KK on 9/17/2023 at 8:11am revealed R45 does not have any behaviors. She stated he does yell out at times, but he is not a aggressive or has aggressive behaviors. Interview on 9/17/2023 at 12:54 pm with the Director of Nursing (DON) confirmed that there was not a stop date for lorazepam oral tablet 0.5 mg by mouth every 4 hours as needed for agitation or anxiety related to anxiety disorder. DON stated that the pharmacy should have put a stop date on it. DON also stated that there should have been a stop date for 30, 60, or 90 days. DON stated that she along with the Social Service Director reviews the stop dates on the psychotropic medications. DON stated R45 is receiving lorazepam frequently. She stated that R45 received lorazepam today on 9/17/2023. DON further stated that she is going to contact the doctor to get a stop date order for the lorazepam.

Based on observations, staff interviews, record review, and review of the facility policy titled Urinary Drainage Bag; the facility failed to maintain dignity by ensuring a dignity bag was provided for three residents (R) (R33, R55, and R2) of 28 residents reviewed for an indwelling urinary catheter. Findings include: Review of the policy titled Urinary Drainage Bag dated December 24, 2014, revealed the intent was to provide appropriate care for urinary drainage bags (bedside bag and leg bag) per current standard of care and/or physician order. 1.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section G-Functional Status: documented R33 required extensive to total dependence for activities of daily living (ADL)s; Section H-Bladder and Bowel: documented R33 had an indwelling catheter. Review of R33's care plan revealed resident had an indwelling urinary catheter with interventions that included to provide care of urinary catheter per policy. Review of the physicians' orders revealed an order dated 8/19/2022 for a urinary catheter. Review of Diagnoses included but not limited to urinary retention, obstructive and reflux uropathy, dysfunction of bladder. Observations on 9/15/2023 at 9:15 am, 9/15/2023 at 10:02 am, 9/16/2023 at 8:51 am, and 9/16/2023 at 10:31 am revealed R33 was in his room with use of an urinary catheter drainage bag that was not in a privacy bag and visible from the hallway. Interview on 9/16/2023 at 9:42 am with Certified Nursing Assistant (CNA) AA confirmed R33 did not have a privacy bag for urinary catheter drainage bag and revealed she was not aware that residents needed a privacy bag for a catheter drainage bag while in bed. Interview on 9/16/2023 at 10:31 am with Registered Nurse (RN) BB revealed she did not realize or see if R33's urinary catheter drainage bag was visible from the doorway when she was in his room administering his medication before breakfast. RN BB stated the urinary catheter drainage bag should have been positioned on the side of the bed away from the doorway. RN BB further stated that she was aware that urinary catheter drainage bag should be positioned or bagged and not visible from the doorway. 2.Review of the Significant Change MDS dated [DATE] revealed Section G-Functional Status: documented R55 required extensive assistance with ADLs; Section H-Bladder and Bowel: documented R55 had an indwelling catheter. Review of R55's care plan revealed R55 had an indwelling urinary catheter with interventions that included to provide a privacy bag at all times. Review of the physicians' orders dated 6/6/2023 revealed an order for a urinary catheter, to continuous drainage every shift. Review of Diagnoses included but not limited to urinary retention, obstructive and reflux uropathy, dysfunction of bladder. Observations on 9/15/2023 at 9:24 am, 9/15/2023 at 11:04 am, 9/15/2023 at 12:29 pm, and 9/16/2023 at 8:58 am revealed R55 was in his room with use of a urinary catheter drainage bag that was not in a privacy bag and visible from the hallway. Observation on 9/15/2023 at 12:29 pm while rounding with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) CC revealed she did not address resident's urinary catheter drainage not in a privacy bag and visibility from the doorway, prior to leaving R55's room. Interview on 9/16/2023 at 10:35 am with LPN EE confirmed R55's catheter drainage bag was visible from the doorway and stated she had just put it in a privacy bag. She stated that she did not notice that the drainage bag was uncovered at the beginning of her shift. 46691 3.Review of the Significant Change MDS dated [DATE] revealed: Sections G-Functional Status: documented R2 required extensive assistance with ADLs; Section H-Bladder and Bowel documented R2 had an indwelling urinary catheter. Review of the physician's orders dated 9/17/2021 revealed: Foley Catheter - 18French with 10 cubic centimeters (cc) bulb related to neuromuscular dysfunction of bladder. Review of Diagnoses included but not limited to neuromuscular dysfunction of bladder and urinary retention. Review of the care plan revealed R2 had an indwelling urinary catheter with interventions that included to provide a privacy bag at all times. Observations on 9/15/2023 at 10:18 a.m., 9/15/2023 at 12:21 p.m., and 9/16/2023 at 9:30 a.m. revealed R2 was in her room with use of a urinary catheter drainage bag that was not in a privacy bag and visible from the hallway. Interview on 9/16/2023 at 9:45 a.m. with CNA JJ stated urinary catheter drainage bags should be placed into a privacy bag when the resident was out of their room and if a resident requested one to be placed while in the room. Observation and Interview on 9/16/2023 at 9:50 a.m. with LPN EE stated urinary catheter drainage bag should be placed in a privacy bag when the resident was out of the room. She further stated when the resident was in the bed, the urinary drainage bag should be placed on the opposite side of the bed from the door, so that the urine could not be observed from the hallway. She stated the privacy bag was used to provide dignity for the resident and to prevent visitors, staff, and other residents from observing the resident's urine. Observation of R2 from the hallway with LPN EE revealed R2's urinary drainage bag was secured to the bed frame on the side of the side of the bed next to the floor, not in a privacy bag, with the resident's urine visible from the hallway. Interview on 9/16/2023 at 11:56 am with the Director of Nursing (DON) revealed Nurses and CNAs are responsible for ensuring that residents urinary catheter bags were in a privacy bag if catheter was positioned with visibility from the doorway. The DON further stated that the Nursing Administrative Team did not check catheter drainage bags for compliance with privacy bags but would begin to implement this now.

Based on record review and staff interviews, the facility failed to ensure that the appropriate mechanical lift was utilized to ensure a safe transfer for one resident (R) #17 who required transfer with a Hoyer lift by two persons. Actual harm was identified when R#17 began to exhibit signs and symptoms of pain and her x-ray results showed bilateral femoral fractures (hip fractures) requiring surgical intervention. Sample size was 24 residents. Findings include: Record review revealed that R#17 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease, dysphagia, [CONDITION(S)], peripheral vascular disease (PVD) and bilateral knee replacement. Continued record review revealed the resident was discharged from the facility to an acute care hospital on 9/10/21 for bilateral femur fractures requiring surgical interventions and returned to the facility on [DATE]. Record review of Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Status Score (BIMS) of two which indicates severe cognitive impairment and total dependent for transfer with two persons assist and balance. Record review of the resident's Comprehensive care plan dated 10/28/20, last revised 12/26/21, documented that R#17 requires a Hoyer lift for transfer. Review of the Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) care plan, CNA Hall Assignment Sheet, and the facility electronic record system, which provides instructional documentation logging on resident care needs, revealed the resident required a Hoyer lift for transfer with two persons assist. Record review of R#17's fall assessment evaluation form titled Morse Fall Schedule completed on 6/30/21 documented an assessment of impairment for the category of Gait/Transferring and bedrest/nurse assist for the category of Ambulatory Aide. The risk score was assessed as a 35 which indicates a level of Low Risk of falls. Record review of Nurse Notes from 9/7/21 to 9/10/21 only documented only one pain assessment completed by facility licensed nursing staff for R#17. Record review of a Nurse Note dated 9/7/21 at 15:14 (3:00 p.m.) documented R#17 denies pain. Record review of Medication Administration Record (MAR) documented no pain assessment completed by facility licensed nursing staff to monitor for R#17's pain level. Record review of the facility investigation revealed it included and documented CNA AA signed statement that she utilized the wrong lift to transfer R#17 and transferred the resident with only person during the transfer. CNA AA confirmed and acknowledged in her statement that in-service training was provided regarding following the assignment sheet for the proper transfer type and using the correct lift device. The investigation also included written statements from CNA AA that resident was in pain on 9/7/21 and 9/8/21. CNA AA reported R#17's complaint of pain to the charge nurse on duty. CNA statement documented that charge nurse provided pain medications to the resident on both days. Record review of Nurse Practitioner (NP) progress note documenting a date of service on 9/8/21 documented staff reports 2 days onset patient yelling and screaming in pain. Right knee is edematous, patient yelling when manipulated. Patient previously ambulate with max assistant in wheelchair. Review of the NP note of 9/10/21 that the resident's right knee remains painful to touch and has swelling. The NP reviewed x-ray results that revealed bilateral fractures and submitted an order for transfer to ER (emergency room ). Review of the Radiology Report documented an x-ray finding for the x-ray of 9/9/21 and results dated 9/10/21: (1). Knee AP or LAT (lateral) 1-2V (views), Left results: Fracture of the femoral shaft with malalignment. Joint spaces replaced. Mild soft issue swelling. Conclusion Left Acute femoral fracture. (2). Knee AP or LAT 1-2V, Right results: Fracture of the femoral shaft with malalignment. Joint space replaced. Mild soft tissue swelling. Conclusion: Acute femoral fracture Record review nurse notes dated 9/10/21 at 11:03 a.m. documented call to Nurse Practitioner (NP) and Responsible Party regarding x-ray results for a femur fracture. R#17 transferred to hospital by EMS (Emergency Medical Transport). Record review of hospital discharge record document on 9/10/21 revealed a diagnosis of unspecified fracture part of the neck of right femur subsequent encounter for closed fracture with routine healing and unspecified fracture part of the neck of left femur subsequent encounter for closed fracture with routine healing. Record review of nurse note dated 9/21/21 at 3:04 p.m. documented resident was readmitted from hospital following a double leg fracture. An interview on 1/27/22 at 3:17 p.m. with CNA BB confirmed and verified providing care to R#17 on 9/7/21, 9/8/21, 9/9/21 and on 9/9/21 from 3-11 p.m. CNA BB reported that the resident was crying/ yelling out in pain from 9/7/21 -9/8/21 and was send out to the hospital 9/10/20. CNA BB revealed that she reported the resident's complaint to the charge nurse on duty. CNA BB revealed that the electronic record system and the CNA care plan sheet are located at the nurse station and indicated what type of lift and required number of persons to perform using a Hoyer lift. She confirmed that the resident was care planned for use of a Hoyer lift for transfer with two persons assist on 9/7/21. Interview with the Director of Rehab on 1/27/22 at 1:45 p.m. revealed that assessed the resident on 8/10/21 for Therapy Screen for Hoyer transfer and that the resident was unable to follow commands to move her extremities. She revealed that since there was no change there was no indication for re-evaluation. Interview with the Administrator on 1/27/22 at 2:00 p.m. revealed that video footage on 9/7/21 was reviewed as part of the facility investigation. The video confirmed that CNA AA rolled a sit and stand lift in the R#17's room instead of a Hoyer lift. During the investigation, CNA AA admitted using the wrong lift and received in-services. There was no evidence that R#17 had fallen. CNA AA was employed as an agency CNA and the facility provided training to CNA AA the same day. CNA AA was knowledgeable of how to use the Hoyer; however, she was not aware that she needed to use the Hoyer lift for the resident and failed to follow the care plan that was in place to use the Hoyer lift. During an interview on 1/27/22 at 2:20 p.m. LPN EE revealed that she worked with the resident on 9/8/21 on the day shift (6 :45 a.m. to 3:15 p.m.) and that she provided the resident with routine pain medications including [MEDICATION(S)], Tylenol, and prn pain cream (Asper Cream) for her knees. She reported that the resident showed no extreme signs of grimacing or pain the on 9/8/21. LPN EE revealed that the resident was assessed for use for a Hoyer for the past four months. LPN EE further revealed that if a CNA has a question of which lift to use, they should ask the nurse. An interview with CNA DD on 1/27/22 at 2:44 p.m. revealed that R#17 was complaining about leg pain during her care and kept saying oh my legs hurt. CNA DD confirmed receiving training on which mechanical lift and the number of support staff to use with the residents' transfers. This information is located on the CNA ADL sheet and in the electronic record form. CNA DD confirmed that the resident always required a two person assist Hoyer transfer prior to 9/7/21. An interview with CNA CC on 1/27/22 at 3:18 p.m. revealed working on the following days 9/7/21, 9/8/21 and 9/9/21 as the assigned CNA for R#17. She revealed that R#17 complained of pain and was screaming during her care. She reported the resident's behavior to the charge nurse on duty. Review of the incident report revealed the incident was sent to the State Survey Agency on 9/11/21.

Based on observations, interviews, and record review, the facility failed to follow the care plan related to transfer for one Resident (R) R#17 resulting in actual harm due to bilateral fractured femurs. The resident sample was 24. Findings include: Record review revealed that R#17 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued record review revealed the resident was dishcharged from the facility to an acute care hospital on 9/10/21 for bilateral femur fractures requiring surgical interventions and returned to the facility on [DATE]. Record review of Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Status Score (BIMS) of two which indicates severely cognitive impaired and total dependent for transfer with two persons assist and balance. Record review of the resident's Comprehensive care plan dated 10/28/20 (last revised 12/26/21) documented that R#17 requires a Hoyer lift for transfer. Review of the Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) care plan, Certified Nursing Assistant Hall Assignment Sheet, and the facility electronic record system, which provides instructional documentation logging on resident care needs, revealed the resident required a Hoyer lift for transfer with two persons assist. Record review of the facility incident report dated 9/11/21, documented that CNA AA failed to utilize the correct method of transfer on 9/7/21 to transport resident. Review of a written statement from CNA AA confirmed and verified that she used a sit and stand lift instead of a Hoyer lift to transfer resident on 9/7/21 by herself. An interview with the Administrator on 1/27/22 at 2:00 p.m. confirmed and verified that the facility investigation was based on the following facts related to CNA AA, an agency CNA, failed to follow the correct transfer procedure for R#17 on 9/7/21. The Administrator further reported that their findings were based on a video footage which showed CNA AA pushing a sit and stand lift into R#17 's room on 9/7/21 and a written statement from CNA AA confirming the use of a Sit and Stand lift instead of the Hoyer lift. No care plan policy provided. Cross refer to F689

Based on record review and staff interviews, the facility failed to follow the care plan for one resident (R#1) regarding two staff assist with transfers. This failure resulted in actual harm when the resident fell during a transfer with one staff assist which caused dislocation of the right shoulder. The resident sample size was six. Findings include: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that R#1 was total dependent for transfers with two person assist. Review of the resident's care plan dated 3/7/17 revealed that the resident needed Activities of Daily Living (ADL) assistance due to being alert with confusion. Continued review revealed that she was up daily in her wheelchair with a two person assist via mechanical lift. She was weak, but able to make her needs known at this time. R#1 was non-ambulatory. Review of the approaches revealed to have a mechanical lift to assist with safe transfers (2 person assist). Review of the Interdisciplinary Note dated 5/13/17 revealed that family stated to staff that help was needed in her mother's room and when the nurse arrived in the room, the resident was on the floor in front of the toilet still attached to the sit-to-stand lift with a Certified Nursing Assistant (CNA) standing beside her. Continued review revealed that when the CNA was getting the resident off the toilet the lift stopped working, so she lowered the resident to the floor. During assessment of the resident, her shoulder appeared to be out of alignment, which was stabilized and the physician notified and she was sent out the emergency room (ER) for an evaluation. Interview with the Interim Director of Nursing (DON) on 6/3/17 at 8:30 p.m., confirmed that the transfer was with only one staff even though R#1 was a two person transfer. Interview with CNA CC on 6/3/17 at 9:54 p.m., revealed that there are care plans in resident's closets in their rooms, but also she gets an off going report from the prior shift. Continued interview revealed that this report includes how to transfer a resident. Interview with CNA DD on 6/3/17 at 9:59 p.m., who works every other weekend, revealed that she gets report from the off going shift, and the residents have care plans that are located inside the closet door. Continued interview revealed that this includes transfers. Cross refer F323

Based on record review, staff interviews and facility policy review, the facility failed to ensure that one resident (R#1) was transferred in a safe manner with a mechanical lift. This failure resulted in actual harm when R#1 had a dislocation to her right shoulder. The resident sample size was six. Findings include: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that she was total dependent for transfers with a two person assist. Review of the May 2017 Physician Orders revealed R#1 was to have a Sit-to-Stand lift for all transfers with two person for all lift usage. Review of the Interdisciplinary Note dated 5/13/17 revealed that the family stated to staff that help was needed in her mother's room and when the nurse arrived in the room, R#1 was on the floor in front of the toilet still attached to the sit-to-stand lift with a Certified Nursing Assistant (CNA) standing beside her. Continued review revealed that when the CNA was getting the resident off the toilet the lift stopped working, so she lowered the resident to the floor. During assessment of the resident her shoulder appeared to be out of alignment, which was stabilized and the physician notified. The resident was sent out the emergency room (ER) for an evaluation. Review of the Interdisciplinary Note dated 5/14/17 revealed that the resident returned to the facility with an immobilizer in place to her right arm. Review of the ED Provider Note dated 5/14/17 revealed that the resident was dropped and sustained an injury to her right shoulder. Continued review revealed that she has a minor skin tear to the right lower anterior leg; however, family stated that the resident seems to be herself otherwise. An x-ray was taken of the shoulder and showed an anterior closed dislocation of the right shoulder. The resident underwent [REDACTED]. The resident was to wear an immobilizer. Review of the Incident Report dated 5/13/17 at 5:45 p.m., revealed that at the time of the incident the resident's shoulder was stabilized and was sent to the hospital due to a suspected fracture. Review of the Lift Service Call Report dated 5/3/17 revealed a total of eight lifts, which this particular lift that was used during the transfer of R#1, had no particular concerns. Continued review revealed that this lift was inspected and no repairs were needed. Review of the Investigative Report dated 5/13/17 from the CNA that transferred the resident revealed that she was in the bathroom with the resident when she pushed the machine up to clean the resident without problems; however, the resident became weak and could not hold on anymore, so attempted to work the machine again, which did not work. Continued review revealed that she pushed the call light for some assistance, then attempted to push the button on the machine, which went down very slow. The staff lowered R#1 towards the toilet seat, but R#1 slipped down slowly, but did not fall. The report stated that the staff lowered her down with the machine and that R#1 gave out with her arms as the staff guided her to the floor because the machine stopped again. Review of the Investigative Report dated 5/13/17 from the off going CNA who gave report to R#1's on coming CNA the day of the incident revealed that she took the staff member down the hall that she would be working and showed her the residents that she had on her assignment sheet, and instructed her that when using the lifts there needs to be two people. Interview with the Interim Director of Nursing (DON) on 6/3/17 at 8:30 p.m., confirmed that during the investigation of this fall, there was only one person that transferred this resident and R#1 was a two person assist. Continued interview revealed that after the investigation the agency staff was not allowed to return to work at the facility. All regular staff were in-serviced on the use of the lifts; however, she is unaware of any documentation for the agency in-services regarding lift use. Interview with CNA AA on 6/3/17 at 9:10 p.m., revealed that she gets a report from the off going staff, which includes how to transfer residents. Interview with CNA CC on 6/3/17 at 9:54 p.m., revealed that there are care plans in resident's closets in their rooms, but also she gets an off going report from the prior shift. Continued interview revealed that this report includes how to transfer a resident. Interview with CNA DD on 6/3/17 at 9:59 p.m., who works every other weekend, revealed that she gets report from the off going shift, and the residents have care plans that are located inside the closet door. Continued interview revealed that this includes transfers. Review of the facility policy Using a Portable Lifting Machine/Mechanical Lift dated 12/30/14 revealed that the portable lift can be used by one nursing assistant if the resident can participate in the lifting Procedural Guidelines. If not, two nursing assistants should be required to perform the Procedural Guidelines.