Every finding on record at Pisgah Manor Health Care Center

Based on record review, on-call transcript review, and interviews with the staff, the Nurse Practitioner (NP), and Medical Director, the facility failed to report accurate and complete information to the on-call Medical Provider after significant medication errors and failed to report the error to Resident #1's Responsible Party (RP). On 06/29/26, Nurse #1, who was an agency nurse, administered Resident #1's scheduled 9:00 PM medications trazodone (antidepressant), apixaban (anticoagulant), acetaminophen (non-opioid analgesic), buspirone (anxiolytic), and donepezil (cholinesterase inhibitor). Nurse #1 then administered scheduled 9:00 PM medications for Resident #2 who resided in the room next to Resident #1, to Resident #1. The nurse administered the following medications to Resident #1: duloxetine (serotonin-norepinephrine reuptake inhibitor), trazodone (antidepressant), amoxicillin-potassium clavulanate (penicillin-class antibacterials combined with beta-lactamase inhibitors), doxycycline (tetracycline antibiotics), metoprolol tartrate (beta blockers), acetaminophen, buprenorphine-naloxone (opioid partial agonists and opioid antagonists), clonazepam (benzodiazepine), and gabapentin (anticonvulsant). On 6/30/26 Resident #1 did not eat lunch and started to exhibit symptoms of altered mental status and nausea and vomiting. Her blood pressure dropped to 96/35 (normal is 120/80), heart rate dropped to 45 (normal is 60-100), and oxygen level was 90% (normal is 95-100%). Emergency Medical Services (EMS) were called, and enroute to the hospital Resident #1 received 10% dextrose (carbohydrate, caloric source, and hypoglycemia antidote) for a low blood sugar reading of 46 hypoglycemia (low blood sugar below 70) and intravenous fluids (IV) with systolic blood pressure (top number) readings mostly in the 90's and heart rate was between 40 and 50. Resident #1 presented at the hospital as somnolent (excessive sleepiness), with pinpoint pupils (abnormally small, constricted pupils clinically significant known effect from opioid use or overdose) and a heart rate of 44 with bradycardia (heart rate below 60) and was significantly encephalopathic (change in body or brain that leads to altered mental status). Resident #1 was admitted to the hospital and placed on a non-invasive bilevel positive airway pressure (BiPap) for mild respiratory acidosis (a medical condition where your blood becomes too acidic (pH below 7.35) because your lungs cannot remove enough carbon dioxide). Resident #1 was diagnosed with accidental overdose, acute kidney injury (decline in the kidneys ability to filter waste, regulate electrolytes and maintain fluid balance), acute/chronic respiratory failure (inability of the lungs to maintain adequate oxygen or carbon dioxide levels), hyperkalemia (high potassium), mild hyponatremia (low sodium), and a junctional escape rhythm with underlying atrial fibrillation (irregular heart rhythm) with the electrocardiogram (ECG) identifying a new second-degree atrioventricular block (impaired electric signals to the lower heart) and noted the cause may be due to additional doses of beta blockers (metoprolol, carvedilol). The deficient practice affected 1 of 3 residents reviewed for notification of change (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's cumulative diagnoses included: dementia, atrial fibrillation, heart failure, hypertension, hyperlipidemia, pulmonary hypertension, and anxiety disorder. Review of Resident #1's active physician orders on 06/29/26 included:trazodone 150 milligrams (mg) at bedtime for insomnia and mood.apixaban 2.5 mg twice a day for atrial fibrillation.acetaminophen 500 mg give 2 tablets (1,000 mg) three times a day for pain.buspirone 15 mg three times a day for anxiety.donepezil 10 mg at bedtime for dementia. Review of Resident #1's Medication Administration Record (MAR) revealed Nurse #1 initialed the following medications scheduled at 9:00 PM on 06/29/26 to indicate trazodone 150 mg, apixaban 2.5 mg, acetaminophen 1,000 mg, buspirone 15 mg, and donepezil 10 mg were administered. Resident #2 was admitted to the facility on [DATE]. Resident #2's cumulative diagnoses included: acute on chronic respiratory failure, heart failure, atrial fibrillation, insomnia, major depressive disorder, anxiety disorder, and chronic pain. Review of Resident #2's active physician orders on 06/29/26 included:duloxetine 30 mg at bedtime for depression.trazodone 100 mg at bedtime for insomnia.amoxicillin-potassium clavulanate 875-125 mg every 12 hours for cellulitis.doxycycline 100 mg twice a day for cellulitis.metoprolol tartrate 12.5 mg every 12 hours for hypertension.acetaminophen 500 mg give 2 tablets (1,000 mg) three times a day for pain or fever.buprenorphine-naloxone 8-2 mg give 1 tablet sublingually three times a day for pain hold if sedated.clonazepam 1 mg give 1 tablet by mouth three times a day for anxiety.gabapentin 300 mg give 1 capsule by mouth three times a day for neuropathy. Review of Resident #2's MAR revealed Nurse #1 initialed the medications scheduled at 9:00 PM and 10:00 PM on 06/29/26 to indicate duloxetine 30 mg, trazodone 100 mg, amoxicillin-potassium clavulanate 875-125 mg, doxycycline 100 mg, metoprolol tartrate 12.5 mg, acetaminophen 1,000 mg, buprenorphine-naloxone 8-2 mg, clonazepam 1 mg, and gabapentin 300 mg were administered. Review of the medication error form dated 06/30/26 completed by Director of Nursing (DON) revealed on 06/29/26, Nurse #1 had administered the wrong medication to Resident #1. The list of medications given in error were duloxetine 30 mg, trazodone 100 mg, amoxicillin-potassium clavulanate 875-125 mg, doxycycline 100 mg, metoprolol tartrate 12.5 mg, acetaminophen 1,000 mg, buprenorphine-naloxone 8-2 mg, clonazepam 1 mg, and gabapentin 300 mg. The information on the form did not include Resident #1 had received her scheduled 9:00 PM medications. The form included a description of what caused the medication error as the use of agency Nurse #1 and first time at facility. Review of Resident #1's list of allergies included erythromycin (macrolide antibiotic) and sulfa (sulfonamides) antibiotics. Review of the documented transcript completed by the on-call Medical Provider dated 06/29/26 at 10:30 PM included what Nurse #1 reported to the on-call provider. Nurse #1 reported she administered sulfamethoxazole/trimethoprim (sulfonamides) by mistake to Resident #1 who had a sulfa allergy to the antibiotic, and Resident #1 had no complaints at this time. Resident #1's vital signs were included for blood pressure of 111/61, heart rate 50, respiratory rate 16, temperature 98.4, and oxygen 97%. The on-call Medical Provider response was to monitor Resident #1 for any reaction, monitor vital signs every two hours for eight hours. The on-call Medical Provider documented Resident #1's care was not escalated, no transfer to emergency department, no radiology order, and no new antibiotic or diuretic orders. There was no documentation to hold Resident #1's medications or to follow-up with the Medical Provider. The documented transcript revealed Nurse #1 had incorrectly reported Resident #1 had received a sulfonamide antibiotic. Review of Nurse #1's progress note dated 06/29/26 at 11:25 PM indicated Resident #1 rested in bed with even and unlabored respirations, had no complaints of pain or discomfort, and Nurse #1 had notified the on-call Medical Provider related to medications. The on-call Medical Provider wanted Resident #1 monitored for the next 24 hours and vital signs taken every 2 hours for the next 8 hours and the Director of Nursing (DON) had been notified. Review of Resident #1's medical records revealed there was no evidence the RP was notified of the medication errors on 06/29/26. During a telephone interview on 07/29/26 at 12:13 PM, Nurse #1 confirmed she accidentally administered Resident #2's scheduled 9:00 PM medications in error on 06/29/26 to Resident #1. Nurse #1 stated when she realized she had given Resident #1 the wrong medications, she called the on-call Medical Provide and reported she administered an antibiotic (she could not recall by name) to Resident #1 and reported Resident #1 had an allergy to sulfa. Nurse #1 stated before she could finish reporting all of the medications she administered, the on-call Medical Provider said to monitor Resident #1 for 24 hours and take vital signs every two hours for eight hours. Nurse #1 stated she did not accurately report the medications that were given to Resident #1 to the on-call Medical Provider because she was interrupted. Nurse #1 revealed after she spoke with the on-call Medical Provider she called the DON and reported she administered Resident #2's medications to Resident #1 and the DON told her to document a nurse's progress note in Resident #1's medical record and inform the on-coming nurse (Nurse #4) and that was what she did. Nurse #1 did not report the medication error to Resident #1's RP and stated she was overwhelmed, frustrated, had no additional help, and was unfamiliar with the facility as it was her first shift. During an interview on 07/29/26 at 2:37 PM, the DON explained she received a call between 10:00 PM or 11:00 PM on 06/29/26 from Nurse #1. Nurse #1 reported she had administered Resident #2's medications to Resident #1 but they did not discuss which medications were given to Resident #1 during the call. The DON revealed Nurse #1 reported she had called the on-call Medical Provider and received orders to monitor Resident #1 and take vital signs every two hours for eight hours. The DON revealed the protocol for a medication error was to inform the Medical Provider and Nurse #1 said she had and the DON thought the medication error had been addressed by the on-call Medical Provider. The DON stated she directed Nurse #1 to write a nurse's progress note in Resident #1's medical record and inform the on-coming nurse (Nurse #4) about the error and monitoring Resident #1's vital signs but did not discuss notifying Resident #1's RP with Nurse #1. The DON revealed on 06/30/26 when Resident #1's change of condition occurred she discussed the medication error with Resident #1's RP who requested the Resident #1 be sent to the hospital. The DON revealed Nurse #1 was expected to notify Resident #1's RP on 06/29/26 about the medication error. Review of a progress note written by Nurse #2 on 06/30/26 at 1:11 PM revealed Resident #1 was groggy and nauseated, the NP was notified and provided new orders for IV fluids and labs that included complete blood count, comprehensive metabolic panel, and urinalysis with culture and sensitivity. A second progress note written by Nurse #2 on 06/30/26 at 1:56 PM revealed Resident #1 complained of lightheadedness and nausea and the NP was notified. A change of condition documented by Nurse #2 on 06/30/26 at 4:11 PM revealed Resident #1 vital signs were abnormal with a blood pressure 96/35, heart rate 45, and oxygen 90% with supplemental oxygen. Nurse #2 noted Resident #1 as having altered mental status, nausea and vomiting, and the NP had recommended to send to emergency room for higher level of care. During an interview on 07/28/26 at 11:31 PM, Nurse #2 revealed during shift change it was reported Resident #1 received Resident #2's medications in error on 06/29/26. She did not know which medications were given but was told the on-call Medical Provider had been notified and they were monitoring Resident #1 and her vital signs had been stable throughout the night. Nurse #2 confirmed she did not notify Resident #1's RP about the medication error that occurred on 06/29/26 and stated either the administering nurse, DON or Medical Provider notified the resident's RP of medication errors. An interview was conducted on 07/29/26 at 11:25 AM and follow-up telephone interview was conducted on 07/31/26 at 10:58 AM with the NP. The NP confirmed on 06/30/26, Nurse #2 called to report Resident #1's change of condition and Resident #1 had received Resident #2's 9:00 PM medications on 06/29/26. The NP confirmed she provided orders to obtain labs, start IV fluids and hold Resident #1's 2:00 PM medications. The NP revealed Resident #1's change of condition and medication error were discussed with Resident #1's RP on 06/30/26 and the decision was made to send Resident #1 to the hospital for further evaluation. The NP stated the medications Resident #1 received on 06/29/26 and 06/30/26 and named metoprolol, carvedilol, clonazepam, buprenorphine-naloxone, trazodone, lorazepam, oxycodone were directly related to Resident #1's change of condition symptoms of bradycardia, decrease in respiratory status, and altered mental status. The NP stated the additional hypertension and sedating medications administered placed Resident #1 at significant risk of an overdose. The NP explained due to risk of overdose she considered the situation as a medical emergency. Review of the emergency medical services (EMS) record revealed on 06/30/26 at 4:15 PM, EMS was called to the facility. EMS noted the reason for Resident #1's transfer to the hospital as administered the wrong medications on 06/29/26 and listed gabapentin, buprenorphine-naloxone, clonazepam, duloxetine, trazodone, amoxicillin-potassium clavulanate and metoprolol. EMS noted Resident #1 had also received her routine medications oxycodone, beta blockers, and insulin on 06/30/26 and developed symptoms of increased hypotension and lethargy. Resident #1 had reported feeling strange, had pinpoint pupils and her respiratory status was noted as equal and adequate. Resident #1 was placed on 4 liters per minute oxygen and vital signs at 4:48 PM were blood pressure 96/63, heart rate 45, respiratory rate 22, oxygen 99%, and blood sugar 46. EMS administered Resident #1, 15 grams of dextrose 10% via IV with improved response and blood sugar at 5:09 PM was 206. Normal saline 500 milliliters IV bolus was administered and EMS noted Resident #1's heart rate as sustained bradycardia at 45 to 50 and systolic blood pressure in the 90's. Review of the emergency room report dated 06/30/26 revealed Resident #1 was transferred for evaluation of altered mental status and bradycardia after accidentally receiving another resident's nighttime medications and listed notable medications given as duloxetine, gabapentin, buprenorphine-naloxone, clonazepam, metoprolol, and trazodone. The report indicated it was unknown if Resident #1 had received her scheduled medications as well but did receive the scheduled medications on 06/30/26 and listed oxycodone, lorazepam, carvedilol, amlodipine, and insulin. The report revealed Resident #1's initial blood glucose with EMS was low and 10 % dextrose was administered during transport. Resident #1's initial vital signs in the emergency room were heart rate 58, blood pressure 108/53, respiratory rate 18, oxygen 98% and Resident #1 presented drowsy but arousable to voice, had pinpoint pupils, and a normal respiratory rate. Resident #1 was placed on a non-invasive bilevel positive airway pressure (BiPap) for mild respiratory acidosis. An electrocardiogram (records the hearts electric activity) noted Resident #1's past history of bradycardia and atrial fibrillation but identified a new second-degree atrioventricular block (impaired electric signals to the lower heart) not previously seen and noted the cause may be due to additional doses of atrioventricular blockers (metoprolol, carvedilol) and calcium gluconate was given as a treatment. Review of the hospital history and physical revealed on 06/30/26 at 5:30 PM Resident #1's heart rate was 44, oxygen saturation 94 % with supplemental oxygen, and blood pressure 108/53. Resident #1 was somnolent, encephalopathic (brain dysfunction), pupils were pinpoint, and labs revealed hyperkalemia 6.4 (normal 3.5 -5.0), sodium 133 (normal 135 - 145), creatinine 1.92 (normal 0.59 -1.04). The hospital diagnoses were accidental medication overdose, hyperkalemia, mild hyponatremia, acute kidney injury, acute/chronic respiratory failure, junctional escape rhythm (a backup heart rhythm that takes over when the heart's main natural pacemaker (the sinus node) slows down or fails) with underlying atrial fibrillation. Resident #1 received a bronchodilator (increases airflow) medication, calcium gluconate, a potassium binder to treat hyperkalemia, normal saline IV fluids, furosemide (diuretic) 40 mg, and sodium bicarbonate and her routine medications were withheld. On 07/03/26 Resident #1 was discharged back to the facility in stable condition. During an interview on 07/28/26 at 5:20 PM and 07/30/26 at 4:03 PM, the Medical Director confirmed the information reported by Nurse #1 on 06/29/26 to the on-call Medical Provider was vital and influenced the on-call Medical Provider's clinical decisions on how to proceed with Resident #1's care. The Administrator was notified of the Immediate Jeopardy (IJ) on 08/17/26 at 2:18 PM. The facility provided the following corrective action plan with a compliance date of 07/04/26. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 6/29/2026, at approximately 10:45 pm Resident #1 was accidentally administered Resident #2's medication which included Duloxetine 30 mg, Montelukast Sodium 10 mg, Omeprazole 20 mg, Trazadone 100 mg, Amoxicillin-Clavulanate 875/125 mg, Metoprolol Tartrate 12.5 mg, Acetaminophen 1000 mg, Doxycycline 100 mg, Buprenorphine HCI-Naloxone 8/2 mg, Gabapentin 300 mg, Bio freeze 4% gel, and Clonazepam 1mg. Resident #1 was administered her routine nighttime medications following the administration of Resident #2's-night time medications which include Buspirone HCI 15mg, Rosuvastatin Calcium 10 mg, Melatonin 3 mg, Aricept 10 mg, Trazadone 150 mg, Apixaban 2.5 mg, Simethicone 180 mg and Acetaminophen 1000 mg by Nurse #1. On 6/29/2026, Nurse #1 notified the on-call Medical Provider but failed to disclose to the on-call Medical Provider the entirety of the medication error. Nurse #1 notified the on-call Medical Provider of medication error related only to an antibiotic and the on-call Medical Provider gave an order to monitor Resident #1 a for change of condition for the next 24 hours and obtain vital signs every 2 hours for 8 hours and if any changes were noted to notify Medical Provider. On 6/29/2026, following communication with on-call Medical Provider, Nurse #1 notified Director of Nursing of the medication error and orders given by Medical Provider. Nurse #1 did not notify Resident #1's family of the medication error during 3:00 pm to 11:00 pm shift. Resident #1 remained stable throughout the night and was at baseline with no changes noted in vital signs. The Nurse Practitioner (NP) was not made aware of the full extent of the medication error until change of condition noted on 6/30/2026 by Nurse #2. On 6/30/2026 Nurse #2 administered Resident #1's routine morning medications as ordered. At approximately 1:00 pm, Resident #1 was unable to consume her afternoon meal due to nausea and lightheadedness. Resident #1 vital signs were obtained by Nurse #2. Blood pressure 96/35, pulse 44, respiratory rate 16, temperature 98.1 and oxygen saturation 90% on 2 liters of oxygen. The NP was notified by Nurse #2 that Resident #1 had received Resident #2's nighttime medications as well as her own routine nighttime medication as listed above and the Nurse Practitioner gave orders to hold 2:00 PM medications which included Buspirone HCI 15mg (Anxiety), Acetaminophen 1000mg (Pain), Oxycodone HCI 2.5mg (Pain), Lorazepam 0.5mg (Anxiety), Simethicone 180mg (Flatulence), Probiotic Oral Capsule (gut health) and to start intravenous (IV) fluids, obtain labs to include a complete blood count and complete metabolic panel and urinalysis with culture and sensitivity. On 6/30/2026, the Administrator updated Resident #1's family of the medication error/change in condition and new orders. At approximately 4:15 pm, Resident #1's family requested the resident be sent to hospital for evaluation and treatment. The NP was notified by Nurse #2 and an order was obtained to send Resident #1 to the Emergency Department (ED) for evaluation and treatment. At approximately 4:50 pm, Resident #1 left facility via stretcher with emergency medical services in route to hospital. On 6/30/2026, Resident #1 was treated in the hospital Emergency Department for bradycardia and hyperkalemia. Treatment included calcium gluconate, furosemide, normal saline IV fluids, sodium zirconium cyclosilicate (treats hyperkalemia by removing potassium from body), and sodium bicarbonate. Resident #1 was monitored throughout the night with improvements in heart rate and potassium levels. On 7/2/2026, Resident #1 resumed chronic medication regimen without any issues. Resident #1 was discharged from hospital and returned to facility on 7/3/2026 with no new orders. On 6/30/2026, the Director of Nursing informed the scheduler that Nurse #1 is to be placed on the do not return list. On 7/3/2026, the Director of Nursing spoke with the Staffing Agency to notify of incident and let them know to place Nurse #1 on the do not return list. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/30/2026, the Director of Nursing reviewed the clinical alerts dashboard and nursing notes for the past 30 days to identify any changes of condition to ensure that they were addressed per facility policy including notification of provider and Responsible Party notified. The results were no acute changes of condition noted that were not addressed to include Medical Provider and Responsible Party notification following review of change of condition assessment and nursing and Medical Provider notes in medical records of residents identified as having a change in condition. This was completed on 6/30/2026. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/30/2026, the DON began in person and via phone education of all full time, part time, and as needed licensed nurses including agency nurses, medication aides and certified nursing assistants on the following topics: Change of Condition- Identification and Response to include notification of all details related to the change in condition at time in which change of condition noted to the provider per facility policy. The policy was reviewed at time education was initiated by the Quality Assurance Nurse Consultant. Following review, the policy outlined the expectations related to resident assessments, provider and resident Responsible Party notification and documentation requirements. No revisions were necessary at this time. Corrective actions focused on staff education and reinforcing the existing policy. Topics Included:What is a change of condition?What to do when a change of condition is noted to include notification of physician or medical provider especially of medication errors in their entirety to include all medications administered in error and to notify the Director of Nursing if there are any issues encountered during communication of change of condition/medication error to the provider to ensure the Medical Provider can make necessary adjustments to the resident care to ensure their safety and wellbeing and notification of resident's Responsible Party and document in resident's medical record. The Director of Nursing confirmed understanding of education provided by having staff to verbalize the steps to be completed when a change of condition is identified including notification of the medical provider and Responsible Party prior to signing in-service sign in log. As of 7/3/2026 15% staff had not attended the in-service. The Director of Nursing and Assistant Director of Nursing are monitoring staff to ensure education is completed. On 7/3/2026, The Regional Director of Operations informed the DON of her responsibility to ensure that any of the above identified staff who does not complete the in-service training by 7/3/2026 will not be allowed to work until the training is completed. This in-service was incorporated into the new agency employee orientation and will continue in the new employee facility orientation for the above identified staff by the Director of Nursing or Staff Development Coordinator. On 7/1/2026, a quality assurance (QA) meeting was held with the Interdisciplinary Team (IDT) to discuss investigation finding and develop a plan to correct with monitoring to begin the week of 7/6/2026. The IDT consist of the Administrator, Director of Nursing, MDS Coordinator, Assistant Director of Nursing, Nurse, Therapy Manager, Health Information Manager, and Dietary Manager. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Beginning the week of 7/6/2026, The DON will monitor this issue using the Change of Condition Quality Assurance Tool. The DON or designee will complete the monitoring tool weekly for 4 weeks then monthly x 2 months to ensure that any change of condition related to medication administration for protentional medication error is identified promptly and addressed to include notification of the medical provider and Responsible Party per facility policy. Additionally, the Director of Nursing will review the Clinical Alerts Dashboard/ 24-hour reports during daily clinical meeting Monday through Friday to evaluate that any changes in condition identified have been communicated fully to the medical provider and Responsible Party including any medication errors. The Director of Nursing will follow-up with the Medical Provider on their next visit to the facility or via phone to ensure any identified changes of condition were fully disclosed at time change noted. The IDT to review in weekly QA meeting or until resolved by the Quality Assurance (QA) Committee. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed and updated if needed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Assistant Director of Nursing, Nurse, Therapy Manager, Health Information Manager, and Dietary Manager.Date of compliance: 7/4/2026On 08/20/26, an onsite validation of the facility's Immediate Jeopardy (IJ) removal plan was conducted.Review of the QA meeting dated 07/01/26 revealed the DON informed the QA committee and discussed the medication errors made by Nurse #1, change of condition requirements, the root cause analysis and the plan of correction was approved and initiated. QA committee meetings continued weekly and included the plan of correction review for notification.Review of monitoring tools for change of condition started on 07/06/26 included weekly review of five residents that were checked for notification to the Medical Provider and RP. Information reviewed for change of condition included clinical reports, progress notes, abnormal change of condition progress notes, vital signs, medication, diagnostics, treatment reports, admitted and discharged residents, and room changes, Review of the educational in-service were signed by licensed nurse staff, Medication Aides, and Nurse Aides (NA) to indicate they attended. The education started on 06/30/26 and the topics reviewed: What is the change of condition and what to do if a change of condition is noted. The education included to always notify the medical provider, especially of medication errors and to include all medications administered, and to notify the Director of Nursing if there are any issues encountered during communication with the Medical Provider. Included in the education was a list of the most common signs of change in condition.Interviews with Licensed Nurse and Medication Aide staff revealed they recently received education on change of condition. Nurses and Medication Aide staff revealed for change of condition the nurse completed a head-to-toe assessment, obtained vital signs, reported their findings to Medical Provider and if a medication error occurred to report all the medications administered to the resident and DON and document their findings and their report to the Medical Provider in the resident's medical record. Nurse revealed they were responsible for notifying a resident's RP of a medication error and change of condition when it occurred. Nurse and Medication Aide staff were able to list what constituted a change in condition as decrease in alertness or altered mental status, increased sleepiness, a new onset of nausea and vomiting, decrease in appetite, change in speech and mobility. Interviews with NA staff revealed they recently received in-service education related to identifying a change of condition in a resident. NA staff identified a change of condition as a decrease in alertness or altered mental status, increased sleepiness, a new onset of nausea and vomiting, decrease in appetite, change in speech and mobility and stated they immediately reported a change of condition to the nurse.Interviews with alert and oriented residents revealed no concerns of being given the wrong medication or a sudden change of condition related to medication administration were shared. The immediate jeopardy removal and compliance date of 07/04/26 was validated.

Based on record review, observations, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to have effective systems in place to prevent significant medication errors. On 06/29/26, Nurse #1, who was an agency nurse, administered Resident #1's scheduled 9:00 PM medications trazodone (antidepressant), apixaban (anticoagulant), acetaminophen (non-opioid analgesic), buspirone (anxiolytic), and donepezil (cholinesterase inhibitor). Nurse #1 then administered scheduled 9:00 PM medications for Resident 2 who resided in the room next to Resident #1, to Resident #1. The nurse administered the following medication to Resident #1: duloxetine (serotonin-norepinephrine reuptake inhibitor), trazodone (antidepressant), amoxicillin-potassium clavulanate (penicillin-class antibacterials combined with beta-lactamase inhibitors), doxycycline (tetracycline antibiotics), metoprolol tartrate (beta blockers), acetaminophen, buprenorphine-naloxone (opioid partial agonists and opioid antagonists), clonazepam (benzodiazepine), and gabapentin (anticonvulsant). On 06/30/26, Nurse #2 administered Resident #1's scheduled 8:00 AM medications: insulin lispro injection (rapid-acting human insulin analog), lorazepam (benzodiazepine), oxycodone (opioid/narcotic analgesics), amlodipine besylate (calcium channel blockers), empagliflozin (sodium-glucose co-transporter 2 inhibitor), fluoxetine (selective serotonin reuptake inhibitor), losartan potassium (angiotensin II receptor blockers), torsemide (loop diuretic), apixaban, carvedilol (non-selective beta-blocker and alpha-1 blocker), acetaminophen, and buspirone. At 9:00 AM, Nurse #2 administered Resident #1's scheduled insulin glargine injection (long-acting insulins) and at 12:00 PM administered the scheduled insulin lispro (rapid-acting human insulin analog) injection. Resident #1 did not eat lunch and started to exhibit symptoms of altered mental status and nausea and vomiting. Her blood pressure dropped to 96/35 (normal is 120/80), heart rate dropped to 45 (normal is 60-100), and oxygen level was 90% (normal is 95-100%). Emergency Medical Services (EMS) were called, and enroute to the hospital Resident #1 received 10% dextrose (carbohydrate, caloric source, and hypoglycemia antidote) for a low blood sugar reading of 46 hypoglycemia (low blood sugar below 70) and intravenous fluids (IV) with systolic blood pressure (top number) readings mostly in the 90's and heart rate was between 40 and 50. Resident #1 presented at the hospital as somnolent (excessive sleepiness), with pinpoint pupils (abnormally small, constricted pupils clinically significant known effect from opioid use or overdose) and a heart rate of 44 with bradycardia (heart rate below 60) and was significantly encephalopathic (change in body or brain that leads to altered mental status). Resident #1 was admitted to the hospital and placed on a non-invasive bilevel positive airway pressure (BiPap) for mild respiratory acidosis (a medical condition where your blood becomes too acidic (pH below 7.35) because your lungs cannot remove enough carbon dioxide). Resident #1 was diagnosed with accidental overdose, acute kidney injury (decline in the kidneys ability to filter waste, regulate electrolytes and maintain fluid balance), acute/chronic respiratory failure (inability of the lungs to maintain adequate oxygen or carbon dioxide levels), hyperkalemia (high potassium), mild hyponatremia (low sodium), and a junctional escape rhythm with underlying atrial fibrillation (irregular heart rhythm) with the electrocardiogram (ECG) identifying a new second-degree atrioventricular block (impaired electric signals to the lower heart) and noted the cause may be due to additional doses of beta blockers (metoprolol, carvedilol). The medications received in error and the continuation of scheduled medications resulted in Resident #1 receiving sedating and antidepressant medications that placed Resident #1 at substantial risk for oversedation, aspiration, falls, hypoventilation, and serotonin syndrome (serotonin syndrome can occur if the dose of a medication was increased, started taking a new medication and most often caused by combining medications that contain serotonin, such as an antidepressant and potentially a life-threatening condition). The addition of metoprolol with Resident #1's donepezil increased the risk of bradycardia and when administered together donepezil, trazodone, and duloxetine, fluoxetine had the high risk of causing a prolonged QT wave (how long it takes for the heart to squeeze and refill with blood before it beats again) which had the high risk of causing a torsades de pointes (life-threatening abnormal heart rhythm), syncope (loss of consciousness), cardiac arrest, and sudden death. The deficient practice affected 1 of 3 residents reviewed for significant medication errors (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's cumulative diagnoses included: dementia, atrial fibrillation, heart failure, hypertension, hyperlipidemia, pulmonary hypertension, and anxiety disorder. Review of Resident #1's active physician orders included:trazodone 150 milligrams (mg) at bedtime for insomnia and mood.apixaban 2.5 mg twice a day for atrial fibrillation.acetaminophen 500 mg give 2 tablets (1,000 mg) three times a day for pain. buspirone 15 mg three times a day for anxiety. donepezil 10 mg at bedtime for dementia. Review of Resident #1's Medication Administration Record (MAR) revealed Nurse #1 initialed the following medications scheduled at 9:00 PM on 06/29/26 to indicate trazodone 150 mg, apixaban 2.5 mg, acetaminophen 1,000 mg, buspirone 15 mg, and donepezil 10 mg were administered. Resident #2 was admitted to the facility on [DATE]. Resident #2's cumulative diagnoses included: acute on chronic respiratory failure, heart failure, atrial fibrillation, insomnia, major depressive disorder, anxiety disorder, and chronic pain. Review of Resident #2's active physician orders included:duloxetine 30 mg at bedtime for depression.trazodone 100 mg at bedtime for insomnia.amoxicillin-potassium clavulanate 875-125 mg every 12 hours for cellulitis.doxycycline 100 mg twice a day for cellulitis. metoprolol tartrate 12.5 mg every 12 hours for hypertension.acetaminophen 500 mg give 2 tablets (1,000 mg) three times a day for pain or fever.buprenorphine-naloxone 8-2 mg give 1 tablet sublingually three times a day for pain hold if sedated.clonazepam 1 mg give 1 tablet by mouth three times a day for anxiety.gabapentin 300 mg give 1 capsule by mouth three times a day for neuropathy. Review of Resident #2's MAR revealed Nurse #1 initialed the medications scheduled at 9:00 PM and 10:00 PM on 06/29/26 to indicate duloxetine 30 mg, trazodone 100 mg, amoxicillin-potassium clavulanate 875-125 mg, doxycycline 100 mg, metoprolol tartrate 12.5 mg, acetaminophen 1,000 mg, buprenorphine-naloxone 8-2 mg, clonazepam 1 mg, and gabapentin 300 mg were administered. Review of the medication error form for Resident #1 completed by the Director of Nursing (DON) revealed on 06/29/26 at 10:15 PM the facility was aware Nurse #1 had administered the wrong medication to Resident #1. The list of medications given in error were duloxetine 30 mg, trazodone 100 mg, amoxicillin-potassium clavulanate 875-125 mg, doxycycline 100 mg, metoprolol tartrate 12.5 mg, acetaminophen 1,000 mg, buprenorphine-naloxone 8-2 mg, clonazepam 1 mg, and gabapentin 300 mg. The information on the form did not include Resident #1 had received her scheduled 9:00 PM medications. The form included a description of what caused the medication error as the use of agency Nurse #1 and first time at facility. Review of Resident #1's list of allergies included erythromycin (macrolide antibiotic) and sulfa (sulfonamides) antibiotics. Review of the documented transcript completed by the on-call Medical Provider dated 06/29/26 at 10:30 PM included what Nurse #1 reported to the on-call provider. Nurse #1 reported she administered sulfamethoxazole/trimethoprim (sulfonamides) by mistake to a resident (Resident #1), who the nurse reported had a sulfa allergy, and Resident #1 had no complaints at this time. Resident #1's vital signs were included for blood pressure of 111/61, heart rate 50, respiratory rate 16, temperature 98.4, and oxygen 97%. The on-call Medical Provider documented their response was to monitor Resident #1 for any reaction, monitor vital signs every two hours for eight hours and Resident #1's care was not escalated, no transfer to emergency department, no radiology order, and no new antibiotic or diuretic order. There was no documentation to hold Resident #1's medications or to follow-up with the Medical Provider. The documented transcript revealed Nurse #1 had incorrectly reported Resident #1 had received a sulfonamide antibiotic. Resident #1 had not received a sulfonamide antibiotic. Review of Nurse #1's progress note dated 06/29/26 at 11:25 PM indicated Resident #1 rested in bed with even and unlabored respirations, had no complaints of pain or discomfort, and Nurse #1 had notified the on-call Medical Provider related to medications. The on-call Medical Provider wanted Resident #1 monitored for the next 24 hours and vital signs taken every 2 hours for the next 8 hours and the Director of Nursing (DON) had been notified. During a telephone interview on 07/29/26 at 12:13 PM, Nurse #1 revealed she was an agency nurse and no longer worked at the facility after 06/29/26. Nurse #1 explained on 06/29/26 she arrived late at approximately 4:00 PM and had difficulty with her login credentials to gain access to the MAR and started her 9:00 PM medication pass late at around 10:00 PM or 10:30 PM. She revealed her medication cart was placed between the rooms of Resident #1 and Resident #2 that were located side-by-side. Nurse #1 stated she administered Resident #2's 9:00 PM scheduled medications first to Resident #2. Nurse #1 confirmed the 9:00 PM medications for Resident #2, she initialed and checked off on Resident #2's MAR indicated she had administered the medications. Nurse #1 revealed she administered Resident #1's 9:00 PM scheduled medications to Resident #1 and confirmed the 9:00 PM medications for Resident #1, she initialed and checked off on Resident #1's MAR indicated she had administered the medications. Nurse #1 further revealed she accidentally administered Resident #2's scheduled 9:00 PM medications in error on 06/29/26 to Resident #1. Nurse #1 stated when she realized she had given Resident #1 the wrong medications; she called the on-call Medical Provider. Nurse #1 stated she reported Resident #1 was given an antibiotic (she could not recall by name) to Resident #1 who had an allergy to sulfa and buprenorphine-naloxone but before she could finish reporting all of the medications she administered, the on-call Medical Provider said to monitor Resident #1 for 24 hours and take vital signs every two hours for eight hours. Nurse #1 confirmed she did not report all the medications that were given to Resident #1 to the on-call Medical Provider. Nurse #1 revealed after she spoke with the on-call Medical Provider she called the DON and reported she administered Resident #2's medications to Resident #1 and the DON told her to document a nurse's progress note in Resident #1's medical record and inform the on-coming nurse (Nurse #4) and that's what she did. Nurse #1 stated she did not tell the DON Resident #1 had received her own medications in addition to Resident #2's medications. When asked why she gave Resident #1 her scheduled 9:00 PM medications and in addition gave Resident #2's scheduled 9:00 PM medications to Resident #1, Nurse #1 stated she felt overwhelmed, frustrated, had no additional help, it was her first shift, and she was unfamiliar with the facility. Nurse #1 explained when administering medications to a resident she reviewed the resident's picture in the medical record, reviewed their MAR, checked the resident's name on their room door, and addressed them by name. During an interview on 07/29/26 at 2:37 PM, the DON explained she received a call between 10:00 PM or 11:00 PM on 06/29/26 from Nurse #1. Nurse #1 reported she had administered Resident #2's medications to Resident #1 and had called the on-call Medical Provider and received orders to monitor Resident #1 and take vital signs every two hours for eight hours. The DON stated she directed Nurse #1 to write a nurse's progress note in Resident #1's medical record and inform the on-coming nurse (Nurse #4) about the error and monitoring Resident #1's vital signs. The DON revealed she did not discuss which medications were given to Resident #1 during her phone call with Nurse #1. The DON revealed the protocol for a medication error was to inform the Medical Provider and Nurse #1 said she had and the DON thought the medication error had been addressed by the on-call Medical Provider. Review of Resident #1's vital signs documented by Nurse #4 on 06/30/26 revealed at 12:05 AM Resident #1's heart rate was 81, respiratory rate 16, blood pressure 127 / 82, oxygen saturation 93%. At 2:03 AM heart rate 83, respiratory rate 16, blood pressure 129 / 83, oxygen saturation 95%. At 4:13 AM heart rate 84, respiratory rate 16, blood pressure 126 / 79, oxygen saturation 95%. At 6:21 AM heart rate 84, respiratory rate 16, blood pressure 127 / 81, oxygen saturation 95%. During a telephone interview on 07/28/26 at 1:32 PM, Nurse #4 confirmed she worked on 06/29/26 and started her shift at 10:45 PM and worked through 6:45 AM on 06/30/26 and was the assigned nurse for Resident #1. Nurse #4 revealed during the shift change report Nurse #1 reported she gave Resident #1 the wrong medication and the on-call Medical Provider and DON were notified. Nurse #4 revealed it was not reported which medications were administered in error, but she was instructed to monitor vital signs every 2 hours and stated she checked the vital signs and Resident #1 slept through the night. Nurse #4 stated she did not administer any medications to Resident #1 during her shift. During an interview on 07/28/26 at 11:31 PM, Nurse #2, confirmed she worked on 06/30/26 and started her shift at approximately 7:00 AM and was the assigned nurse for Resident #1. Nurse #2 revealed during shift change report Nurse #4 reported Resident #1 had received Resident #2's medications in error on 06/29/26. Nurse #2 further explained Nurse #4 had informed her she did not know which medications were given but was told the on-call Medical Provider had been notified, they were monitoring Resident #1, and her vital signs had been stable throughout the night. Review of Resident #1's MAR revealed on 06/30/26, Nurse #2 administered the following scheduled medications: 8:00 AM:losartan potassium 100 mg. torsemide 20 mg give 3 tablets (60 mg). apixaban 2.5 mg. carvedilol 6.25 mg. acetaminophen 500 mg give 2 tablets (1,000 mg). buspirone 15 mg. insulin lispro inject 10 units subcutaneously before meals for diabetes mellitus with blood sugar reading of 214. lorazepam 0.5 mg. oxycodone 2.5 mg. amlodipine besylate 10 mg. empagliflozin 25 mg. fluoxetine 20 mg.9:00 AM:insulin glargine subcutaneous inject 40 units one time a day for diabetes mellitus. 12:00 PM:insulin lispro inject 10 units subcutaneously before meals for diabetes mellitus with blood sugar reading at 12:00 PM of 102. Review of a progress note written by Nurse #2 on 06/30/26 at 1:11 PM revealed Resident #1 was groggy and nauseated, and the NP was notified and provided new orders for intravenous fluids, obtain the following labs, a complete blood count, comprehensive metabolic panel, and urinalysis with culture and sensitivity. A progress note written by Nurse #2 on 06/30/26 at 1:56 PM revealed Resident #1 complained of lightheadedness and nausea, and the blood pressure was 96/35 and heart rate 44 and the NP was notified. On 06/30/26 at 2:11 PM, Nurse #2 initialed Resident #1's MAR to indicate one-liter normal saline fluids at 65 milliliters per hour one time only for 2 days for low blood pressure was started and STAT (immediately) labs ordered for comprehensive metabolic panel, complete blood count, urinalysis with culture for nausea and low blood pressure. A change of condition progress note documented by Nurse #2 on 06/30/26 at 4:11 PM revealed Resident #1's vital signs were abnormal with a blood pressure 96/35, heart rate 45, and oxygen 90%. Resident #1 change of condition was noted as altered mental status, nausea and vomiting. Nurse #2 notified the provider who recommended to send to emergency room for higher level of care. During an interview on 07/28/26 at 11:31 PM, Nurse #2 explained when she administered Resident #1's morning medications around 7:30 AM or 8:00 AM, Resident #1 seemed fine and it was after lunch when Resident #1 complained of nausea and lightheadedness. Nurse #2 revealed she did not know which medications Resident #1 received in error on 06/29/26 when she first called the NP and they did not discuss the medications. When she called the NP a second time, Nurse #2 revealed she did inform the NP about the medication error on 06/29/26 and Nurse #1 administered Resident #2's scheduled 9:00 PM medications to Resident #1. Nurse #2 revealed the NP provided new orders to collect labs and start IV fluids and withhold Resident #2's scheduled 2:00 PM medications. Nurse #2 revealed when Resident #1's change of condition occurred with symptoms of altered mental status and the heart rate and blood pressure dropped; she notified the NP and received an order to send Resident #1 to the hospital. An interview was conducted on 07/29/26 at 11:25 AM and follow-up telephone interview was conducted on 07/31/26 at 10:58 AM with the NP. The NP confirmed on 06/30/26, Nurse #2 called to report Resident #1's complaints of nausea, feeling groggy and lightheadedness. The NP revealed she was not aware of all the medications Resident #1 was administered on 06/29/26 but received report from Nurse #2 on 06/30/26, Resident #1 had received Resident #2's 9:00 PM medications and she provided orders to obtain labs, start IV fluids and hold Resident #1's 2:00 PM medications. The NP revealed the medications Resident #1 received on 06/29/26 and 06/30/26 and named metoprolol, carvedilol, clonazepam, buprenorphine-naloxone, trazodone, lorazepam, oxycodone were directly related to Resident #1's change of condition symptoms of bradycardia, decrease in respiratory status, and altered mental status. The NP stated the additional hypertension and sedating medications administered placed Resident #1 at significant risk of an overdose. The NP explained due to risk of overdose she considered the situation as a medical emergency. Review of the emergency medical services (EMS) record revealed on 06/30/26 at 4:15 PM, EMS was called to the facility. EMS noted the reason for Resident #1's transfer to the hospital as administered the wrong medications on 06/29/26 and listed gabapentin, buprenorphine-naloxone, clonazepam, duloxetine, trazodone, amoxicillin-potassium clavulanate and metoprolol. EMS noted Resident #1 had also received her routine medications oxycodone, beta blockers, and insulin on 06/30/26 and developed symptoms of increased hypotension and lethargy. Resident #1 reported feeling strange, had pinpoint pupils and her respiratory status noted as equal and adequate. Resident #1 was placed on 4 liters per minute oxygen and vital signs at 4:48 PM were blood pressure 96/63, heart rate 45, respiratory rate 22, oxygen 99%, and blood sugar 46. EMS administered Resident #1, 15 grams of dextrose 10% via IV with improved response and blood sugar at 5:09 PM was 206, normal saline 500 milliliters IV bolus. EMS noted Resident #1's heart rate as sustained bradycardia at 45 to 50 and systolic blood pressure in the 90's. Review of the emergency room report dated 06/30/26 revealed Resident #1 was transferred for evaluation of altered mental status and bradycardia after accidentally receiving another resident's nighttime medications and mentioned the notable medications given as duloxetine, gabapentin, buprenorphine-naloxone, clonazepam, metoprolol, and trazodone. The report indicated it was unknown if Resident #1 had received her scheduled medications as well but did receive the scheduled medications on 06/30/26 which included oxycodone, lorazepam, carvedilol, amlodipine, and insulin. The report revealed Resident #1's initial blood glucose with EMS was low and 10 % dextrose was administered during transport. Resident #1's initial vital signs in the emergency room were heart rate 58, blood pressure 108/53, respiratory rate 18, oxygen 98% and presented drowsy but arousable to voice, had pinpoint pupils, and a normal respiratory rate. Resident #1 was placed on a non-invasive bilevel positive airway pressure (BiPap) for mild respiratory acidosis. An electrocardiogram (records the hearts electric activity) noted Resident #1's past history of bradycardia and atrial fibrillation but identified a new second-degree atrioventricular block (impaired electric signals to the lower heart) not previously seen and noted the cause may be due to additional doses of atrioventricular blockers (metoprolol, carvedilol) and calcium gluconate was given as a treatment. Review of the hospital history and physical revealed on 06/30/26 at 5:30 PM Resident #1's heart rate was 44, oxygen saturation 94 % with supplemental oxygen, and blood pressure 108/53. Resident #1 was somnolent, encephalopathic (brain dysfunction), pupils were pinpoint, and labs revealed hyperkalemia 6.4 (normal 3.5 -5.0), sodium 133 (normal 135 - 145), creatinine 1.92 (normal 0.59 -1.04). The hospital diagnoses were accidental medication overdose, hyperkalemia, mild hyponatremia, acute kidney injury, acute/chronic respiratory failure, junctional escape rhythm (a backup heart rhythm that takes over when the heart's main natural pacemaker (the sinus node) slows down or fails) with underlying atrial fibrillation. Resident #1 received a bronchodilator (increases airflow) medication, calcium gluconate, a potassium binder to treat hyperkalemia, normal saline IV fluids, furosemide (diuretic) 40 mg, and sodium bicarbonate and her routine medications were withheld. On 07/03/26 Resident #1 was discharged back to the facility in stable condition. During telephone interviews on 07/28/26 at 5:20 PM and 07/30/26 at 4:03 PM, the Medical Director stated the medications Resident #1 received, he considered as significant error due to the sedating side effects that included bradycardia, decreased respiratory rate, and altered mental status. The Medical Director confirmed the contributing factor to Resident #1's change of condition on 06/30/26 was related to medications administered on 06/29/26 by Nurse #1 and the combination of the scheduled medications administered on 06/30/26. The Administrator was notified of the Immediate Jeopardy (IJ) on 08/17/26 at 2:18 PM. The facility provided the following corrective action plan with a compliance date of 07/04/26. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 6/29/2026, at approximately 10:45 pm Resident #1 was accidentally administered Resident #2's medication which included Duloxetine 30 milligrams, Trazadone 100 mg, Amoxicillin-Clavulanate 875/125 mg, Metoprolol Tartrate 12.5 mg, Acetaminophen 1,000 mg, Doxycycline 100 mg, Buprenorphine HCI-Naloxone 8/2 mg, Gabapentin 300 mg, and Clonazepam 1mg. Resident #1 was administered her routine nighttime medications following the administration of Resident #2-nighttime medications which include Buspirone HCI 15mg, Donepezil 10 mg, Trazadone 150 mg, Apixaban 2.5 mg, and Acetaminophen 1,000 mg by Nurse #1. On 6/29/2026, following communication with on-call Medical Provider, Nurse #1 notified Director of Nursing of medication error and the Director of Nursing provided verbal education via phone to Nurse #1 of medication administration policy specifically of reviewing picture of resident in chart, checking name on door prior to entering room and identifying resident by calling name prior to administering medications as well as following the six rights of medication administration prior to administering medications. On 6/29/2026, on-call Medical Provider was notified of medication error only related to antibiotic administered by Nurse #1 and order was given to monitor resident for change of condition for next 24 hours and obtain vital signs every 2 hours for 8 hours and if any changes noted to notify provider. On 6/29/2026, following communication with on-call Medical Provider, Nurse #1 notified Director of Nursing of medication error and orders given by the Medical Provider. Resident #1 remained stable throughout the night and was at baseline with no changes in vital signs noted. The Nurse Practitioner (NP) was not made aware of the full extent of the medication error until a change of condition was noted on 6/30/2026 by Nurse #2. On 6/30/2026 Nurse #2 administered Resident #1's routine morning medications as ordered. At approximately 1:00 pm, Resident #1 was unable to consume her afternoon meal due to nausea and lightheadedness. Resident #1 vital signs were obtained by Nurse #2. Blood pressure 96/35, pulse 44, respiratory rate 16, temperature 98.1 and oxygen saturation 90% on 2 liters of continuous oxygen. The NP was notified by Nurse #2 that Resident #1 had received Resident #2 nighttime medications as well as her own routine nighttime medication as listed above and the Nurse Practitioner gave orders to hold 2:00 PM medications which included Buspirone HCI 15mg, Acetaminophen 1,000mg, Oxycodone HCI 2.5mg, Lorazepam 0.5mg, and to start intravenous (IV) fluids, obtain labs to include a complete blood count and complete metabolic panel and urinalysis with culture and sensitivity. At approximately 4:15 pm, Resident #1's family requested the resident be sent to hospital for evaluation and treatment. The NP was notified by Nurse #2, and an order was obtained to send Resident #1 to the Emergency Department (ED) for evaluation and treatment. At approximately 4:50 pm, Resident #1 left facility via stretcher with emergency medical services in route to hospital. On 6/30/2026, Resident #1 was treated in the hospital Emergency Department for bradycardia and hyperkalemia. Treatment included Calcium gluconate, furosemide, normal saline intravenous fluids, sodium zirconium cyclosilicate (treats hyperkalemia by removing potassium from body) and sodium bicarbonate. Resident #1 was monitored throughout the night with improvements in heart rate and potassium levels. On 7/2/2026, Resident #1 resumed chronic medication regimen without any issues. Resident #1 was discharged from hospital and returned to facility on 7/3/2026 with no new orders. On 6/30/2026, the Director of Nursing informed the scheduler that Nurse #1 is to be placed on the do not return list. On 7/3/2026, the Director of Nursing spoke with the Staffing Agency to notify of incident and let them know to place Nurse #1 on the do not return list. On 7/1/2026, root cause analysis completed by the Administrator and Director of Nursing and determined Nurse #1 completed medication error due to failing to follow facility policy related to medication administration, taking short cuts due to arriving to work late, having issues logging into the Electronic Medication Administration Record and distractions from residents requesting medications caused Nurse #1 to become distracted and she walked into the wrong room and administered meds to Resident #1 without following the 6 rights of medication administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/30/2026, 100% of residents on the hall where Nurse #1 worked were assessed by completing body audits and observing residents for any visible changes of condition by the Assistant Director of Nursing and the Staff Development Coordinator. The vital signs dashboard was reviewed for any abnormal results. The results were: no acute change of condition noted. On 7/1/2026, residents on all halls with BIMS of 13 or higher were interviewed by the Assistant Director of Nursing to identify any concerns with medication administration. The results were no other concerns identified related medication administration. On 7/1/2026, the Director of Nursing (DON) and Unit Mangers initiated medication pass observation to ensure medications were being administered following the 6 rights of medication administration. Medication pass observations were completed for two nurses on day/afternoon shift which consist of 7am to 7pm or 7am-3pm/3pm-11pm shifts and two nurses on evening/night shift 7pm to 7am or 11pm- 8am shifts. The results were: no other issues identified with medication administration. Medication pass observations were completed for all full-time nurses. Additionally, on 7/1/2026, the Director of Nursing reviewed medication administration records to include narcotics by reviewing the electronic medical records and narcotic inventory log to ensure all medications administered as ordered for residents on the hall Resident #1 resided. The results were no other deficient practices noted for any other resident following review of electronic medical records and narcotic inventory logs. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/30/2026, the DON began in person and via phone education of all full time, part time, and as needed licensed nurses including agency nurses and medication aides on the following topics: Medication Errors/Medication Administration including the 6 rights of Medication Administration Topics included:what is a medication error? what is a significant medication error?types of medications errorswhat to do once medication error is discoveredHow to avoid making a medication error during transcription and order entry How to avoid errors during medication administration by ensuring right patient, right route, right drug, right dose, right time and right documentationAdministering medications timelyOrdering medications and obtaining stat or emergency drugs Additionally, on 6/30/2026, the DON began in person and via phone education of all full time, part time, and as needed licensed nurses including agency nurses, medication aides and certified nursing assistants on the following topic: Change of Condition- Identification and Response.Topics Included:What is a change of condition?What to do when a change of condition is noted to include notification of physician and resident's responsible party and document in resident's medical record. The Director of Nursing confirmed understanding of education provided by having staff to verbally state the six rights of medication administration and steps to be completed when a change of condition is identified prior to signing in-service sign in log for all full time, part time, and as needed licensed nurses including agency nurses and medication aides. As of 7/3/2026 15% staff had not attended the in-service. The Director of Nursing is monitoring staff to ensure education is completed. On 7/3/2026, The Regional Director of Operations informed the DON of her responsibility to ensure that any of the above identified staff who does not complete the in-service training by 7/3/2026 will not be allowed to work until the training is completed. This in-service was incorporated into the new agency employee orientation and will continue in the new employee facility orientation for the above identified staff by the Director of Nursing or Staff Development Coordinator. Education consisted of facility policies related to medication administration, medication errors as well as pharmacy guidelines for medication administration and will be provided by the Director of Nursing or Staff Development Coordinator. On 7/1/2026, the Director of Nursing confirmed plan with the Pharmacy Consultant to continue monthly medication pass observations during monthly site visits for any newly hired or any current staff identified with issues related to medication pass administration to ensure staff are adhering to facility policies related to medication administration On 7/1 2026, a quality assurance (QA) meeting was held with the Interdisciplinary Team (IDT) to discuss investigation finding and develop a plan to correct monitoring to start the week of 7/6/2026 to include 100% medication pass observations a

Based on record review, observation, and interviews with the resident and staff, the facility failed to follow their abuse policy and procedures in the areas of immediately reporting to the Administrator, state survey agency, law enforcement, and Adult Protective Services (APS), and in the area of protection after a resident alleged he was placed in a chokehold by Nurse Aide (NA) #2. The deficient practice occurred for 1 of 3 residents sampled for abuse (Resident #3). Findings included:Review of the facility's policy for Abuse with no revision date, read in part, Abuse of any kind was not tolerated in the facility, employees must report any allegation of abuse. If a resident stated they were abused it must be reported. Reporting to the nurse, the nurse must immediately contact the Director of Nursing (DON) and the Administrator. If the nurse received notification an employee may have abused the resident, they were to immediately ask the employee to leave the facility. Prompt notification to the DON and Administrator was important for the two hours to file a formal report with the state. The nurse should assess the resident for injury, contact the physician to notify them of the event, document the assessment and notification in the resident's medical chart. To ensure the resident is safe, employees who have been accused of abuse will be suspended until the investigation is complete. When suspected abuse has occurred against a resident, the facility must report to the state survey agency using initial allegation report (24-hour report), notify local law enforcement, and APS. Within 5 working days the investigation needs to be finalized and submitted to the state survey agency. Resident #3 was admitted on [DATE] with diagnoses that included recurrent dislocation of the right shoulder, non-traumatic rotator cuff and tear of the right shoulder, bipolar disorder, personality disorder, generalized anxiety disorder and panic disorder. Review of quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3's cognition was moderately impaired, was dependent on staff for toileting hygiene and required substantial to maximal assistance with bed mobility. Review of the NA staff assignments revealed on 07/22/26, NA #1 was assigned to work from 7:00 AM through 11:00 PM and at 3:00 PM was assigned to Resident #3. NA #2 was assigned to work from 3:00 PM through 11:00 PM and was not assigned to Resident #3. Review of a progress note documented by Nurse #3 on 07/22/26 at 7:57 PM revealed she observed Resident #3 and NA #1 in a verbal altercation and noted Resident #3 yelled and threw his water pitcher in NA #1's direction and NA #1 left the room. Later in the shift NA #1 requested NA #2's assistance with changing Resident #3. Nurse #3's progress note indicated Resident #3 reported he was assaulted by NA #1 and NA #2. During a telephone interview on 7/30/26 at 5:05 PM, Nurse #3 explained on 07/22/26, she was at her medication cart further down the hall and heard a commotion and Resident #3 yelling at NA #1. She revealed NA #1 reported Resident #3 was rude and yelled at her and hit her with a water pitcher and stated she did not witness Resident #3 hit NA #1 with the water pitcher. She explained sometime after NA #1 reported Resident #3 hit her with the water pitcher, NA #1 requested NA #2's help with changing Resident #3. After care was provided, Nurse #3 stated she went to check on Resident #3, and he reported NA #1 and NA #2 had assaulted him. When she asked Resident #3 what happened and how NA #1 and NA #2 assaulted him, Resident #3 only reported he was assaulted. Nurse #3 stated Resident #3 did not share he was put in a chokehold by NA #2, or he was physically assaulted and she assessed Resident #3's upper body, arms and neck area for injury and did not observe any bruising or redness or anything that stood out to her as abuse. Nurse #3 revealed she did not ask NA #2 to leave the facility, and she did not report Resident #3's allegation of assault to anyone. Nurse #3 revealed she was not aware she needed to report Resident #3 allegation of assault immediately to the DON or Administrator and was not aware of the 2-hour timeframe for reporting to the state survey agency. Review of the facility's reported incidents revealed there was no initial report to the state survey agency, law enforcement or APS for Resident #3's allegation of abuse until submitted by the Administrator on 08/03/26 due to the surveyor's intervention. During an interview and observation on 07/29/26 at 5:48 PM, Resident #3 was resting in bed with no signs of distress or discomfort with the call light placed within reach but not engaged. When asked how he was assaulted, Resident #3 stated he was attacked last week by an NA, and the short version was NA #2 put him in chokehold, and it was hard for him to breathe, and his larynx was being crushed. Resident #3 stated it happened on a Wednesday (07/22/26) during the evening or night shift and described NA #1 came in the room while he slept and realized she couldn't wake him up. NA #1 called another staff member NA #3 to help, and both NAs were having trouble waking Resident #3 up to change him and got NA #2 to come in the room. Resident #3 stated NA #2 was the person who attacked him and rolled him up against the bedrail and put him in a police chokehold. Resident #3 stated he could not breathe and could not talk and after a while he quit resisting and NA #2 let go. He stated there was no way for him to get away because he cannot walk. He revealed NA #2 had not been back in the room since 07/22/26 but he did not feel safe at the facility. Resident #3 revealed he spoke with the DON and Administrator on 07/23/26 and was asked to provide details about what happened. Review of a grievance report form dated 07/24/26 completed by the DON indicated on 07/23/26 a grievance was submitted on behalf of Resident #3 for poor customer service with repositioning when incontinence care was provided. Pertinent findings noted all staff present indicated Resident #3 was cursing and combative and at no point was Resident #3 put in chokehold. NA #2 reported he was defending himself passively by holding Resident #3's arm down to prevent injury to all staff. The grievance was substantiated and noted the reason as poor de-escalation of Resident #3's agitation and aggression. The facility's response indicated all staff involved were re-educated and as requested NA #2 would no longer assist Resident #3 with care. The grievance form indicated the findings were reviewed during in-person meetings with Resident #3 on 07/23/26, 07/24/26, and 07/27/26 and was signed by the DON and Administrator. During an interview on 07/30/26 at 10:27 AM, the DON confirmed she was not notified by Nurse #3 after Resident #3 alleged he was assaulted by NA #1 and NA #2 on 07/22/26 at 7:57 PM. The DON revealed on 07/23/26 at approximately 11:00 AM, she checked on Resident #3 after being told he was attempting to put himself on the floor. She revealed that's when Resident #3 reported, NA #2 put him in a chokehold, and she called the Administrator to notify him. The DON confirmed both NA #1 and NA #2 continued to work their assignment on 07/22/26 and were not placed on leave. The DON explained a grievance was filed on behalf of Resident #3 related to poor deescalation during care when Resident #3 became aggressive towards NA #1 and NA #2 and stated if she thought NA #2 put Resident #3 in a chokehold, she would have reported it. The DON revealed with Resident #3's history of false accusations, the inconsistencies in reporting what happened and request for time to think about pressing assault charges, the decision was made not to report abuse to the state survey agency, law enforcement, APS and not suspend NA #2. During an interview on 07/30/26 at 10:13 AM, the Administrator stated he was notified on 07/23/26 at approximately 11:00 AM when the DON called and reported Resident #3 alleged NA #2 put him in a chokehold. The Administrator stated he interviewed Resident #3 on 07/23/26 and the description Resident #3 gave of being put in chokehold from behind did not make sense because the head of the bed was positioned against the wall and it was not clear how NA #2 held Resident #3 in a chokehold and pinned him against the bedrail. He revealed Resident #3 did not recall NA #3 was in the room when asked what the other NAs were doing when he was held in a chokehold. The Administrator stated a decision was made not to file an abuse report with the state agency based on Resident #3's description of what happened was not clear but was investigated as a grievance on 07/23/26. He stated the grievance investigation included a body audit to check Resident #3 for injury consistent with the allegation of abuse and none were identified, other residents were interviewed and none shared concerns of being abused, other resident body audits were completed and no signs of abuse were identified therefore NA #2 was not suspended. He confirmed he was the Abuse Coordinator and stated that anytime a staff member was made aware of an allegation of abuse, he was to be notified immediately, and he and the DON would begin their investigation within 2 hours to determine if it needed to be reported to the state agency, APS, and law enforcement. He revealed if a resident alleged abuse that involved an employee, the employee would be suspended and/or placed on administrative leave until the 5-day investigation was completed and reported to the state agency. He acknowledged Resident #3's allegation of assault on 07/22/26 should have been reported immediately by Nurse #3. He stated NA #2 was asked to help with Resident #3's care but was not assigned to assist Resident #3 on 07/22/26 and did return to his assigned hall and assisted other residents until the end of the shift and confirmed the policy was to immediately remove NA #2 from the building.

Based on record review and staff interviews, the facility failed to meet professional standards of care when Nurse #1 administered Resident #2's medications to Resident #1. The deficient practice occurred for 1 of 3 residents reviewed for significant medication errors (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's cumulative diagnoses included: dementia, atrial fibrillation, heart failure, hypertension, hyperlipidemia, pulmonary hypertension, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was intact. Review of Resident #1's Medication Administration Record (MAR) revealed the medications scheduled on 06/29/26 at 9:00 PM were initialed by Nurse #1 to indicated she had administered the medications to Resident #1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's active physician orders included montelukast sodium (used in the maintenance treatment of asthma) 10 milligrams (mg) at bedtime for allergies and omeprazole (proton pump inhibitor) 20 mg at bedtime for gastroesophageal reflux disease, 4% menthol (analgesic) gel apply to lower back and bilateral knees three times a day for chronic pain and osteoarthritis. Review of Resident #2's MAR revealed the medications scheduled on 06/29/26 at 9:00 PM were initialed by Nurse #1 to indicated she had administered the medications to Resident #2. Review of Nurse #1's progress note dated 06/29/26 at 11:25 PM revealed the on-call Medical Provider and Director of Nursing (DON) had been notified of a medication error. The on-call Medical Provider guided Nurse #1 to monitor Resident #1 for the next 24 hours and take vital signs every 2 hours for the next 8 hours. Nurse #1's documentation indicated Resident #1 rested in bed with even and unlabored respirations and had no complaints of pain or discomfort. During a telephone interview on 07/29/26 at 12:13 PM, Nurse #1 revealed on 06/29/26 she accidentally administered Resident #2's scheduled 9:00 PM medications to Resident #1 and called the DON and reported the error. Nurse #1 explained her medication cart was placed between Resident #1 and Resident #2's rooms that were located side-by-side and stated it was her first shift at the facility, and she was unfamiliar with the facility as reasons for the error. Review of the medication error form for Resident #1 completed by the DON revealed on 06/29/26 at 10:39 PM the DON was made aware Nurse #1 had administered Resident #2's medication to Resident #1. The list of medications given in error included montelukast sodium 10 mg, omeprazole 20 mg, and 4% menthol gel. During an interview on 7/29/26 at 2:37PM, the DON confirmed on 06/29/26 she received a phone call from Nurse #1 who reported Resident #2's medications were administered to Resident #1 in error. The DON revealed the contributing factors to the medication error was Nurse #1 went into the wrong resident's room to administer medications and did not follow the facility's policy of rights of medication administration. The facility provided the following corrective action plan with a compliance date of 07/04/26. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 6/29/2026, at approximately 10:45 pm Resident #1 was accidentally administered Resident #2's medication which included Duloxetine 30 milligrams, Trazadone 100 mg, Amoxicillin-Clavulanate 875/125 mg, Metoprolol Tartrate 12.5 mg, Acetaminophen 1,000 mg, Doxycycline 100 mg, Buprenorphine HCI-Naloxone 8/2 mg, Gabapentin 300 mg, Clonazepam 1mg, montelukast sodium 10 mg, omeprazole 20 mg, and 4% menthol gel. Resident #1 was administered her routine nighttime medications following the administration of Resident #2-nighttime medications which include Buspirone HCI 15mg, Donepezil 10 mg, Trazadone 150 mg, Apixaban 2.5 mg, and Acetaminophen 1,000 mg by Nurse #1. On 6/29/2026, following communication with on-call Medical Provider, Nurse #1 notified Director of Nursing of medication error and the Director of Nursing provided verbal education via phone to Nurse #1 of medication administration policy specifically of reviewing picture of resident in chart, checking name on door prior to entering room and identifying resident by calling name prior to administering medications as well as following the six rights of medication administration prior to administering medications. On 6/29/2026, on-call Medical Provider was notified of medication error only related to antibiotic administered by Nurse #1 and order was given to monitor resident for change of condition for next 24 hours and obtain vital signs every 2 hours for 8 hours and if any changes noted to notify provider. On 6/29/2026, following communication with on-call Medical Provider, Nurse #1 notified Director of Nursing of medication error and orders given by the Medical Provider. Resident #1 remained stable throughout the night and was at baseline with no changes in vital signs noted. The Nurse Practitioner (NP) was not made aware of the full extent of the medication error until a change of condition was noted on 6/30/2026 by Nurse #2. On 6/30/2026 Nurse #2 administered Resident #1's routine morning medications as ordered. At approximately 1:00 pm, Resident #1 was unable to consume her afternoon meal due to nausea and lightheadedness. Resident #1 vital signs were obtained by Nurse #2. Blood pressure 96/35, pulse 44, respiratory rate 16, temperature 98.1 and oxygen saturation 90% on 2 liters of continuous oxygen. The NP was notified by Nurse #2 that Resident #1 had received Resident #2 nighttime medications as well as her own routine nighttime medication as listed above and the Nurse Practitioner gave orders to hold 2:00 PM medications which included Buspirone HCI 15mg, Acetaminophen 1,000mg, Oxycodone HCI 2.5mg, Lorazepam 0.5mg, and to start intravenous (IV) fluids, obtain labs to include a complete blood count and complete metabolic panel and urinalysis with culture and sensitivity. At approximately 4:15 pm, Resident #1's family requested the resident be sent to hospital for evaluation and treatment. The NP was notified by Nurse #2, and an order was obtained to send Resident #1 to the Emergency Department (ED) for evaluation and treatment. At approximately 4:50 pm, Resident #1 left facility via stretcher with emergency medical services in route to hospital. On 6/30/2026, Resident #1 was treated in the hospital Emergency Department for bradycardia and hyperkalemia. Treatment included Calcium gluconate, furosemide, normal saline intravenous fluids, sodium zirconium cyclosilicate (treats hyperkalemia by removing potassium from body) and sodium bicarbonate. Resident #1 was monitored throughout the night with improvements in heart rate and potassium levels. On 7/2/2026, Resident #1 resumed chronic medication regimen without any issues. Resident #1 was discharged from hospital and returned to facility on 7/3/2026 with no new orders. On 6/30/2026, the Director of Nursing informed the scheduler that Nurse #1 is to be placed on the do not return list. On 7/3/2026, the Director of Nursing spoke with the Staffing Agency to notify of incident and let them know to place Nurse #1 on the do not return list. On 7/1/2026, root cause analysis completed by the Administrator and Director of Nursing and determined Nurse #1 completed medication error due to failing to follow facility policy related to medication administration, taking short cuts due to arriving to work late, having issues logging into the Electronic Medication Administration Record and distractions from residents requesting medications caused Nurse #1 to become distracted and she walked into the wrong room and administered meds to Resident #1 without following the 6 rights of medication administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 6/30/2026, 100% of residents on the hall where Nurse #1 worked were assessed by completing body audits and observing residents for any visible changes of condition by the Assistant Director of Nursing and the Staff Development Coordinator. The vital signs dashboard was reviewed for any abnormal results. The results were: no acute change of condition noted.On 7/1/2026, residents on all halls with BIMS of 13 or higher were interviewed by the Assistant Director of Nursing to identify any concerns with medication administration. The results were no other concerns identified related medication administration.On 7/1/2026, the Director of Nursing (DON) and Unit Mangers initiated medication pass observation to ensure medications were being administered following the 6 rights of medication administration. Medication pass observations were completed for two nurses on day/afternoon shift which consist of 7am to 7pm or 7am-3pm/3pm-11pm shifts and two nurses on evening/night shift 7pm to 7am or 11pm- 8am shifts. The results were: no other issues identified with medication administration. Medication pass observations were completed for all full-time nurses. Additionally, on 7/1/2026, the Director of Nursing reviewed medication administration records to include narcotics by reviewing the electronic medical records and narcotic inventory log to ensure all medications administered as ordered for residents on the hall Resident #1 resided. The results were no other deficient practices noted for any other resident following review of electronic medical records and narcotic inventory logs. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 6/30/2026, the DON began in person and via phone education of all full time, part time, and as needed licensed nurses including agency nurses and medication aides on the following topics: Medication Errors/Medication Administration including the 6 rights of Medication Administration.Topics included:what is a medication error? what is a significant medication error?types of medications errorswhat to do once medication error is discoveredHow to avoid making a medication error during transcription and order entry How to avoid errors during medication administration by ensuring right patient, right route, right drug, right dose, right time and right documentationAdministering medications timelyOrdering medications and obtaining stat or emergency drugs Additionally, on 6/30/2026, the DON began in person and via phone education of all full time, part time, and as needed licensed nurses including agency nurses, medication aides and certified nursing assistants on the following topic: Change of Condition- Identification and Response.Topics Included:What is a change of condition?What to do when a change of condition is noted to include notification of physician and resident's responsible party and document in resident's medical record. The Director of Nursing confirmed understanding of education provided by having staff to verbally state the six rights of medication administration and steps to be completed when a change of condition is identified prior to signing in-service sign in log for all full time, part time, and as needed licensed nurses including agency nurses and medication aides. As of 7/3/2026 15% staff had not attended the in-service. The Director of Nursing is monitoring staff to ensure education is completed. On 7/3/2026, The Regional Director of Operations informed the DON of her responsibility to ensure that any of the above identified staff who does not complete the in-service training by 7/3/2026 will not be allowed to work until the training is completed. This in-service was incorporated into the new agency employee orientation and will continue in the new employee facility orientation for the above identified staff by the Director of Nursing or Staff Development Coordinator. Education consisted of facility policies related to medication administration, medication errors as well as pharmacy guidelines for medication administration and will be provided by the Director of Nursing or Staff Development Coordinator. On 7/1/2026, the Director of Nursing confirmed plan with the Pharmacy Consultant to continue monthly medication pass observations during monthly site visits for any newly hired or any current staff identified with issues related to medication pass administration to ensure staff are adhering to facility policies related to medication administration On 7/1 2026, a quality assurance (QA) meeting was held with the Interdisciplinary Team (IDT) to discuss investigation finding and develop a plan to correct monitoring to start the week of 7/6/2026 to include 100% medication pass observations are completed by 7/23/2026. The IDT consist of the Administrator, Director of Nursing, MDS Coordinator, Assistant Director of Nursing, Nurse, Therapy Manager, Health Information Manager, and Dietary Manager. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Beginning the week of 7/6/2026, The DON will monitor this issue using the Change of Condition and Medication Pass Observation Quality Assurance Tool for Monitoring. The DON or designee will complete medication pass observations weekly to include 2 nurses including agency nurses and 2 medication aides to including morning/afternoon shift which consist of 7 AM to 7 PM and evening/night shift which consist of 7 PM to 7 AM to ensure medications are being administered following the 6 rights of medication administration and to ensure that any change of condition is identified promptly and addressed per facility policy. The monitoring will be completed weekly between Monday and Friday as staff rotate working every other weekend for 4 weeks then monthly x 2 months. Additionally, the Director of Nursing will review the Clinical Alerts Dashboard during daily clinical meeting Monday through Friday to evaluate any changes in condition that have occurred that could be related to medication error. The IDT to review in weekly QA meeting or until resolved by Quality Assurance (QA) Committee. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed and updated if needed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Assistant Director of Nursing, Nurse, Therapy Manager, Health Information Manager, and Dietary Manager.Date of compliance: 07/4/2026 On 08/20/2026, an onsite validation of the facility's corrective action was conducted. Review of the body audits completed on 06/30/26 revealed no residents were identified with a new onset of acute distress or change of condition. Review of the QA meeting dated 07/01/29 revealed the DON informed the QA committee and discussed the medication errors made by Nurse #1, change of condition requirements, the root cause analysis and the plan of correction was approved and initiated. QA committee meetings continued weekly and reviewed the plan of correction. No newly identified medication administration errors occurred, and the plan of correction was last reviewed on 08/17/26. Review of the educational in-service signed by licensed nurse staff, Medication Aides, and Nurse Aides indicated they attended. The education started on 06/30/26 and the topics reviewed: Medication Errors/Medication Administration including the 6 rights of Medication Administration and What is the change of condition and what to do if a change of condition is noted. The education included to always notify the medical provider, especially of medication errors and to include all medications administered, and to notify the Director of Nursing if there are any issues encountered during communication with the Medical Provider. Included in the education was a list of the most common signs of change in condition.Review of medication administration policy and procedures (P&P) revealed nurse and Med Aide staff had signed the document to indicate they would follow P&P related to medications and understood what a medication error was and the rights of medication administration that were listed as right patient, right route, right medication, right dose, right time, and right documentation. Review of resident interviews completed on 07/01/26 revealed residents were asked if they had any concerns with receiving medications, if they were in distress or pain, or had any issues with medication administration. No issues were identified. Review of Nurse and Med Aide medication pass observations started on 07/01/26 revealed observations were continued weekly and nurse and Med Aide staff were observed during first, second, and third shifts. The nurse or Med Aide was observed by the DON, Staff Development Coordinator or designee to ensure the resident was identified, the medication and strength were verified, the correct dose was administered by the correct route at the correct time, the resident was observed to take the medication, and the medication was documented after given. Review of the staffing agency communication sent on 07/03/26 revealed Nurse #1 was not to return to the facility. Nurse and Med Aide staff were observed during medication administration, and there were no significant medication errors. Interviews with nurse and Med Aide staff revealed they recently received education on what a medication error was that included the rights of medication administration and change of condition. They were able to list the rights of medication administration and explain how to prevent a medication error by identifying the resident by the picture in medical record, asked the resident their name, or addressed the resident by name before giving medications. Nurses and Med Aide staff revealed for change of condition the nurse completed a head-to-toe assessment, obtained vital signs, reported their findings to Medical Provider and if a medication error occurred to report all the medications administered to the resident and DON and document their findings and report to the provider in the resident's medical record. Nurse and Med Aide staff were able to list what constituted a change in condition as decrease in alertness or altered mental status, increased sleepiness, a new onset of nausea and vomiting, decrease in appetite, change in speech and mobility. Interviews with Nurse Aide (NA) staff revealed they recently received in-service education related to identifying a change of condition in a resident. NA staff identified a change of condition as a decrease in alertness or altered mental status, increased sleepiness, a new onset of nausea and vomiting, decrease in appetite, change in speech and mobility and stated they report immediately to the nurse. Interviews with alert and oriented residents revealed they were either greeted by name or asked their name before medications were administered. Residents did not share concerns of being given the wrong medication or had a sudden change of condition related to medication administration. The facility's compliance date of 07/04/26 was validated.

Based on observation and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #1 failed to wear a gown while performing catheter care for Resident #3. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Nurse #1).Findings included:Review of the facility's policy and procedure last approved 6/2025 entitled Enhanced Barriers read in part: It is the policy of this facility to use enhanced barrier precautions (EBP) based on guidance from the center of Disease Control (CDC). Enhanced barrier precautions expand use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluid is anticipated (standard precautions). Enhanced precautions refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi drug resistant organisms (MDROs) to staff hands and clothing. Applies to all residents with any of the following; wounds and or indwelling medical devices regardless of MDRO colonization. Indwelling medical devices that have exit ports outside of the body. Central line catheters, urinary catheters, feeding tube, tracheostomy. Examples of high contact resident care activities requiring enhanced barriers; device care (central lines, catheters, tubes, trachs/vents).An observation was completed on 5/20/26 from 11:14 AM to 11:31 AM of Resident #3's room and of Nurse #1 performing catheter care for Resident #3. An EBP sign was outside of Resident #3 door and there was a PPE cart located inside his room that contained gowns. Nurse #1 performed hand hygiene when she entered Resident #3's room and put on clean gloves. She did not put on a gown. She used a premoistened disposable cleaning cloth and cleaned around Resident #3's indwelling urinary catheter at the urinary meatus and disposed of the wipe in the trash. She used another premoistened disposable cleaning cloth to clean down the length of the indwelling urinary catheter and disposed of the wipe in the trash. Nurse #1 repeated the same process of cleaning around and down Resident #3 indwelling urinary catheter 3 to 4 times. Nurse #1 then removed her gloves, disposed of the gloves in the trash, and performed hand hygiene. Nurse #1 put on new gloves and adjusted the catheter securement device on Resident #3's thigh; she did not put on a gown. She removed her gloves, disposed of her gloves in the trash, and performed hand hygiene when she exited the room.An interview was conducted with Nurse #1 on 5/20/26 at 11:33 AM. Nurse #1 said she thought EBP were for residents who had wounds. She explained a gown and gloves were supposed to be worn for wound care. She reported Resident #3 had a wound and said the EBP were just for his wound care. She did not think EBP were needed when doing catheter care or for indwelling devices. Nurse #1 stated she did not need to wear a gown when doing Resident #3's catheter care that she was aware of. Nurse #1 explained performing hand hygiene and wearing gloves was all that was required when providing care for catheters and indwelling devices. Nurse #1 reviewed the EBP sign outside of Resident #3 door. After reviewing the EBP sign, Nurse #1 said she was wrong and stated the sign said EBP were supposed to be used when caring for indwelling devices. Nurse #1 stated she was not aware EBP were supposed to be used for catheters or indwelling devices and that was why she had not worn a gown. Nurse #1 reported she had received training from the facility on EBP.An interview was conducted with the Director of Nursing (DON), who was the facility's Infection Preventionist, and Nurse #1 on 5/20/26 at 12:51 PM. Nurse #1 said she had been nervous when doing Resident #3's catheter care. She explained she did know EBP were supposed to be used when caring for indwelling devices and when doing catheter care. She stated she was nervous when the surveyor had asked her about EBP and that was why she initially stated she did not know EBP were needed for indwelling devices. Nurse #1 stated she knew she should have worn a gown when doing Resident #3's catheter care but had been nervous and forgot to put one on. The DON stated EBP should be used for residents with catheters and indwelling devices. The DON stated Nurse #1 should have worn a gown when performing Resident #3's catheter care. An interview was conducted with the Administrator on 5/20/26 at 1:51 PM. The Administrator said the facility should follow their infection prevention and control policies.

Based on observations, record review, and staff, Medical Director, and Health Department (HD) Nurse interviews, the facility failed to operationalize infection control policy and procedures in accordance with current Centers for Disease Control and Prevention (CDC) guidance. A) The facility failed to implement a broad-based approach to COVID testing for staff and residents when contact tracing testing failed to stop the transmission of COVID. Broad-based COVID testing per the (CDC) guidance was not implemented until 3/25/25. Before broad-based testing was implemented on 3/25/25, a total of 7 staff members and 14 residents tested positive for COVID. Results of the broad-based testing from 3/25/25 to 3/31/25 yielded one (1) staff member and 8 additional residents positive for COVID. B) In addition, the facility failed to implement staff source control to help prevent transmission while working in the facility during the COVID outbreak. C) The facility also failed to restrict staff from returning to work after testing positive for COVID in accordance with current CDC guidance. D) The facility failed to have updated COVID policies and procedures that aligned with current CDC guidance for source control and work restriction guidance for healthcare personnel. The resident census at the time of the survey was 106; there were 59 residents whose COVID vaccinations were up to date. The facility provided a list of 128 staff members and reported there were 11 staff members whose COVID vaccinations were up to date. These cumulative practices and system failures occurred during a COVID outbreak and had the high likelihood of continued transmission of COVID to residents and staff and a serious adverse outcome. Immediate Jeopardy began on 3/11/25 when 3 staff members and 5 residents on three different resident halls tested positive for COVID and the facility failed to implement a broad-based approach COVID testing for staff and residents. Immediate jeopardy was removed on 3/27/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of F (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings included: A. A facility policy entitled COVID response program dated as last approved on 2/2025 read in part: Perform COVID viral testing: Anyone with even mild symptoms of COVID, regardless of vaccination status, should receive a viral test for COVID as soon as possible. Asymptomatic residents with close contact with someone with COVID infection should have a series of three viral tests for COVID infection. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1, day 3, and day 5. Create a process to respond to COVID exposures among health care personnel (HCP) and others: Exposures will be investigated by the infection control practitioner and other team members. Decisions to test all contacts will depend on the ability to identify all of the contacts. In cases where contacts are not identified then broad based of facility wide testing for resident and HCP will be initiated. Initial testing will be completed as a three series test. This process is described above. After the three series, testing is finished then the testing group will continue to be tested every 3-7 days until there are no new cases for 14 days. Responding to a newly identified COVID infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdictions' public health authority. A single new case of COVID infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach is preferred if all contacts cannot be identified or managed with contact tracing or if contract tracing fails to halt transmission. Perform testing for all resident and HCP identified as close contacts or on the affected units if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1, day 3, and day 5. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility as part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days) should be considered. A review of the facility's COVID testing logs and list of COVID positive residents and staff revealed the facility's COVID outbreak started on 3/11/25 when Nurse #1, Nurse #2, and the Speech Therapist tested positive for COVID and two residents on K hall, two residents on F hall, and one resident on S hall tested positive for COVID. Additional residents on halls F, K, and S tested positive from 3/11/25 through 3/16/25. Facility testing logs indicated all Residents on F and K hall were tested and most of the residents on S hall were tested ; the log indicated rooms S18, S19, and S20 were not tested . The COVID testing log indicated a resident on C hall tested positive on 3/15/25 and a resident on W hall tested positive on 3/17/25. The COVID testing logs revealed no additional residents were tested from C hall or W hall until 3/25/25. Broad-based testing was not conducted until 3/25/25. - On 3/11/25 Nurse #1 tested positive for COVID. - On 3/11/25 Nurse #2 tested positive for COVID. - On 3/11/25 the Speech Therapist tested positive for COVID. - On 3/11/25 Resident #8 in room F10 was positive for COVID. - On 3/11/25 Resident #92 in room K1 was positive for COVID. - On 3/11/25 Resident #95 in room F9 was positive for COVID. - On 3/11/25 Resident #38 in room S3 was positive for COVID. - On 3/11/25 Resident #92 in room K9 was positive for COVID. - On 3/12/25 the Physician Assistant (PA) tested positive for COVID. - On 3/12/25 Resident #42 in room S16 tested positive for COVID. - On 3/13/25 Nurse Aide (NA) #1 tested positive for COVID. - On 3/13/25 Resident #52 in room K10 was COVID positive. - On 3/14/25 Resident #74 in room S15 was COVID positive. - On 3/14/25 Resident #106 in room F1 was COVID positive. - On 3/15/25 Resident #15 in room C10B was COVID positive. - On 3/16/25 Resident #363 in room F3 was COVID positive. - On 3/16/25 NA #2 tested positive for COVID. - On 3/17/25 Resident #93 in room W4 was COVID positive. - On 3/17/25 the Minimum Data Assessment (MDS) Nurse tested positive for COVID. - On 3/22/25 Resident #99 in room C1A was COVID positive. - On 3/24/25 Resident #39 in room C1B was COVID positive. The following were the results of COVID-19 testing after broad-based testing was initiated: - On 3/25/25 Resident #91 in room C3A was COVID positive. - On 3/25/25 Resident #43 in room C3B was COVID positive. - On 3/25/25 Resident #9 in room C5A was COVID positive. - On 3/25/25 Resident #45 in room C5B was COVID positive. - On 3/25/25 Resident #16 in room W2 was COVID positive. - On 3/25/25 Resident #70 in room W3 was COVID positive. - On 3/25/25 Resident #364 in room F5 was COVID positive. - On 3/31/25Resident #36 in room C4A was COVID positive. - On 3/31/25 Nurse #8 tested positive for COVID. Review of Resident #42's electronic medical record revealed on 3/12/25 she had a fall, generalized weakness, altered mental status, and a positive COVID test at the facility. Her blood pressure was 94/63, pulse was 137, temperature was 97.6, and her oxygen saturation level was 93% on room air. The electronic medical indicated the provider was notified and ordered for her to be transferred to the hospital. Resident #42's hospital discharge summary dated 3/18/25 revealed she was hospitalized from 3/12/25 to 3/18/25 with acute hypoxic respiratory failure secondary to COVID and atrial fibrillation. The hospital history and physical dated 3/12/25 read in part: patient stated she started feeling poorly for 2-3 days with a productive cough, sore throat, and increased thirst. Endorses, normal PO (oral) intake, fever/chills, shortness of breath, mild swelling in both legs, dizziness when standing, diarrhea. Resident #42 was readmitted to the facility on [DATE]. Review of Resident #363's electronic medical record revealed that on 3/16/25 he had anxiety and was complaining of pain and shortness of breath. The medical record indicated Resident #363 requested to go to the hospital. The on-call provider was notified and specified Resident #363 could be transferred to the hospital. The medical record indicated Resident #363 was transferred to the hospital on 3/16/25. Resident #363 did not return to the facility. An interview was conducted with the Administrator on 3/31/25 at 2:15 PM. The Administrator stated Resident #363 was transferred to the hospital on 3/16/25 and tested positive for COVID at the hospital on 3/16/25. She said Resident #363 had been admitted to the hospital and then discharged home after his hospitalization . An interview was conducted with Nurse #10 on 3/24/25 at 9:15 AM. Nurse #10 said she was assigned to halls W, S, and C hall (rooms C1-C6). She reported the facility had recently had several residents and staff who were positive for COVID. She stated staff were not being tested for COVID on a routine schedule. Nurse #10 said she was tested for COVID one time earlier this month, after the first COVID case was identified at the facility but that not all staff got tested to her knowledge. She explained staff were only tested for COVID if they had symptoms or if they requested to be tested . Nurse #10 reported she had tested herself at the facility, she thought on 3/16/25 but was not entirely sure of the date. Nurse #10 stated she had tested herself because she had worked with the residents who had tested positive prior to them being identified as COVID positive. She said she had tested herself as a precaution. She reported she had not been tested for COVID since she had tested herself on 3/16/25. Nurse #10 explained the facility had COVID tests available in the provider office and at the nursing station that staff could use to self-test. She said if staff tested positive, they were supposed to let their supervisor know but otherwise the facility did not log the test results to her knowledge. She reported staff COVID testing was done per staff discretion, if they started showing symptoms, or they felt they needed to take one. An interview was conducted with Housekeeper #1 on 3/24/25 at 10:09 AM. She reported that the facility tested residents but did not test staff unless they had symptoms. She reported she had not been tested for COVID because she had not had any symptoms. An interview was conducted on 3/24/25 at 1:35 PM with NA #13. She reported staff were only tested for COVID if they had symptoms or if they had exposure from a family member. She explained she had been tested 2 weeks ago because she had an exposure to a family member outside of her home who had COVID. She stated there had been no facility wide testing of staff since the COVID outbreak began. An interview was conducted with NA #8 on 3/24/25 at 1:45 PM. She reported she had not been tested for COVID. NA #8 said individuals were only tested if they had symptoms. An interview was conducted with Physical Therapy Assistant (PTA) #1 on 3/25/25 at 8:54 AM. PTA #1 reported she had worked with the residents on the rehab unit before it was known they were COVID positive. She stated she had not been tested for COVID because she did not have any symptoms. She explained if she did not have any symptoms then she did not need to be tested . An interview was conducted on 3/25/25 at 8:55 AM with Occupational Therapy Assistant (OTA) #1. She reported she had worked with the residents on the rehab unit who had tested positive for COVID. She explained she had been tested for COVID around 3/11/25 when the first residents had tested positive because she had symptoms. OTA #1 said her COVID test had been negative. She stated she had not been tested for COVID since then. An interview was conducted with the Rehab Director on 4/1/25 at 11:27 AM. The Rehab Director reported that the Speech Therapist had started not feeling well and had tested positive for COVID on 3/11/25. She recalled OTA #1 had a scratchy throat on 3/11/25 and had been tested for COVID as a precaution, and her test was negative. The Rehab Director reported no other staff in the therapy department were asked to get tested . An interview was conducted with the Director of Nursing (DON) who also served as the Infection Preventionist (IP) with the Staff Development Coordinator (SDC) present on 3/24/25 at 3:52 PM. The DON said the facility's SDC was going to eventually assume the role of IP but had not yet attended the North Carolina State Program for Infection Control and Epidemiology (SPICE). The DON indicated she had completed the SPICE training. The DON explained that the SDC assisted with infection control but that she oversaw the facility's infection control program. The DON explained that the facility's COVID outbreak began on 3/11/25 when 5 residents and 3 staff members tested positive for COVID. The DON said since the outbreak had begun the facility had 12 residents who had tested positive for COVID. She reported that the residents who had tested positive for COVID were located on F hall, K hall, S hall, W hall, and C hall. The DON said when Nurse #1 tested positive for COVID on 3/11/25 the residents on Nurse #1's work assignment was tested . She explained Nurse #1's assignment included F hall, K hall, and the top of S hall (S1-S14). The DON stated testing was initiated for those residents due to exposure to Nurse #1 and they were tested on days 1 (3/11/25), 3 (3/13/25), and 5 (3/15/25). During the initial day 1 testing on 3/11/25, the DON reported 5 residents (Resident #8, Resident #92, Resident #95, Resident #38, and Resident #105) on halls F, K, S were identified as being positive for COVID. On day 3 testing (3/13/25) an additional resident (Resident #52) on K hall tested positive for COVID. The DON reported, Resident #74 in room S15 was not part of the initial COVID exposure testing group but was tested on [DATE] due to symptoms and was positive for COVID. The DON explained, Resident #42 in room S16 was also not part of the initial COVID exposure testing group but was tested on [DATE] due to falls. Resident #42 was COVID positive on 3/12/25, was transferred to the emergency room for evaluation, and admitted to the hospital. The DON reported, Resident #15 residing in room C10B and Resident #93 in room W4 were tested due exposure from the PA and had tested positive for COVID. The DON said residents were placed on transmission-based precautions for 10 days when they tested positive for COVID. She verbalized the Administrator had notified the local Health Department (HD) of the facility's COVID outbreak on 3/11/25 and had not been given any recommendations from the HD. The DON stated the facility advised staff after residents tested positive for COVID that maybe they should be tested for COVID if they had worked on the halls where the COVID residents were located and if they had symptoms. The DON stated the facility had not done any official contact tracing of staff to see if they needed to be tested . She said the facility did not have a system for tracking and logging staff test results to identify when and who were tested . The DON indicated staff tests were logged if, they were positive. An interview was conducted on 3/25/25 at 2:43 PM with the HD Nurse. The HD Nurse said facilities were supposed to call and report to the HD if there were two or more confirmed cases of COVID with 72 hours of each other. She said the HD used an outbreak reporting email system. The HD nurse reported she went through all her emails, logs, and phone call records and she did not have any information or contact from the facility. The HD further reported the last contact with the facility had been after a large storm in September 2024 when the HD reached out to the facility to see if they needed anything. The HD nurse explained that the HD also held quarterly calls with the local facilities and had a call last week, and the facility had not been present on the call. The HD nurse reported that she had received an email from the Administrator this morning (3/25/25). She reported the email content from the Administrator had said she was following up on an email she had sent last week. The HD said the email from this morning (3/25/25) had a forwarded email attached that looked like it had been sent on 3/17/25. The HD Nurse said she had double checked and could not find anything in the HD email that had been sent on 3/17/25 from the facility. The HD nurse stated the email she had received from the facility today had said 2 employees were positive for COVID. The HD Nurse explained if the facility had gotten in touch with the HD on 3/11/25 she would have asked if the staff were symptomatic, where they had worked, and who they had taken care of on those shifts. She reported that if the positive staff had worked on several hallways or if residents had tested positive on several hallways, she would have recommended testing all residents and staff in the facility and would have also recommended wearing masks for source control. The HD Nurse said if staff were not wearing a mask there could be more exposure. She stated as soon as the facility had additional positive staff or residents on the initial serial testing, they should have moved up to broad-based facility wide testing of residents and staff. She indicated it was hard to contact trace and identify all the potential contacts when there were that many positive cases on multiple units. The HD nurse said after the initial 1-, 3-, and 5-day testing the facility should have continued testing residents and staff every 3 days or two times a week until they had no new cases for 14 days. She further stated the facility should have also implemented face masks for source control on 3/11/25 when multiple residents and staff had tested positive for COVID because the facility would have been in outbreak status. The HD Nurse stated the facility would not have continued to see more cases typically after 5 days if they were doing everything right and wearing masks. She reported the facility should have notified the HD on 3/11/25 or at least within a few days. The HD Nurse explained if for some reason the facility was not able to get in touch with the HD or she was not available the information was available on the CDC website. The HD Nurse reported there was a packet that she sent via email to all facilities in outbreak status that had specific infection control practices to implement and follow to help mitigate the outbreak. An additional interview was conducted with the DON on 3/25/25 at 3:58 PM. She reported that the facility had received a phone call from Resident #99's son on 3/24/25 who communicated Resident #99 had tested positive for COVID at the hospital on 3/22/25. The DON stated Resident #99 had been transferred to the hospital on 3/21/25 for evaluation due to a fall. The DON explained the facility tested Resident #99's roommate (Resident #39) on 3/24/25 and she had also been positive for COVID. She said the facility decided to branch out and do more testing today (3/25/25) because they did not have a known source of COVID exposure for Resident #99. The DON reported they had decided to test all of the residents on C hall. She said when additional residents on C hall (Residents #91, #43, #9, and #45) tested positive, they decided to test the NA assignment from yesterday (3/24/25), which was split between C and W hall. She said the residents at the top of W hall were tested and 2 residents (Resident #16 and #70) were positive. She was not sure if they had tested all the residents on W hall. An interview was conducted with the Administrator on 3/25/25 at 5:44 PM. The Administrator said she felt like what the facility was doing was working to mitigate the facility's COVID outbreak. Even though there was a positive COVID resident located on C hall (C10B) and W hall (W4), the Administrator reported she thought the new COVID cases on C hall and W hall were a separate outbreak from the original outbreak because there had been 5 days since the last COVID case had been identified. She said they had more staff who had been tested but did not have an official log of who. The Administrator said she had spoken with the HD Nurse by phone this afternoon but had not spoken to anyone at the HD before today. The Administrator indicated she had emailed the HD Nurse on 3/11/25 that the facility had COVID cases and then she had followed back up with her today. The Administrator reported that she was not sure what happened that the HD Nurse had not received the email on 3/11/25. The Administrator indicated that when she spoke with the HD Nurse today, she gave the HD Nurse all the information and discussed the facility's thought process for contact tracing. She reported she explained the facility rational with how they had identified and tracked the positive COVID cases and had explained what they had been doing. The Administrator reported the HD Nurse was comfortable with what the facility was doing and what they were doing for staff. A report dated 3/26/25 from the HD Nurse was provided after she had talked to the facility on [DATE]. The report indicated the facility's positive COVID cases from 3/11/25 through 3/16/25 on halls F, K, S had been discussed and the cases from 3/22/25 through 3/25/25 on halls W and C had been discussed. The report did not include the positive case that occurred on C hall on 3/15/25 or W hall on 3/17/25. The report indicated corrective actions identified were facility masking and testing staff. The HD nurse indicated that the facility Administrator had contacted her on the morning of 3/26/25 with updated information that additional C hall residents and one resident on F hall had tested positive. The HD nurse indicated the facility was conducting facility wide testing of all staff and residents going forward. The HD nurse reported that the facility planned to test all residents and staff twice weekly going forward, until there were no new cases for 14 days. An interview was conducted on 3/31/25 at 1:49 PM with the Medical Director. The Medical Director indicated that since the end of the pandemic the CDC guidance was not as clear and not as distinct. He stated the CDC tried to establish the standard of practice. He said who to test, when to test, and how long to test afterwards was not clear cut. He reported the CDC was not as clear as they could be and that it was hard to keep up with the guidance for a little while with all the changes and there was a lot of confusion about the requirements and standard of care and what that should be. He said the facility was following its policy whether it was correct or not he was not sure, but it was a corporate policy. He thought broad based testing should be used if there was a significant outbreak. He said for him a significant outbreak would be 2 or more cases and indicated the facility outbreak that started on 3/11/25 was significant. He explained the only way to find asymptomatic people that were COVID positive would be to test the asymptomatic people. The Medical Director stated asymptomatic individuals could still be infectious and pass the virus. The Medical Director further stated, if there was a significant outbreak the facility should follow their testing policy to identify individuals who were COVID positive and isolate people. He reported there was not a lot of testing that had been going on since 3/11/25 and that the broad-based COVID testing was not being done. The Medical Director said there were a few residents who had gone to the hospital due to COVID symptoms. He reported Resident #99 had gone to the hospital for evaluation on 3/21/25 after a fall and had tested positive for COVID at the hospital on 3/22/25. The Medical Director indicated the residents were okay, there were no deaths, and the residents were treated with antivirals. Additional COVID testing logs for residents and staff were provided on 3/31/25 by the Administrator. The Administrator indicated the COVID testing logs included staff and Residents who were tested due to possible exposure. The COVID testing log and daily staff schedules were reviewed. There were no therapy staff, except for the Speech Therapist listed on the COVID testing log. Nurse #3 worked on: 3/11/25, 3/15/25, 3/17/25 on F hall, K hall, S hall 3/16/25 and 3/20/25 on B hall A negative COVID test was documented on 3/11/25 and 3/13/25. There was no additional testing for exposure documented for Nurse #3. NA #3 worked on: 3/9/25 on halls B, W, and S 3/11/25 on halls K and S 3/18/25 on halls C, W, and S There was no documentation of COVID testing for NA #3 Medication Aide #1 worked on: 3/11/25, 3/15/25, 3/16/25, 3/17/25 on halls F, K, and S 3/14/25 on halls F and K 3/19/25 on halls B and W A negative COVID test was documented on 3/20/25 but no prior testing was documented for Medication Aide #1. Nurse #4 worked on: 3/11/25 and 3/13/25 on halls F, K, and S There was no documentation of COVID testing for Nurse #4 NA #4 worked on: 3/11/25, 3/12/25, and 3/13/25 on halls F and K There was no documentation of COVID testing for NA #4 Medication Aide #2 was also an NA and worked on: 3/11/25 and 3/15/25 on halls F, K, and S (Medication Aide) 3/12/25 on halls B and W (NA) 3/13/25 and 3/16/25 on halls W and S (NA) 3/17/25 on hall S (NA) There was no documentation of COVID testing for Medication Aide #4 Nurse #5 worked on: 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/17/25 on halls W, C, and S. There was no documentation of COVID testing for Nurse #5 Medication Aide #3 worked on: 3/9/25, 3/13/25, 3/14/25, 3/17/25 on halls F, K, and S. There was no documentation of COVID testing for Medication Aide #3 NA #5 worked on: 3/12/25 on hall S 3/17/25 on halls F and K There was no documentation of COVID testing for NA #5 Medication Aide # 4 also worked as a NA and worked on: 3/9/25 and 3/16/25 on halls F, K, and S (Medication Aide) 3/10/25 on halls C and E (NA) 3/11/25 on halls B and W 3/13/25 on halls C and W A negative COVID test was documented on 3/11/25 but no additional testing was documented for Medication Aide #4. NA #6 worked on: 3/10/25 and 3/15/25 on halls F, K, and S 3/9/25 on halls F and K There was no documentation of COVID testing for NA #6 NA #7 worked on: 3/10/25 on halls F and K 3/12/25 on hall B 3/15/25 on halls C, W, and S. There was no documentation of COVID testing for NA #7 Nurse #10 worked on: 3/10/25 on halls F and K 3/11/25, 3/12/25, and 3/16/25 on halls W, C, and S 3/13/25 on halls F, K, and S A negative COVID test was documented on 3/16/25 but no prior testing was documented for Nurse #10 NA # 8 worked on: 3/10/25 on hall S 3/11/25 on halls A and E 3/12/25 on hall C 3/14/25 on halls F and K 3/15/25 on halls W and S 3/16/25 and 3/17/25 on halls A and E And 3/18/25 on halls K and S There was no documentation of COVID testing for NA #8 NA #9 worked on: 3/12/25 on halls W and S 3/14/25 on halls S, W, And C 3/15/25 on halls C and E 3/16/25 on halls A, E, and C There was no documentation of COVID testing for NA #9 A follow-up interview with the Administrator was conducted on 3/31/25 at 11:04 AM. The Administrator said the original resident COVID testing log provided on 3/24/25 was for the initial exposure testing. She explained the facility had also tested the residents on halls F, K, and S two more times after the initial 1, 3, and 5-day testing. She reported the original testing log provided was not clear, she said there were a couple different formats people were using, and they were tracking things differently and that needed to be merged. She said the residents were tested again on 3/18/25 and 3/20/25. When asked why the testing was not included in the log originally provided, she said the information had been kept in different places by several different staff. The Administrator said the facility had a transition of management roles and that was why they did not have a clear and concise list of who was tested and how things were monitored. The Administrator stated historically she had kept up the COVID testing log but that as things progressed the DON and SDC had started tag teaming that. She reported they had to sit down and get everything on one comprehensive list. The Administrator indicated the facility had tested staff due to symptoms and exposure from working on units that had COVID positive residents because they were not masked. She said most staff who worked on halls F, K, and S were tested . She stated the facility tested staff for exposure on days 1, 3, and 5. The Administrator said some staff had not been tested and had not had repeat testing depending on their work schedule, such as if it was a part time or as needed staff member that did not work again for a while. She said some staff were not tested because they were beyond the exposure risk time frame when they returned to work. The Administrator reported she wanted to do what was best and felt like they had been following their systems and processes for doing that. An interview was conducted with the PA on 3/31/25 at 4:46 PM. She reported her symptoms had started on 3/8/25 and she had tested positive on 3/12/25. The PA said she had last been at the facility on 3/7/25. The PA stated the facility had not asked her what residents she had seen on 3/7/25 but that they could determine that. The PA explained she always emailed a list of all the residents she saw every day she was at the facility and said the facility would have the list of who she saw from 3/7/25. The PA said she notified the facility when she tested positive on 3/12/25. A follow-up interview was conducted with the DON on 4/1/25 at 3:30 PM. The DON explained the testing for staff had not been logged because several individuals were involved in testing and the information had not been compiled. She reported some of the staff had not been tested who had worked on the exposed units because they had been following their policy and had only been testing staff who had symptoms. She explained the policy was a corporate policy and she had assumed it aligned with the CDC recommendation. The DON had not been aware that NA #2 who tested positive for COVID on 3/16/25 had worked on 3/15/25 on halls S and W. She agreed that the residents residing on W hall should have been tested due to exposure if NA#2 had worked on the hall. B. A facility policy entitled COVID response program dated as last approved on 2/2025 read in part: Source control is recommended: Universal source control is not required but is recommended when a person

Based on observations and staff interviews, the facility failed to date and seal leftover frozen food stored in 1 of 1 walk-in freezer. This practice had the potential to affect foods served to the residents. The findings included: On 3/23/2025 at 10:05 AM the initial kitchen observation was conducted with the Dietary Director and revealed the following: a. Walk-in freezer - A clear plastic bag open to air which was a quarter full of breaded fish filets with no date on the bag, edges of breaded fish filets were observed with a thin white layer around the edges. During an interview on 3/23/2025 at 10:11 AM the Dietary Director stated that all opened foods should be dated and sealed. During an interview on 3/25/2025 at 11:55 AM the Registered Dietitian stated opened food should be dated and sealed. During an interview on 3/25/2025 at 4:22 PM the Administrator stated the Registered Dietitian completed rounds every Monday morning and the breaded fish filets would have been thrown away on 3/24/2025 after rounds were completed. The Administrator provided a menu that showed baked fish had been served on 3/21/2025. The Administrator stated that opened food should have a date on it when put back in the refrigerator or freezer, but she was not sure if it needed to be sealed.

Based on record review, observations and staff interviews, the facility failed to label an open vial and discard expired medications in 2 of 10 medication carts ([NAME] 2 and [NAME] 2 medication carts), and secure 1 of 10 medication carts ([NAME] medication cart). The findings included: 1.a. An observation of the [NAME] 2 medication cart on 12/6/23 at 2:37 PM with Nurse #2 revealed an open and unlabeled vial of Lidocaine and an Insulin Lispro pen with an open date of 9/16/23. A sticker was attached to the insulin pen that indicated to discard after 28 days of opening. Both medications were available for use in the top drawer of the medication cart. During the observation, an interview with Nurse #2 revealed the open vial of Lidocaine was not currently being used because it had been used to dilute an antibiotic and the antibiotic had been discontinued. Nurse #2 stated that the Insulin Lispro pen had also been discontinued and that it expired after 28 days of opening. Nurse #2 also stated that both medications should have been discarded but that she did not notice them when she administered medications from the medication cart that morning. She further stated that the nurses should check the medications in the medication carts when they had time to do so. b. An observation of the [NAME] 2 medication cart on 12/6/23 at 3:19 PM with Nurse #3 revealed an open bottle of Geri-Lanta available for use in the middle drawer and it was marked with a manufacturer's expiration date of 10/23. (Geri-Lanta is an antacid, anti-gas oral suspension containing alumina, magnesia, and simethicone.) Nurse #3 stated she had just received report from the outgoing nurse. Nurse #3 who was an agency nurse stated she was not sure about the facility's procedure regarding who was assigned to check the medications in the medication carts. She stated that she knew the night shift nurses were assigned to clean the medication carts, but all the nurses should be accountable for discarding expired medications. An interview with the Director of Nursing (DON) on 12/6/23 at 5:17 PM revealed the expired medications in the medication carts should have been discarded and the open vial of Lidocaine should have been labeled. The Lidocaine vial was supposed to be used for just one resident. The DON stated that the charge nurses and the unit managers including herself looked at the medication carts periodically. The nurses were responsible for each medication cart whenever they had them. In addition, the plan was for the night shift nurse to check the medication carts weekly. 49000 2. During the observation of [NAME] Hall on 12/4/23 from 8:33 AM to 8:55 AM the medication cart was unlocked. The cart was left unlocked across from the common area on [NAME] Hall. During this time the nurse assigned to the [NAME] Hall medication cart was not around the medication cart and it was later revealed that she was now using a different medication cart on the [NAME] Hall. During this time no residents passed the unlocked cart, however staff were observed passing the unlocked cart. At 8:55 AM the Director of Nursing passed the cart and locked it and kept walking down the hall. An interview with the Director of Nursing (DON) on 12/4/23 at 8:55AM revealed that she did lock the cart and confirmed that the medication cart should have been locked. An interview with Nurse #2 on 12/4/23 at 9:00 AM revealed that she was assigned to administer medications on the [NAME] Hall, back of [NAME] Hall, and [NAME] Hall. The nurse stated that she must have forgotten to lock the cart after administering the medication. The nurse stated she gave the medication right around 8:30 AM. After administering the medication she went to [NAME] Hall to start administering medications using the medication cart for [NAME] Hall.

Based on observations and staff interviews, the facility failed to remove expired food stored for use in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and the dry goods storage room and failed to date perishable food stored for use in the walk-in cooler. This practice had the potential to affect food served to residents. The findings included: During the initial tour of the kitchen on [DATE] from 9:30 AM to 9:45 AM an observation with the Assistant Dietary Manager of the walk-in cooler revealed the following: - 1 opened, ,d+[DATE] used bag of hashbrown with no date - whole bag of hashbrowns with no date -1 medium sized bag of baby sized carrots expired packaged date of [DATE] -1 5-pound bag of shredded cheese expired packaged date of [DATE] An observation with the Assistant Dietary Manager of the walk-in freezer at 9:45 AM revealed the following problem: -1 cooked casserole with expired written date to use by of [DATE] -1 cooked vanilla cake with expired written date to use by of [DATE] -1 cooked chocolate cake with no date -1 opened, bag of breaded shrimp with no date -1 clear extra-large reusable plastic bag labeled chicken salad expired written date to use by of [DATE] -1 whole bag of hushpuppies expired packaged date of [DATE] -1 clear large reusable plastic bag of hot dogs expired written date to use by of [DATE] -1 clear large reusable plastic bag of hot dogs expired written date to use by of [DATE] -1 white container of hot dog chili expired packaged date of [DATE] -1 cooked pan of hot dog chili expired written date to use by of [DATE] -1 bag of queso dip expired packaged date of [DATE] -1 opened, box of vegetable hot dogs expired packaged date of [DATE] -1 opened, box of vegetable sausages expired packaged date of [DATE] -4 clear extra-large reusable plastic bags labeled diced chicken expired written date to use by of [DATE] An observation with the Assistant Dietary Manager of the dry storage room at 10 AM revealed the following problem: -Eight- 33.8 fluid ounce bottles of Glucerna expired packaged date of [DATE] -Seven- 28-ounce bags of chocolate pudding mix expired packaged date of [DATE] -Six- 8.75-ounce bags of chocolate pie filling mix expired packaged date of [DATE] The Assistant Dietary Manager observed on [DATE] at 9:30 AM the food stored inside of the walk-in cooler, walk-in freezer, and dry storage room that were unsealed and expired. She revealed the process for food storage was making sure all foods were sealed, labeled, and dated with a opened date and discard date. She verbalized all food dates should be checked by all dietary staff on a regular basis and any expired foods should be properly discarded. She indicated she would have the food items discarded. An interview with the Dietary Manager on [DATE] at 10:30 AM revealed all food items should be sealed, labeled, and dated when being stored. He stated should be checking food items on a regular basis and discarding any items that are not sealed, labeled, dated, or have expired immediately. An interview with the Corporate Registered Dietician (RD) on [DATE] at 11:04 AM revealed staff should make sure all open food containers were labeled, sealed, dated, and any expired food items should be removed and properly discarded. An interview with the Administrator on [DATE] at 6:16 PM revealed all food containers should be labeled, sealed, dated, and expired foods should be discarded immediately.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on [DATE]. This was for seven repeat deficiencies that were originally cited during the recertification and complaint survey on [DATE] and were subsequently recited during the recertification and complaint survey on [DATE] in the areas of resident rights/exercise of rights, accuracy of assessments, coordination of PASRR and assessments, activities of daily living care provided for dependent residents, treatment or services to prevent/heal pressure ulcers, sufficient nursing staff, and food procurement. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F550 - Based on record review, family and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance to a resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 7 residents reviewed for dignity. The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity and not having to wait for incontinence care after having a bowel movement. During the recertification and complaint investigation survey conducted on [DATE], the facility failed to maintain resident's dignity when there was a delay in answering their call light when toileting/incontinence care was needed, not providing showers/bathing assistance as scheduled and not providing assistance out of bed when requested resulting in residents feeling dirty, mad, isolated and forgotten about. F641 - Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of cognitive patterns, mood, behavior and participation in assessment and goal setting for 2 of 6 residents (Resident #57 and Resident #11) whose MDS were reviewed. During the recertification and complaint investigation survey conducted on [DATE], the facility failed to accurately code Minimum Data Set assessments in the areas of wandering behavior, pressure ulcers, discharge, and restraints. F644 - Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed after new mental health diagnoses for 2 of 3 residents (Resident #37 and #39) reviewed for PASRR. During the recertification and complaint investigation survey conducted on [DATE], the facility failed to request a Preadmission Screening and Resident Review (PASRR) for a resident with a new mental health diagnosis. F677 - Based on record review, observation, family and staff interviews, the facility failed to provide incontinence care to a dependent resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 6 residents reviewed for activities of daily living. During the recertification and complaint investigation survey on [DATE], the facility failed to provide showers or bed baths as scheduled for residents. F686 - Based on observation, record review, and interviews with resident and staff, the facility failed to provide pressure ulcer care per physician orders for 1 of 4 residents (Resident #94) reviewed for pressure ulcers. During the recertification and complaint investigation survey conducted on [DATE], the facility failed to complete weekly skin assessments for residents with pressure ulcers. F725 - Based on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist a resident with incontinence care for 1 of 6 residents reviewed for staffing (Resident #66). During the recertification and complaint investigation survey conducted on [DATE], the facility failed to maintain sufficient nursing staff to ensure a resident was not left lying in a soiled brief while waiting for staff to respond to an engaged call light for incontinence care. The facility failed to ensure requests from a resident dependent on staff for transfer was not left in bed after multiple requests to get out of bed. The facility failed to ensure residents dependent on staff to provide physical assistance with bathing received showers as scheduled. F812 - Based on observations and staff interviews, the facility failed to remove expired food stored for use in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and the dry goods storage room and failed to date perishable food stored for use in the walk-in cooler. This practice had the potential to affect food served to residents. During the recertification and complaint investigation survey on [DATE], the facility failed to ensure kitchen equipment was kept clean by not removing a buildup of debris from an ice machine. During an interview on [DATE] at 7:00 PM, the Administrator stated she was surprised that they were still having concerns with all these areas. She stated these were addressed previously with Performance Improvement Plans, especially with showers as part of their Quality Assurance process. She stated they monitored compliance with the plan of correction after the last survey. The call lights were also a part of their Quality Assurance and Performance Improvement program. The Administrator presented PIP on adequate nursing staffing and call light response time. No other follow up on record was provided once target goals were met on [DATE] for both areas.

Based on record review, family and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance to a resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 7 residents reviewed for dignity. The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity and not having to wait for incontinence care after having a bowel movement. Findings included: Resident #66 was admitted to the facility on [DATE] for mononeuritis complex (damage to different areas of the peripheral or sometimes the brain nervous system that can cause paralysis, tingling, numbness, pain, and changes in brain function), osteoarthritis and depression. Resident #66's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. She required extensive assistance with bed mobility, and total dependence with transfer and toileting. Resident #66 was always incontinent of bladder and was frequently incontinent of bowel. The resident had clear speech and had clear comprehension during assessment. During an attempt to interview on 12/3/23 at 11:58 PM, Resident #66 looked at the surveyor but would not answer questions. She had laid still in bed with hands crossed over her abdomen and stared at the ceiling most of the time. Resident's room had a mild smell of a bowel movement during interview. During an interview on 12/3/23 at 11:59 AM, Resident #66's family member stated that on 12/2/23, she noticed the resident had a bowel movement and wet her brief when she checked the resident at around 9:30 AM. Family member stated she turned the call light on as soon as she noticed it. She waited for almost an hour, and nobody came to check on what they needed even though the call light was on. The family member stated she was aggravated and went out to the hallway looking for a staff member. She stated she could not find the nurse aide, so she asked for assistance from the medication nurse that was in the other hallway. The nurse assisted the family member in cleaning Resident #66 and in changing the resident's brief at around 10:30 AM. The family member stated it happened a lot when she visited, and it happened again the next day on 12/3/23. She stated she came in after 9:30 AM and checked on Resident #66. She stated the resident had a bowel movement and wet her brief again. The family member stated she did not press the call light because she asked the lady who was passing out ice if she could send the nurse aide in to help her clean and change the resident's brief. The family member stated nobody came to check on them except for the nurse aide who came at around 12:10 PM that day to assist in cleaning the resident. During an interview on 12/5/23 at 10:00 AM, the hospice nurse stated Resident had declined a lot within seven weeks due to her condition. She stated resident went from walking and feeding herself to being bed bound and total assist with feeding. She stated the resident was able to communicate some days depending upon which nerve was flaring up. The hospice nurse stated the resident's family had complained a lot about the call light not being answered immediately. During an interview on 12/5/23 at 11:50 AM with Nurse #1, she stated that she was the nurse assigned to Resident #66 on first shift from 7:00 AM to 3:00 PM on 12/2/23. She stated she was almost done passing out medications that morning when Resident #66's family member asked her to help with cleaning the resident up and changing her brief. She stated there was one nurse aide assigned to W hall, but the family member stated she could not find her. Nurse #1 stated she stopped passing out medications and assisted the resident's family member in providing incontinence care. She stated she did not notice if the call light was on when she went into the resident's room. Nurse #1 stated Resident #66 had a bowel movement and was wet. She stated there was no redness or irritation. The resident was not wet through her brief and stool was not dried on her. During an interview on 12/6/23 at 10:20 AM, Nurse Aide (NA) #1 stated she worked on W hall on 12/2/23 and 12/3/23. She stated that she was assigned to two other halls and had around 18 to 20 residents those days. NA #1 stated she was doing her first round and was trying to get residents to sit up on their chairs by herself. She stated she was busy in S hall and was not aware that Resident #66's call light was on. She stated Resident #66's family member talked to her after lunch and told her they were not happy with having to wait for a long time and it was the same when the family member visited in the past. The nurse aide stated another staff told her before lunch on 12/3/23 that Resident #66's family member needed help with changing the resident's brief. She stated she was busy trying to finish giving a shower to a resident and trying to finish rounds on S hall and was not able to get to them immediately. She went to assist the family member at around 12:10 PM. NA #1 stated Resident #66 had a medium bowel movement and had wet her diaper, but she did not notice any red areas on her bottom. During an interview on 12/6/23 at 3:30 PM, the Feeding Assistant stated she was passing out ice on 12/3/23 when Resident #66's family member asked her to have the nurse aide help her change the resident's brief at around 10:00 AM to 10:30 AM. She stated she told the nurse aide when she saw her in the other hallway, but the nurse aide was also busy assisting a resident. The Feeding Assistant stated she was not sure when the nurse aide went to assist the family member, but she told the nurse aide mid-morning between breakfast and lunch on Sunday (12/3/23). During an interview on 12/6/23 at 9:05 AM, another family member stated he came in everyday to care for Resident #66. He stated he came in at 11:30 AM on 12/2/23 to feed the resident and the visiting family member told him she was upset about Resident #66 not being cleaned up for a long time until she had to get the nurse to help her. During a follow up telephone interview on 12/5/23 at 2:43PM, Resident #66's family member stated she turned the call light on as soon as she got in on 12/2/23 at around 9:30 AM and noticed the resident had wet her brief and had a bowel movement. After an hour, she got up and walked up and down the hallway looking for a staff to assist her but did not see anybody. She stated she found the nurse in the other hallway and asked her to help. The family member stated she turned the call light off when she went back to the resident's room with the nurse. She stated Resident #66 was considered cognitively impaired because of her condition and would not be able to communicate if she was wet or had a bowel movement. She stated on 12/3/23, she did not turn the call light on and just sent a message through the staff passing out ice that she needed assistance with cleaning up Resident #66. The family member stated it was very frustrating because the resident laid there the whole time with a bowel movement and a wet brief until the nurse aide came in at 12:10 PM. During an interview on 12/6/25 at 5:00 PM, the Director of Nursing stated the staffing numbers on the weekends were not different on any other day. There were no ancillary staff during the weekends to help with answering the call lights. The nurse and the nurse aide were responsible for answering the call lights on the weekends and assist residents with their needs such as changing their brief. She also stated her goal was to increase staffing.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of cognitive patterns, mood, behavior, and participation in assessment and goal setting for 2 of 6 residents (Resident #57 and Resident #11) whose MDS were reviewed. The findings included: 1. Resident #57 was admitted on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 indicated the questions in the sections for cognitive patterns, mood, behavior, and participation in assessment and goal setting were not assessed. An interview with the Social Services Director on 12/6/23 at 8:52 AM revealed she just started in her new role in October 2023, but she was responsible for filling out the sections for cognitive patterns, mood, behavior, and participation in assessment and goal setting in the MDS assessments. An interview with the MDS Coordinator on 12/6/23 at 3:56 PM revealed the previous SSD left and ended her notice sooner than required. The MDS Coordinator stated that the previous SSD was already gone when she realized that her sections in the MDS had not been filled out. She stated she went ahead and transmitted Resident #57's MDS even though some sections had not been assessed but all questions should have been answered and signed by the person who completed the assessment. An interview with the Administrator on 12/6/23 at 6:16 PM revealed because Resident #57's MDS was due, the MDS Coordinator went forward with closing them even though they weren't completed. A follow-up interview with the Administrator on 12/6/23 at 7:48 PM revealed she had completed an assessment on 8/30/23 for the sections that the SSD should have completed on Resident #57's MDS but it had already been closed at that time. She documented the assessment on a separate Social Services form by hand and it included questions about resident review, behavior, advanced directives, discharge planning, psychiatric consult, PASRR (Preadmission Screening and Resident Review), and social and transportation. She stated she communicated this to the MDS nurses, but she was not sure if a modification would have been done and she did not know if this required a modification. 2. Resident #11 was admitted on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 indicated the questions in the sections for cognitive patterns, mood, behavior, and participation in assessment and goal setting were not assessed. An interview with the Social Services Director on 12/6/23 at 8:52 AM revealed she just started in her new role in October 2023, but she was responsible for filling out the sections for cognitive patterns, mood, behavior, and participation in assessment and goal setting in the MDS assessments. An interview with the MDS Coordinator on 12/6/23 at 3:56 PM revealed the previous SSD left and ended her notice sooner than required. The MDS Coordinator stated that the previous SSD was already gone when she realized that her sections in Resident #11's MDS had not been filled out. She stated she went ahead and transmitted the MDS even though some sections had not been assessed but all questions should have been answered and signed by the person who completed the assessment. An interview with the Administrator on 12/6/23 at 6:16 PM revealed because Resident #11's MDS was due, the MDS Coordinator went forward with closing them even though they weren't completed. A follow-up interview with the Administrator on 12/6/23 at 7:48 PM revealed she had completed an assessment on 8/31/23 for the sections that the SSD should have completed on Resident #11's but the MDS had already been closed at that time. She documented the assessment on a separate Social Services form by hand and it included questions about resident review, behavior, advanced directives, discharge planning, psychiatric consult, PASRR (Preadmission Screening and Resident Review), and social and transportation. She stated she communicated this to the MDS nurses, but she was not sure if a modification would have been done and she did not know if this required a modification.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR), level II was completed after new mental health diagnoses for 2 of 3 residents (Resident #37, #39) reviewed for PASRR. The findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with anxiety disorder on 10/07/22 and other phobic anxiety disorder on 10/13/22. No PASRR level II was completed. During an interview on 12/06/23 at 8:53 AM with the Social Worker (SW) revealed she had begun her position as SW in October 2023 and had no knowledge why a PASRR level II had not been completed for Resident #37 when she received new mental health diagnosis. She stated a PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. The SW revealed the admissions coordinator would inform her if a resident required a PASRR level II upon admission and she also attends weekly behavior meetings and daily morning meetings where the team would discuss any residents with a change of condition or a newly added diagnosis that could also require a PASRR level II to be completed. She stated based on Resident #37 recent diagnosis of anxiety disorder and other phobic anxiety disorder a PASRR level II should have been completed. During an interview on 12/06/23 at 6:16 PM with the Administrator she revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #37 recent diagnosis of anxiety disorder and other phobic anxiety disorder a PASRR level II should have been completed. 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with major depressive disorder on 06/12/23. No PASRR level II was completed. During an interview on 12/06/23 at 8:53 AM with the Social Worker (SW) revealed she had begun her position as SW in October 2023 and had no knowledge why a PASRR level II had not been completed for Resident #37 when she received new mental health diagnosis. She stated a PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. The SW revealed the admissions coordinator would inform her if a resident required a PASRR level II upon admission and she also attends weekly behavior meetings and daily morning meetings where the team would discuss any residents with a change of condition or a newly added diagnosis that could also require a PASRR level II to be completed. She stated based on Resident #39 recent diagnosis of major depressive disorder a PASRR level II should have been completed. During an interview on 12/06/23 at 6:16 PM with the Administrator she revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #39 recent diagnosis of major depressive disorder a PASRR level II should have been completed.

Based on record review, observation, family and staff interviews, the facility failed to provide incontinence care to a dependent resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 6 residents reviewed for activities of daily living. Findings included: Resident #66 was admitted to the facility on [DATE] for mononeuritis complex (damage to different areas of the peripheral or sometimes the brain nervous system that can cause paralysis, tingling, numbness, pain, and changes in brain function), osteoarthritis and depression. Resident #66's care plan on 10/10/23 indicated a problem with bladder incontinence with increased risk for skin breakdown and infections. Interventions included notifying nursing if incontinent during activities, establishing voiding patterns when possible and providing assistance with all incontinence care. Resident #66's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. She required extensive assistance with bed mobility, and total dependence with transfer and toileting. Resident #66 was always incontinent of bladder and was frequently incontinent of bowel. She had not exhibited rejection of care behaviors. Resident #66 was impaired on both upper and lower extremities. During an attempt to interview on 12/3/23 at 11:58 PM, Resident #66 looked at the surveyor but would not answer questions. She had laid still in bed with hands crossed over her abdomen and stared at the ceiling most of the time. Resident's room had a mild smell of a bowel movement during interview. During an interview on 12/3/23 at 11:59 AM, Resident #66's family member stated that on 12/2/23, she noticed the resident had a bowel movement and wet her brief when she checked the resident at around 9:30 AM. Family member stated she turned the call light on as soon as she noticed it. She waited for almost an hour, and nobody came to check on what they needed even though the call light was on. The family member stated she was aggravated and went out to the hallway looking for a staff member. She stated she could not find the nurse aide, so she asked for assistance from the medication nurse that was in the other hallway. The nurse assisted the family member in cleaning Resident #66 and in changing the resident's brief at around 10:30 AM. The family member stated it happened a lot when she visited, and it happened again the next day on 12/3/23. She stated she came in after 9:30 AM and checked on Resident #66. She stated the resident had a bowel movement and wet her brief again. The family member stated she did not press the call light because she asked the lady who was passing out ice if she could send the nurse aide in to help her clean and change the resident's brief. The family member stated nobody came to check on them except for the nurse aide who came at around 12:10 PM that day to assist in cleaning the resident. During an interview on 12/5/23 at 10:00 AM, the hospice nurse stated Resident had declined a lot within seven weeks due to her condition. She stated resident went from walking and feeding herself to being bed bound and total assist with feeding. She stated the resident was able to communicate some days depending upon which nerve was flaring up. The hospice nurse stated the resident's family had complained a lot about the call light not being answered immediately. During an interview on 12/5/23 at 11:50 AM with Nurse #1, she stated that she was the nurse assigned to Resident #66 on first shift from 7:00 AM to 3:00 PM on 12/2/23. She stated she was almost done passing out medications that morning when Resident #66's family member asked her to help with cleaning the resident up and changing her brief. She stated there was one nurse aide assigned to W hall, but the family member stated she could not find her. Nurse #1 stated she stopped passing out medications and assisted the resident's family member in providing incontinence care. She stated she did not notice if the call light was on when she went into the resident's room. Nurse # 1 stated Resident #66 had a bowel movement and was wet. Nurse # 1 stated Resident #66 had a bowel movement and was wet. She stated there was no redness or irritation. The resident was not wet through her brief and stool was not dried on her. During an interview on 12/6/23 at 10:20 AM, Nurse Aide (NA) #1 stated she worked on W hall on 12/2/23 and 12/3/23. She stated that she was assigned to two other halls and had around 18 to 20 residents those days. NA #1 stated she was doing her first round and was trying to get residents to sit up on their chairs by herself. She stated she was busy in S hall and was not aware that Resident #66's call light was on. She stated Resident #66's family member talked to her after lunch and told her they were not happy with having to wait for a long time and it was the same when the family member visited in the past. The nurse aide stated another staff told her before lunch on 12/3/23 that Resident #66's family member needed help with changing the resident's brief. She stated she was busy trying to finish giving a shower to a resident and trying to finish rounds on S hall and was not able to get to them immediately. She went to assist the family member at around 12:10 PM. NA #1 stated Resident #66 had a medium bowel movement and had wet her diaper, but she did not notice any red areas on her bottom. During an interview on 12/6/23 at 3:30 PM, the Feeding Assistant stated she was passing out ice on 12/3/23 when Resident #66's family member asked her to have the nurse aide help her change the resident's brief at around 10:00 AM to 10:30 AM. She stated she told the nurse aide when she saw her in the other hallway, but the nurse aide was also busy assisting a resident. The Feeding Assistant stated she was not sure when the nurse aide went to assist the family member, but she told the nurse aide mid-morning between breakfast and lunch on Sunday (12/3/23). During a follow up telephone interview on 11/5/23 at 2:43 PM, Resident #66's family member stated she turned the call light on as soon as she got in on 12/2/23 at around 9:30 AM and noticed the resident had wet her brief and had a bowel movement. After an hour, she got up and walked up and down the hallway looking for a staff to assist her but did not see anybody. She stated she found the nurse in the other hallway and asked her to help. The family member stated she turned the call light off when she went back to the resident's room with the nurse. She stated Resident #66 was detuned because of her condition and would not be able to communicate if she was wet or had a bowel movement. She stated on 12/3/23, she did not turn the call light on and just sent a message through the staff passing out ice that she needed assistance with cleaning up Resident #66. During an interview on 12/6/25 at 5:00 PM, the Director of Nursing stated the staffing numbers on the weekends were not different on any other day. There were no ancillary staff during the weekends to help with answering the call lights. The nurse and the nurse aide were responsible for answering the call lights on the weekends and assist residents with their needs such as changing their brief. She also stated her goal was to increase staffing.

Based on observation, record review, and interviews with resident and staff, the facility failed to provide pressure ulcer care per physician orders for 1 of 4 residents (Resident #94) reviewed for pressure ulcers. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (bone inflammation from infection) and sacral region stage 4 pressure ulcer (wound on the coccyx from prolonged pressure on the skin). A review of the wound providers' admitting assessment dated [DATE] indicated Resident #94 had an existing stage 4 pressure ulcer on the coccyx area that measured 2.9 centimeters (cm) in length by 2.1 cm in width and 0.9 cm deep. The area had moderate serous drainage. The Admission Minimum Data Set (MDS) on 9/2/23 indicated Resident # 94 was cognitively intact. She had a stage 4 pressure ulcer on her coccyx and was receiving wound care. She was at risk of developing pressure ulcers. She used pressure reducing devices on her bed and her chair. She required limited assistance with bed mobility and one person assist with bathing. She used a walker for mobility. She was always continent of bowel and bladder function. Resident #94's care plan dated 11/3/23 indicated she had a pressure ulcer to her coccyx area and was at risk for developing additional pressure ulcer due to decreased ability to reposition and incontinence. Interventions included administering treatments as ordered and monitoring for effectiveness. A review of the wound provider's note on 12/1/23 indicated the area on coccyx is 2.1 cm in length x 1.5 cm in width and 0.5 deep with moderate serous dressing. No necrosis noted. A review of physician order dated 12/1/23 for wound care stated to clean the coccyx wound with normal saline or wound cleanser, pat dry, apply collagen to wound bed, cover with gauze, secure with a silicone bordered dressing daily on day shift for wound care. A review of Resident #94's Treatment Administration Record (TAR) for December 2023 indicated the treatment order for Resident #94 for 12/2/23 and 12/3/23 were initialed by Nurse #1 indicating the wound care was performed. During an interview on 12/3/23 at 3:44 PM, Resident #94 stated the nurse did not change the wound dressing on her coccyx on 12/2/23. She stated it was supposed to be changed every day, but the nurses skipped some days. During an observation of Nurse #4 perform the wound dressing on Resident #94's coccyx on 12/4/23 at 3:01 PM, it was noted that the wound was approximately 2 cm long, 1.5 wide and 0.5 cm deep with a minimal amount of thick brownish drainage. The surrounding areas were pink and did not have a noticeable odor. During an interview on 12/5/23 12:15 PM, Nurse #1 stated Resident #94 wanted her wound care done first thing in morning. She stated she changed the resident's dressing on her coccyx on both Saturday (12/2/23) and Sunday (12/3/23). Nurse #1 described the pressure ulcer as a little tinee tiny hole and that the order was for silver alginate dressing then changed to calcium alginate with foam dressing. She stated the wound on resident's coccyx looked like a tiny pin hole. Nurse #1 explained the resident stood up during dressing changes and assistance of another staff member was not needed for the dressing change. During a follow up interview on 12/6/23 9:30 AM, Resident #94 stated she did not refuse her dressing on Saturday (12/2/23). She stated the nurse never came back after she gave her medications. During an interview on 12/6/23 at 10:30 AM, Nuse Aide (NA) #1 stated on 12/3/23 Resident #94 told her the nurse did not do her dressing change on 12/2/23. She had not seen Nurse #1 do any treatments on 12/2/23 and she never came to get her to help with dressing changes for any residents. NA #1 stated some residents needed two staff for the nurse to change dressings on their buttocks or to apply treatment. She stated Resident #94 stood up during dressing changes to her coccyx. During an interview on 12/6/23 at 5:00 PM, the Director of Nursing (DON) revealed Resident #94 was cognitively intact and could verbalize what had occurred or not. She stated the resident could tell you if her dressings were changed or not. She stated the agency nurses do not just pass medications. They were supposed to do treatments as well.

Based on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist a resident with incontinence care for 1 of 6 residents reviewed for staffing (Resident #66). The findings included: This tag was cross-referenced to: F550 - Based on record review, family and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance to a resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 7 residents reviewed for dignity. The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity and not having to wait for incontinence care after having a bowel movement. F677 - Based on record review, observation, family and staff interviews, the facility failed to provide incontinence care to a dependent resident (Resident # 66) with a soiled brief when requested by a family member for 1 of 6 residents reviewed for activities of daily living. A review of the Centers for Medicare and Medicaid Services (CMS) payroll-based journal (PBJ) staffing data revealed the facility triggered excessively low weekend staffing levels for all four quarters for the fiscal year 2023. During an interview on 12/4/23 at 9:30 AM, Nurse #4 indicated staffing in the facility comes and goes. He stated they were staffed well with nurses, but they call in sick. The Director of Nursing, Assistant Director of Nursing and the Nurse Manager helped run the medication carts. During an interview on 12/5/23 at 9:00 AM, Nurse Aide (NA) #4 stated she usually had 18 to 20 residents by herself. She felt terrible for the residents because they do not receive the care they deserve. They do not get turned, showered properly, and do not receive care in general. She also stated she was showering a resident, and she came out to angry family members and residents because they had their call lights on for a long time. She stated she called for help over the radio for help with the lift, but nobody came. She heard another nurse aide kept her radio off because the nurse aide did not have time to help. She was only able to complete a resident shower one per day instead of two. During an interview on 12/6/23 at 0910, NA #3 stated she was assigned to 18 or 20 residents most of the time depending on the hallway and who showed up to work. She stated some days were hard and she did her best to provide care as much as she can. She stated she had some residents that were aggravated because their call light was on for a while, and she was busy attending to somebody. She stated the facility did not have enough staff, but they had good staff and she had good experience so far. During an interview on 12/6/23 at 10:20 AM, NA #1 stated they were short of staff. Sometimes she worked double shift twice a week to help. She stated she had an average of 24 residents each shift and only had three nurse aides that worked the other hallways. She stated she did not have time to provide all the care the residents needed when she had 24 residents. She only got to do rounds twice a shift only. She had residents or family members tell her their call lights had been on for a long time. She stated she could not answer the call light if she was attending to other residents in their room. Nobody else was out on the hallway to check on the other residents. She stated there were three agency nurse aides and a regular nurse aide each day. Some nurse aides were not getting residents up because they did not have anybody to help them. They did not have regular staff that knew these residents. The facility just recently closed F hall because management knew they were short-staffed. She stated they had to complete 1 to 2 showers a day, but it was hard if nobody was there to help with transfers or with lifts. She stated the residents got wiped down with wipes and did not have a real bed bath. She stated she tried talking to the nurse manager and made them aware of what was going on. During a telephone interview on 12/06/23 at 11:48 AM, NA #2 stated staffing was pretty good. The facility had a lot of agency staff. She said sometimes there were four to five nurse aides for the day shift. NA #2 said on a really bad day, they only had three and this happened once every 4 months. There were a few times when some residents complained about having to wait a long time for staff to answer call lights. During a telephone interview on 12/06/23 at 12:02 PM, NA #5 stated staffing was okay, but it could be a lot better. The number of resident assignments depended on the staffing. She had 16 if they had enough staff but she has had up to 25 residents. NA #5 stated it was more normal having 25 residents assigned to her than 16 residents. She stated she tried to do two to three incontinence rounds. If there were multiple call lights, she would pop in and tell the residents that she was assisting another resident, but she would come back. NA #5 stated that she turned the residents' call lights off once she informed them that she would be back. She stated some residents had complained to her about other shifts not answering their call light immediately but not on her shift. During an interview on 12/05/23 at 4:45 PM, the Scheduler stated she went by the daily census when scheduling staff on all shifts. She stated there were four nurses and a medication aide or five nurses on first and second shift. She stated she would like to have 5 or 6 nurse aides for a census of 100 on first and second shift. She stated the facility had that number of nurse aides by using agency staff. Nurse staffing was a challenge and having agency nurses helped. The nurse managers also helped on the floor working as needed. The Scheduler stated she knew how short they were but tried to staff the halls with who was best at knowing and meeting the residents' needs. The Scheduler stated they had open positions for nurses, nurse aides and medication aides on both the first and second shift. The Scheduler stated it was easier to schedule for the weekend because there were more staff that could work the weekends. She stated the third shift was well staffed with four nurse aides and two nurses in the building for a census of 100. If there were call outs, the nursing supervisors assist in calling staff in and the Scheduler tried to contact agencies for any available staff. During an interview on 12/5/23 at 3:53 PM, the Director of Nursing (DON) stated she reviewed and approved the schedules completed by the Scheduler. She stated the schedule was based on daily census. One nurse can have up to 28 residents. The number of nurses in the rehabilitation hall (K Hall and top half of S) varied. She stated F Hall was empty to accommodate short staffing. The DON stated they did not stop admissions and had two more residents that came in that week. She stated they usually have a nurse and a medication aide for the rehabilitation area due to higher acuity and daily skilled nursing documentation. The DON explained the weekend staffing was the same as the weekdays. If somebody called in, nursing management called other nurses to come in or asked agencies for nurses. She stated they would be severely short-staffed without agency staff. Her goal was to reduce shortage. The facility posted job vacancies on the internet. Corporate also sent them applications they received from their website. The DON stated they raised the nurse wages and just recently created part time positions and increased hourly wage for part timers. The goal was to get them to stay and work part time. She stated the nurse managers covered the floor and were ready to help as needed. The common complaint that the residents and their families brought to her attention was related to low staffing. The DON stated they talked individually to them about their recruitment efforts and what they were doing. They had a hall closed and were being careful not to overfill the building and not have enough staff to accommodate the residents' needs. Human Resources and nursing management also talked to staff that were quitting to see what the issues were. Most of their reason was their need for more education. She stated they never had low staff on weekends because they staffed the same as every other day. They found staff to cover if there were sick calls. The DON stated the weekends feel short-staffed to residents and families since ancillary staff were not in the facility. During a follow-up interview on 12/6/23 at 5:00 PM, the Director of Nursing (DON) stated her goal was to increase staffing. She stated the facility would not have enough staff without the agencies. During an interview on 12/6/23 at 7:00 PM, the Administrator stated the facility had the same number of staff scheduled 7 days a week. If they did not have enough staff, then they filled them with agency staff. The department heads rotated to work 4 hours every weekend and had to be present during mealtimes. They also answered call lights when they are in the building during the weekends, but they were not primarily responsible for answering call lights. The Administrator stated she thought there were enough staff to meet the residents' needs during the weekends. She stated staffing was based on census and they were scheduling the same number of staff 7 days a week.

Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity when there was a delay in answering their call light when toileting/incontinence care was needed, not providing showers/bathing assistance as scheduled and not providing assistance out of bed when requested resulting in residents feeling dirty, mad, isolated and forgotten about. This affected 3 of 14 sampled residents (Residents #46, #84 and #87) reviewed for activities of daily living and dignity. Findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #46 with intact cognition. Resident #46 required physical assistance of one staff member, limited to transfer only, for bathing and displayed no rejection of care during the MDS assessment period. During an interview on 06/06/22 at 11:50 AM, Resident #46 was unaware of how many showers she was scheduled to receive each week and reported only receiving one shower since her admission to the facility. Resident #46 did not recall receiving any bed baths. Resident #46 stated due to her risk of falls, she needed staff assistance and when she didn't receive her showers, she stated sometimes it's like I can feel the dirt on my face and I just feel dirty. During an interview on 06/09/22 at 2:27 PM, NA #2 revealed she had only been employed for about two months and since that time, staffing had been challenged. NA#2 stated she was typically assigned to Resident #46's hall as the only NA with anywhere from 18 to 28 residents on her assignment. NA #2 stated she could usually get scheduled showers provided if her assignment was 18 residents but any more than that, she had to prioritize resident care, such as meals and incontinence care, and showers would not get provided. NA #2 further stated this past week she was unable to provide any of her assigned residents with their scheduled showers due to being the only NA on the hall. During an interview on 06/09/22 at 2:45 PM, NA #3 revealed she was typically assigned to Resident #46's hall with anywhere from 20 to 22 residents on her assignment and on some occasions, 28 residents. NA #3 explained when short-staffed and the only NA assigned to the hall, it was difficult to get all resident care provided such as resident showers and documentation. During an interview on 06/09/22 at 3:17 PM, NA #4 confirmed residents had voiced complaints they had not received their showers. NA #4 explained she was assigned to Resident #46's hall during the months of April 2022 to June 2022 and typically had over 20 residents on her assignment which made it difficult to get all resident care done. NA #4 stated due to being short-staffed this past week, she was unable to provide residents with their scheduled showers but did try to provide them with a bed bath which she described as washing the face, underarms, and private areas. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 5:16 PM. Both the Administrator and DON confirmed the facility had faced staffing challenges and the hiring process was ongoing. The DON explained they had identified the issue with showers not being provided back in January 2022 and in response, a shower team was developed utilizing former employees who came to the facility on certain nights of the week to give residents showers. The Administrator and DON both stated they would never want any resident to feel dirty due to not receiving a shower and were unaware Resident #46 voiced feeling that way. The Administrator and DON both stated they felt the provision of showers had improved since the issue was first identified and a shower team was developed. 2. Resident #84 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #84 with intact cognition. He required extensive assistance of one staff member with part of the bathing activity, total staff assistance with toileting and displayed no rejection of care during the MDS assessment period. During interviews on 06/06/22 at 11:02 AM and 06/09/22 at 10:30 AM, Resident #84 reported he had not had a complete bed bath or shower in months. Resident #84 stated staff would clean him up after a bowel movement but not what he would consider a good wiping down. Resident #84 further stated he was unable to get up to the bathroom independently and relied on staff to assist him with incontinence care but often had to lie in a soiled brief waiting on staff to respond to his call light. Resident #84 explained when waiting on staff assistance, he would tell himself staff were busy but then when he noticed them walking back and forth past his door without stopping to help him, it just made him mad. Review of the facility call light response report provided by the Administrator on 06/09/22 for Resident #84's room revealed the following: · On 06/03/22, the bedroom call light was engaged a total of 7 times throughout the day. The average response time was 16 minutes and the max response time was one hour and eleven minutes. · On 06/04/22, the bedroom call light was engaged a total of 3 times throughout the day. The average response time was 13 minutes and the max response time was 22 minutes. · On 06/05/22, the bedroom call light was engaged a total of 5 times throughout the day. The average response time was 16 minutes and the max response time was 45 minutes. · On 06/06/22, the bedroom call light was engaged a total of 7 times. The average response time was 12 minutes and the max response time was 39 minutes. · On 06/07/22, the bedroom call light was engaged a total of 7 times. The average response time was 12 minutes and the max response time was 35 minutes. · On 06/08/22, the bedroom call light was engaged a total of 7 times. The average response time was 12 minutes and the max response time was 32 minutes. During an interview on 06/09/22 at 12:01 PM, the Administrator explained the call light response report did not distinguish the specific resident, only the room number where the call light was engaged and if it was engaged in the residents' room or bathroom. The Administrator stated all facility staff, not just the nursing staff, were instructed to assist with answering call lights and if the requested assistance was something the staff member was unable to provide, such as toileting or transfers, they were instructed to leave the call light on and notify the assigned NA. During an interview on 06/09/22 at 2:27 PM, NA #2 revealed she had only been employed for about two months and since that time, staffing had been challenged. NA#2 stated she was typically assigned to Resident #84's hall as the only NA with anywhere from 18 to 28 residents on her assignment. NA #2 stated she could usually get scheduled showers provided if her assignment was 18 residents but any more than that, she had to prioritize resident care, such as meals and incontinence care, and showers would not get provided. NA #2 further stated this past week she was unable to provide any of her assigned residents with their scheduled showers due to being the only NA on the hall. During an interview on 06/09/22 at 2:45 PM, NA #3 revealed she was typically assigned to Resident #84's hall with anywhere from 20 to 22 residents on her assignment and on some occasions, 28 residents. NA #3 explained when short-staffed and the only NA assigned to the hall, it was difficult to get all resident care provided such as resident showers and documentation. During an interview on 06/09/22 at 3:17 PM, NA #4 confirmed residents had voiced complaints they had not received their showers. NA #4 explained she was assigned to Resident #84's hall during the months of April 2022 to June 2022 and typically had over 20 residents on her assignment which made it difficult to get all resident care done. NA #4 stated due to being short-staffed this past week, she was unable to provide residents with their scheduled showers but did try to provide them with a bed bath which she described as washing the face, underarms, and private areas. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 5:16 PM. Both the Administrator and DON confirmed the facility had faced staffing challenges and the hiring process was ongoing. The DON explained they had identified the issue with showers not being provided back in January 2022 and in response, a shower team was developed utilizing former employees who came to the facility on certain nights of the week to give residents showers. The Administrator and DON both stated they felt the provision of showers had improved since the issue was first identified and a shower team was developed. In addition, both the Administrator and DON stated they would never want a resident to become mad while waiting for staff assistance and it was never acceptable for a resident to wait an hour and eleven minutes for staff to respond to their call light. 3. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #87 with mild impairment in cognition. She required extensive assistance of one staff member with part of the bathing activity, total assistance of two staff members for transfers and displayed no rejection of care during the MDS assessment period. During an interview on 06/06/22 at 10:45 AM, Resident #87 stated she was supposed to receive two showers per week but did not get them regularly. Resident #87 further stated whenever she asked staff for a shower, they would tell her they were short-staffed. Resident #87 also voiced she engaged her call light this morning at 7:00 AM to request staff assistance with getting up out of bed and into her wheelchair. She could not recall the exact time her call light was answered but indicated the staff member turned off the call light, stated they were busy and would be back to assist her out of bed before lunch. Resident #87 voiced she preferred to be up out of bed right after breakfast but usually did not get assistance until mid-morning or just before lunch. A follow-up interview and observation was conducted with Resident #87 on 06/08/22 at 10:25 AM. Resident #87 was lying in bed and stated she had engaged her call light to request assistance but staff had turned it off. Resident #87 voiced she did not like lying in bed until noon and wanted to up in her wheelchair so she could go out into the facility. Resident #87 stated she felt isolated and forgotten about when left in the bed. Review of the facility call light response report provided by the Administrator on 06/09/22 for Resident #87's room revealed the following: · On 06/03/22, the bedroom call light was engaged a total of 5 times throughout the day. The average response time was 12 minutes and the max response time was 45 minutes. · On 06/04/22, the bedroom call light was engaged a total of 5 times throughout the day. The average response time was 17 minutes and the max response time was 36 minutes. · On 06/05/22, the bedroom call light was engaged a total of 5 times throughout the day. The average response time was 24 minutes and the max response time was 48 minutes. · On 06/06/22, the bedroom call light was engaged a total of 10 times. The average response time was 16 minutes and the max response time was 28 minutes. · On 06/07/22, the bedroom call light was engaged a total of 5 times. The average response time was 14 minutes and the max response time was 35 minutes. · On 06/08/22, the bedroom call light was engaged a total of 4 times. The average response time was 4 minutes and the max response time was 41 minutes. During an interview on 06/09/22 at 12:01 PM, the Administrator explained the call light response report did not distinguish the specific resident, only the room number where the call light was engaged and if it was engaged in the residents' room or bathroom. The Administrator stated all facility staff, not just the nursing staff, were instructed to assist with answering call lights and if the requested assistance was something the staff member was unable to provide, such as toileting or transfers, they were instructed to leave the call light on and notify the assigned NA. During an interview on 06/09/22 at 2:27 PM, NA #2 revealed she had only been employed for about two months and since that time, staffing had been challenged. NA#2 stated she was typically assigned to Resident #87's hall as the only NA with anywhere from 18 to 28 residents on her assignment. NA #2 stated she could usually get scheduled showers provided if her assignment was 18 residents but any more than that, she had to prioritize resident care, such as meals and incontinence care, and showers would not get provided. NA #2 further stated this past week she was unable to provide any of her assigned residents with their scheduled showers due to being the only NA on the hall. NA #2 confirmed Resident #87 preferred to be up out of bed after breakfast and she tried her best to accommodate her preference but when she was the only NA assigned to the hall, it might take her a little longer to provide assistance. During an interview on 06/09/22 at 2:45 PM, NA #3 revealed she was typically assigned to Resident #87's hall with anywhere from 20 to 22 residents on her assignment and on some occasions, 28 residents. NA #3 explained when short-staffed and the only NA assigned to the hall, it was difficult to get all resident care provided such as resident showers and documentation. During an interview on 06/09/22 at 3:17 PM, NA #4 confirmed residents had voiced complaints they had not received their showers. NA #4 explained she was assigned to Resident #87's hall during the months of April 2022 to June 2022 and typically had over 20 residents on her assignment which made it difficult to get all resident care done. NA #4 stated due to being short-staffed this past week, she was unable to provide residents with their scheduled showers but did try to provide them with a bed bath which she described as washing the face, underarms, and private areas. During an interview on 06/09/22 at 4:41 PM, NA #6 revealed she was routinely assigned to Resident #87's hall with anywhere from 20 to 27 residents on her assignment. NA #6 explained when short-staffed and assigned 20 or more residents, she wasn't able to provide residents with their scheduled showers and focused on keeping the residents safe, dry and fed. NA #6 confirmed Resident #87 preferred to be up out of bed right after breakfast and would yell out for staff if they were not there to assist her right when she expected. NA #6 explained although they tried to answer call lights as soon as possible, when working short-staffed call light response time increased. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 5:16 PM. Both the Administrator and DON confirmed the facility had faced staffing challenges and the hiring process was ongoing. The DON explained they had identified the issue with showers not being provided back in January 2022 and in response, a shower team was developed utilizing former employees who came to the facility on certain nights of the week to give residents showers. The Administrator and DON both stated they felt the provision of showers had improved since the issue was first identified and a shower team was developed. In addition, both the Administrator and DON stated they would never want any resident to feel isolated or forgotten about and were not aware Resident #87 felt that way. The DON explained it was likely the NA was waiting on another staff member to assist them with transferring Resident #87; however, she should not have to wait 45 minutes for staff to respond to her call light and provide assistance.

Based on observations, record review, resident and staff interviews the facility failed to maintain sufficient nursing staff to ensure a resident (Resident #84) was not left lying in a soiled brief while waiting for staff to respond to an engaged call light for incontinence care. The facility failed to ensure requests from a resident dependent on staff for transfer (Resident #87) was not left in bed after multiple requests to get out of bed. The facility failed to ensure residents dependent on staff to provide physical assistance with bathing received showers as scheduled (Resident #18, 28, 38, 46, 47, 84, 85, 87). As a result of these failures residents expressed feeling dirty, mad, isolated, and forgotten about. These failures affected 8 of 17 residents sampled in the areas of dignity, choices, and activities of daily living. The findings included: This tag is cross referenced to: 1. F 550: Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity when there was a delay in answering their call light when toileting/incontinence care was needed, not providing showers/bathing assistance as scheduled and not providing assistance out of bed when requested resulting in residents feeling dirty, mad, isolated and forgotten about. This affected 3 of 14 sampled residents (Residents #46, #84 and #87) reviewed for activities of daily living and dignity. 2. F 561: Based on record review, observations, resident and staff interviews, the facility failed to provide residents with their preferred method of bathing and number of showers per week (Residents #47, #38, #28, and #18) and failed to accommodate a resident's request to be assisted out of bed at their preferred time of day (Resident #87) for 4 of 15 residents reviewed for choices and Activities of Daily Living (ADL). 3. F 677: Based on observations, record review, resident and staff interviews, the facility failed to provide showers or bed baths as scheduled for 4 of 13 sampled residents (Residents #46, #84, #87, and #85) reviewed for Activities of Daily Living (ADL). An interview with the Director of Nursing (DON) on 06/07/22 at 2:55 PM revealed she reviewed the nursing schedule and tried to ensure 6 to 7 Nurse Aide (NA) staff were assigned for day and evening shifts and 4 to 6 assigned for night shift. The DON revealed there were times staffing goals were not met. During an interview on 06/08/22 at 9:20 AM the Scheduler revealed she was responsible for creating the nursing staff schedule. On 06/08/22 there were five Nurse Aides (NA), a Medication Aide, and four Nurses scheduled for day shift. Each NA was assigned approximately 22 residents to provide care. The Scheduler revealed she did not use a staffing agency to cover shifts and if there were callouts, she would ask someone already working to stay over, call other staff, or stay herself until the shift was covered. An interview was conducted on 06/10/22 at 5:34 PM with the Administrator. The Administrator revealed the facility had experienced a high turnover in nursing staff. They had used two agencies to help but hadn't had good response with agency staff showing up. The Administrator revealed she was aware there were issues with residents getting their scheduled showers and a delay with call light response times. To help with staffing issues the Administrator indicated the resident census and number of staff were considered and new admissions were either passed or deferred for a couple days and eleven residents were discharging from the facility this week. The Administrator revealed the facility also implemented a retention program and gave a $500 bonus if staff met criteria. Wage adjustments were also made and just got approval for another pay increase. The Administrator revealed she had spoken with staff about communication when they were unable to provide showers and the role they play in group assignments including recruiting new staff, and in providing ideas to help with staffing issues. The Administrator revealed admissions were stopped for a short period of time or postponed until staffing stabilized but new resident admissions hadn't stopped for any significant length of time.

Based on observations, record review, and staff interviews, the facility failed to: 1) establish infection control policies and procedures to reduce the risk of growth and spread of Legionella in the building water systems that could affect 107 of 107 residents, 2) ensure nursing staff followed the facility's infection control policy when Nurse #5 did not don gloves when administering an insulin injection and did not perform hand hygiene after checking a resident's blood glucose (Resident #7 and Resident #101) during medication administration, 3) ensure nursing staff changed gloves and performed hand hygiene after performing incontinence care (Resident # 85) for 1 of 13 sampled residents, and 4) ensure hand hygiene was performed after removing gloves and soiled dressings during wound care (Resident #71 and Resident #79) for 2 of 3 sampled residents. Findings included: 1. Review of the facility's Emergency Preparedness plan revealed no information related to a facility water safety management program to minimize the risk of transmission of Legionella Disease to the residents staff and visitors. In an interview on 6/10/22 at 4:15 PM, The Administrator stated she was unaware of the requirement to develop a program to minimize the risk of transmission of Legionella through the facility's water system. She stated that she spoke with the facility Maintenance Director, and he was also unaware of the requirement. She further revealed the facility water was supplied by the city and no water testing had been completed by the facility. 2. Review of the facility policy entitled Hand Hygiene approved on 12/2021 revealed the following statement: It is the policy of the facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. This policy is developed using the Centers for Disease Control's Guidelines for Hand-Hygiene in Health-Care Settings. Under the Definition section of the policy, hand hygiene was defined as performing hand washing, antiseptic hand wash, alcohol-based hand rubs, surgical hand hygiene/antisepsis. The policy then listed specific indications for activities that required hand hygiene including after removing gloves and after handling used dressings or other items potentially contaminated with any resident's blood, excretions, or secretions. An observation of Nurse #3 performing wound care for Resident # 79 was completed on 06/08/22 at 11:27 AM. Resident # 79 had a wound on the top of her right foot and a wound on her left heel. Nurse #3 washed her hands with soap and water in the resident's bathroom sink and donned gloves. She then removed the existing dressing from the wound on the top of Resident # 79's foot and cleaned the wound bed with saline. She removed her gloves and without performing hand hygiene, donned a new pair of gloves and applied a new dressing to the wound. She then washed her hands with soap and water and donned clean gloves. Nurse #3 removed the dressing on Resident #79's left heel and cleaned the wound bed with saline. She removed her gloves and without performing hand hygiene, she donned a new pair of gloves. She applied the new dressing to the wound on Resident #79's left heel, removed her gloves and washed her hands with soap and water in the resident's bathroom sink. In an interview with Nurse #3 on 06/08/22 at 1:45 PM, she stated she changed her gloves frequently but should have performed hand hygiene after she removed her gloves between cleaning and applying new dressings to both wounds. In a joint interview on 6/10/22 at 5:20 PM the Director of Nursing and the Administrator indicated the hand hygiene policy should be followed by staff and hand hygiene should be performed when a soiled dressing is removed and when gloves are removed. 3. Review of the facility's policy titled Hand Hygiene approved 12/2021 read as follows, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. This policy is developed using the Centers for Disease Control's Guidelines for Hand Hygiene in Health-Care Settings. Under the Definition section of the policy hand hygiene was defines as performing hand washing, antiseptic hand wash, alcohol-based hand rub, and surgical hand hygiene/antisepsis. The policy then listed specific indications for hand hygiene including after offering incontinence care. The Other Hand Hygiene Guidelines section of the policy read in part as, if gloves are worn for a procedure, hand hygiene is to be completed after removal and deposit of gloves in an appropriate container. The use of gloves does not replace hand hygiene. A continuous observation of Nurse Aide (NA) #3 and NA #4 providing Resident #85 with incontinence care and morning care was made on 06/08/22 from 09:33 AM to 09:50 AM. With her gloved hands NA #3 cleaned stool with resident care wipes, rolled a clean brief under Resident #85, discarded the soiled brief in a trash bag, secured the tabs of the brief, rolled Resident #85 over on her side and placed the mechanical lift sling under her, rolled the mechanical lift over to the bed, used the bed control to adjust the head of the bed, attached the sling to the mechanical lift, used the control on the lift to raise Resident #85 off the bed, moved the lift to the resident's wheelchair, lowered Resident #85 into the wheelchair using the lift control, removed the sling from the mechanical lift, pushed the mechanical lift beside the closet, removed Resident #85's sweater and gown, touched multiple dresser drawer handles while looking for deodorant, applied deodorant to the resident, put an undershirt and a dress on Resident #85, picked up a comb and handed it to NA #4, pushed back the privacy curtain, and removed her soiled gloves. NA #3 then opened multiple dresser drawers until she found Resident #85's pony-tail holders and handed a pony-tail holder to NA #4. NA #3 then cleaned her hands with alcohol-based hand rub. NA #3 did not remove her gloves and perform hand hygiene after removing stool during incontinence care and continued to touch other items in Resident #85's room while wearing soiled gloves. NA #3 did not perform hand hygiene after removing soiled gloves and before touching other items in Resident #85's room. During an interview with NA #3 on 06/08/22 at 09:51 AM she confirmed she wore the same gloves after removing stool during incontinence care that she used to touch other items in Resident #85's room and did not immediately perform hand hygiene after removing soiled gloves. She stated she had been trained to remove her gloves and perform hand hygiene after providing incontinence care and before touching other items in the resident's environment. NA #3 stated it was an oversight that she did not remove her soiled gloves and perform hand hygiene after providing incontinence care for Resident #85. An interview with the Director of Nursing (DON) on 06/09/22 at 05:01 PM revealed she expected hand hygiene to be performed after providing incontinence care and before touching other items in the resident's environment. An interview with the Administrator on 06/09/22 at 05:28 PM revealed she expected hand hygiene to be performed any time staff went from a dirty task to a clean task. 4. Review of the facility's policy titled Hand Hygiene approved 12/2021 read as follows, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. This policy is developed using the Centers for Disease Control's Guidelines for Hand Hygiene in Health-Care Settings. Under the Definition section of the policy hand hygiene was defines as performing hand washing, antiseptic hand wash, alcohol-based hand rub, and surgical hand hygiene/antisepsis. The policy then listed specific indications for hand hygiene including after handling items potentially contaminated with any resident's blood and after removing gloves. On 06/06/22 at 11:54 AM Nurse #5 was observed with her gloved hands pricking Resident #101's right index finger with a lancet, applying a drop of blood onto a glucometer test strip, wiping Resident #101's right index finger with a gauze pad, obtaining the glucose reading, removing the test strip from the glucometer, discarding the test strip and gauze pad in the trash can, discarding the lancet in the sharps container (a puncture proof box), and removing and discarding her gloves in the trash can. Nurse #5 then began typing on her computer. No hand hygiene was performed after removing gloves and before typing on her computer. An interview with Nurse #5 on 06/06/22 at 12:04 PM revealed she should have performed hand hygiene after removing her gloves and before typing on the computer. She stated not performing hand hygiene after glove removal was an oversight. An interview with the Director of Nursing (DON) on 06/06/22 at 01:22 PM revealed she expected nurses to removed soiled gloves and perform hand hygiene after checking a fingerstick blood glucose. An interview with the Administrator on 06/09/22 at 05:28 PM revealed she expected nursing staff to remove soiled gloves and perform hand hygiene either by washing their hands or using alcohol-based hand rub after checking a fingerstick blood glucose. 5. Review of the facility's policy titled Medication Administration approved 12/2021 read in part as follows, for administration of injections always wear gloves. An observation of Nurse #5 on 06/06/22 at 12:16 PM revealed she cleaned Resident #7's left upper arm with an alcohol swab and administered 12 units of insulin subcutaneously (an injection in the subcutaneous layer of skin) without wearing gloves. During an interview with Nurse #5 on 06/06/22 at 12:21 PM she confirmed she did not wear gloves when she administered Resident #7's insulin injection. Nurse #5 stated she did not usually wear gloves when she administered insulin. An interview with the DON on 06/06/22 at 01:22 PM revealed she expected gloves to be worn when administering injectable medication. An interview with the Administrator on 06/09/22 at 05:28 PM revealed she expected nursing staff to wear gloves administering insulin. 6. Review of the facility policy titled Hand Hygiene approved on 12/21 read in part: It is the policy of the facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. This policy was developed using the Centers for Disease Control's Guidelines for Hand-Hygiene in Health-Care Settings. The policy's definitions for hand hygiene included perform hand washing or use an alcohol-based hand rub. The policy also listed specific activities requiring hand hygiene to include after removing gloves, after handling a used dressing or other items potentially contaminated with a resident's blood, excretions, or secretions. An observation of Resident #71's wound care was made on 06/08/22 at 11:47 AM. Upon entering the room Nurse #1 used the dispenser of alcohol-based hand sanitizer located inside the room to sanitize her hands. Nurse #1 donned a pair of gloves and began to remove tape, an absorbent pad, and gauze packed inside the sacrum wound. The gauze was moderately soaked with a brown colored drainage and an odor was noted coming from the wound. Nurse #1 removed her gloves and without performing hand hygiene donned a pair of gloves and began to clean the wound bed with gauze moistened with a chlorine antiseptic. Nurse #1 discarded the used gauze then removed her gloves and without hand hygiene donned a pair of gloves and begun to pack the sacrum wound bed with gauze moistened with a chlorine antiseptic. Nurse #1 removed her gloves and without performing hand hygiene donned a pair of gloves and begun to cover the sacrum wound with an absorbent pad and secure with tape. When finished with wound care Nurse #1 removed her gloves and performed hand hygiene. An interview was conducted with Nurse #1 on 06/08/22 at 11:59 AM. Nurse #1 stated she probably should have washed her hands when she changed her gloves. She reported she was trained to wash her hands after removing her gloves. Nurse #1 stated she didn't wash her hands and was trying to get the wound care completed and get back to her assigned hall. During an interview on 06/10/22 at 5:27 PM the Director of Nursing stated it was her expectation the nurses perform hand hygiene and don new gloves after removing a soiled dressing.

Based on record review, observations, resident and staff interviews, the facility failed to provide residents with their preferred method of bathing and number of showers per week (Residents #47, #38, #28, and #18) and failed to accommodate a resident's request to be assisted out of bed at their preferred time of day (Resident #87) for 5 of 15 residents reviewed for choices and Activities of Daily Living (ADL). Findings included: 1. Resident #47 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #47 with moderate impairment in cognition. He required physical assistance of one staff member with part of the bathing activity and displayed no rejection of care during the MDS assessment period. Review of Resident #47's care plans, last reviewed/revised on 04/29/22, revealed a plan of care that addressed an ADL self-care performance deficit related to fatigue status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Aide (NA) Master Shower Schedule (MSS) provided by the facility, dated 01/25/22, was reviewed. The MSS indicated the shower team assignments were scheduled for Monday, Tuesday and Wednesday and noted in bold. Resident #47 was scheduled to receive his showers on Wednesdays and Saturdays during the hours of 3:00 PM and 11:00 PM and was not listed in bold to indicate his showers would be completed by the shower team. Review of the NA bathing documentation reports provided by the facility for Resident #47 for the period April 2022 to June 2022 revealed the following: · April: Showers were documented as provided on 04/02/22, 04/20/22, and 04/30/22. There were no bed baths documented as provided. · May: Bed baths were documented as provided on 05/04/22, 05/05/22, and 05/28/22. There were no showers documented as provided. · June: There was no bathing activity documented as provided. During an observation and interview on 06/06/22 at 11:18 AM, Resident #47 was sitting up in his wheelchair with visible beard stubble and no obvious body odor. Resident #47 was unaware how many showers he was scheduled to receive per week and could not recall when he last received a shower but stated he had not had one since his last doctor's visit over a month ago. Resident #47 voiced he preferred showers in lieu of a bed bath and would like to receive one shower per week on Friday evenings. During an interview on 06/09/22 at 2:27 PM, NA #2 revealed she had only been employed for about two months and since that time, staffing had been challenged. NA#2 stated she was typically assigned to Resident #47's hall as the only NA with anywhere from 18 to 28 residents on her assignment. NA #2 stated she could usually get scheduled showers provided if her assignment was 18 residents but any more than that, she had to prioritize resident care, such as meals and incontinence care, and showers would not get provided. NA #2 further stated this past week she was unable to provide any of her assigned residents with their scheduled showers due to being the only NA on the hall. During an interview on 06/09/22 at 2:45 PM, NA #3 revealed she was typically assigned to Resident #47's hall with anywhere from 20 to 22 residents on her assignment and on some occasions, 28 residents. NA #3 explained when short-staffed and the only NA assigned to the hall, it was difficult to get all resident care provided such as resident showers and documentation. NA #2 stated if she was able to provide some of the residents on her assignment with their scheduled showers, she chose the residents who had gone the longest without receiving a shower. During an interview on 06/09/22 at 3:17 PM, NA #4 confirmed residents had voiced complaints they had not received their showers. NA #4 explained she was assigned to Resident #47's hall during the months of April 2022 to June 2022 and typically had over 20 residents on her assignment which made it difficult to get all resident care done. NA #4 stated due to being short-staffed this past week, she was unable to provide residents with their scheduled showers but did try to provide them with a bed bath which she described as washing the face, underarms, and private areas. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 5:16 PM. The Administrator and DON both confirmed the facility had faced staffing challenges and the hiring process was ongoing. The DON revealed they had identified the issue with showers not being provided back in January 2022 and in response, a shower team was developed utilizing former employees who came to the facility on certain nights of the week to give residents showers. The DON explained the MSS was created to divide resident showers between the NAs and shower team, the NAs could look at the schedule and if their assigned resident was not in bold lettering then they knew they would have to provide the resident with their scheduled shower. The Administrator added they also had an active Performance Improvement Plan (PIP) related to showers that they were still working on and have asked staff to communicate when they were challenged with getting resident care done. The Administrator and DON both stated as part of the PIP, they monitored bathing documentation but could not explain why residents were still not receiving their scheduled showers. The Administrator and DON both stated they felt the provision of showers had improved since the issue was first identified and a shower team was developed. During a follow-up interview on 06/10/22 at approximately 6:30 PM, the Administrator stated the Performance Improvement Plan related to showers was started on 02/01/22, last reviewed at a QAPI (Quality Assurance and Performance Improvement) meeting on 04/18/22 and was ongoing. 2. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #87 with moderate impairment in cognition. She required total staff assistance of two staff members with transfers and displayed no rejection of care during the MDS assessment period. Review of Resident #87's care plans, last reviewed/revised on 05/25/22, revealed a plan of care that addressed an altered ADL self-care performance deficit and altered mobility status with low activity intolerance. Interventions included: required total assistance of 2 staff members with transfers using a mechanical lift and totally dependent on staff for lower body dressing. During an interview on 06/06/22 at 10:45 AM, Resident #87 revealed she engaged her call light this morning at 7:00 AM to request staff assistance with getting up out of bed and into her wheelchair. She could not recall the exact time her call light was answered but indicated the staff member turned off the call light, stated they were busy and would be back to assist her out of bed before lunch. Resident #87 voiced she preferred to be up out of bed right after breakfast but usually did not get assistance until mid-morning or just before lunch. A follow-up interview and observation was conducted with Resident #87 on 06/08/22 at 10:25 AM. Resident #87 was lying in bed and stated she had engaged her call light to request assistance to get out of bed but staff had turned it off. Resident #87 voiced she did not like lying in bed until noon and wanted to up in her wheelchair so she could go out into the facility. Resident #87 stated she felt isolated and forgotten about when left in the bed. During an interview on 06/09/22 at 2:27 PM, Nurse Aide (NA) #2 revealed she had only been employed for about two months and since that time, staffing had been challenged. NA #2 confirmed Resident #87 preferred to be up out of bed after breakfast and she tried her best to accommodate her preference but when she was the only NA assigned to the hall, it might take her a little longer to provide assistance. During an interview on 06/09/22 at 4:41 PM, NA #6 revealed she was routinely assigned to Resident #87's hall with anywhere from 20 to 27 residents on her assignment. NA #6 explained when short-staffed and assigned 20 or more residents, she focused on keeping the residents safe, dry and fed. NA #6 confirmed Resident #87 preferred to be up out of bed right after breakfast and would yell out for staff if they were not there to assist her right when she expected. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 5:16 PM. Both the Administrator and DON confirmed the facility had faced staffing challenges and the hiring process was ongoing. The Administrator and DON both stated they would never want any resident to feel isolated or forgotten about and were not aware Resident #87 felt that way. The DON agreed Resident #87 should be assisted out of bed at her preferred time of day and explained it was likely the NA was waiting on another staff member to assist them with transferring Resident #87 since she required the use of a mechanical lift for transfers. The DON stated a resident's preference should be accommodated if at all practicable. 3. Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #28 was cognitively intact. Resident #28 required extensive assistance with personal hygiene and physical assistance by 1-person with bathing. The MDS also indicated Resident #28 had no rejection of care behaviors during the lookback period. Resident #28's care plan identified her as having a self-care deficit related to limited mobility, impaired vision, and needed extensive assistance for activities of daily living. The goals included Resident #28 would receive assistance from staff with all aspects of daily care to ensure her needs were met. Interventions initiated on 09/16/20 included staff to assist with personal hygiene and indicated Resident #28's bathing preference was to receive showers. Review of the Nurse Aide staff documentation from March through June 2022 revealed Resident #28's showers were scheduled on Tuesday and Friday during day shift. Based on the recorded showers one shower had been given on 04/26/22. During an interview on 06/09/22 at 10:35 AM Resident #28 revealed her shower days were scheduled on Tuesday and Friday but she couldn't remember when her last shower was given. Resident #28 revealed when she doesn't get a shower, she doesn't get a bed bath either. Resident #28 revealed she had to ask Nurse Aide (NA) staff for help wiping her off and used the bathroom sink to clean her face. Resident #28 stated she wanted her showers as scheduled and it use to be the NA would give her shower regularly but that doesn't happen anymore. Resident #28 revealed she had given up on asking about her showers and stated nothing was done when she did. Resident #28 revealed the facility does have staff that come to give showers but if you weren't on their list, you didn't get one. An interview was conducted on 06/07/22 at 03:30 PM with NA #1. NA #1 was assigned to work on 06/06/22 on the hall Resident #28 resided. NA #1 revealed she was scheduled to work on day shift and had worked for the facility approximately one year. NA #1 revealed on 06/06/22 she was assigned 28 residents along with two nurses and stated she didn't even look at which residents were scheduled a shower. NA #1 stated staffing was horrible, and her typical assignment was 20 or more residents, and she does what she can to provide care. NA #1 revealed she does try to give a bed bath by wiping down the residents face, under arms, and peri-area. NA #1 revealed the facility tried to keep five NA staff scheduled which gave each approximately 20 to 21 residents but that didn't always happen. NA #1 revealed the shower team does a lot of the residents showers who require 2-person assistance with bathing. An interview was conducted on 06/10/22 at 5:34 PM with the Administrator and Director of Nursing (DON). It was shared Resident #28 didn't receive consistent bathing on the days her preferred showers were scheduled. The Administrator stated they recognized residents not receiving their showers was a concern and implemented a shower team in January 2022. The DON revealed the shower team comes 3 to 4 days a week and one staff on Sunday to do showers. The Administrator revealed with showers being an ongoing concern additional support staff were hired including paid feeding assistants. The Administrator stated the facility was ongoing to address missed showers and ask NA staff communicate if they couldn't provide a resident's shower. The Administrator stated she may be looking into extending the shower teams hours. 4. Resident #38 was admitted to the facility 05/10/10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively intact and required physical assistance of one staff member with part of the bathing activity. The MDS indicated Resident #38 had no rejection of care during the lookback assessment period. Review of the activities of daily living (ADL) care plan last updated 04/09/22 revealed Resident #38 required extensive assistance with bathing. The Nurse Aide (NA) Master Shower Schedule (MSS) revealed Resident #38 was scheduled to receive her showers on Mondays and Thursdays during the hours of 03:00 PM to 11:00 PM. The MSS indicated the shower team was scheduled to perform Resident #38's shower on Mondays. Resident #38's showers for Thursdays were not scheduled to be completed by the shower team. Review of NA bathing documentation reports provided by the facility for Resident #38 for May 2022 and June 2022 revealed the following: May: A shower was documented as being provided on 05/02/22. Bed baths were documented as being provided 05/03/22, 05/14/22, and 05/18/22. June: A bed bath was documented as being provided 06/03/22. A shower was documented as being provided 06/06/22. An interview with NA #1 on 06/07/22 at 03:30 PM revealed she usually worked the 07:00 AM to 03:00 PM shift but also worked the 03:00 PM to 11:00 PM shift at times and cared for Resident #38. She stated there were times when she was assigned 28 residents. NA #1 stated when she was assigned that many residents she was unable to provide showers as scheduled. She stated she would try to provide a bed bath when she knew she was not going to be able to provide a shower. NA #1 stated the nurses were aware that showers often did not get done as scheduled. An interview with NA #8 on 06/09/22 at 02:00 PM revealed she worked the 03:00 PM to 11:00 PM shift and frequently cared for Resident #38. She stated there were times when there were only 3 to 4 NAs for the entire 03:00 PM to 11:00 PM shift (she was unable to provide an exact number of residents on her assignment when there only 3 to 4 NAs for the entire facility) and when staffing was that short she had to prioritize care, by ensuring by residents received incontinence care and feeding assistance. NA #8 stated she documented that a shower was given if she was able to provide a shower, but there were frequently times when she was not able to get scheduled showers done and if she was unable to provide showers she notified the nurse. An interview with Resident #38 on 06/09/22 at 06:02 PM revealed she was supposed to receive 2 showers a week and she often did not receive her showers. She stated she preferred showers over bed baths and would like to receive 2 showers a week. A joint interview was conducted with the Administrator and Director of Nursing (DON) on 06/10/22 at 05:16 PM. Both the Administrator and DON confirmed the facility had faced staffing challenges and the hiring process was ongoing. The DON revealed an issue had been identified with showers not being provided back in January 2022 and in response, a shower team was developed utilizing former employees who came to the facility certain nights of the week to give residents showers. The DON explained the MSS was created to divide resident showers between NAs and shower team and the NAs could look at the schedule and if their assigned resident was not in bold lettering then they knew they would have to provide the resident with their scheduled shower. The Administrator added they also had an Active Performance Improvement Plan (PIP) related to showers that they were still working on and have asked staff to communicate when they were challenged with getting resident care done. The Administrator and DON both stated as part of the PIP, they monitored bathing documentation but could not explain why residents were still not receiving their scheduled showers. The Administrator and DON both stated they felt the provision of showers had improved since the issue was first identified and a shower team was developed. During a follow-up interview on 06/10/22 at approximately 06:30 PM, the Administrator stated the PIP related to showers was started on 02/01/22, was last reviewed at a Quality Assurance and Performance Improvement (QAPI) meeting on 04/18/22, and was ongoing.

Based on staff interview and medical record review, the facility failed to administer a correct dose of medication, resulting in a significant medication error for 1 of 3 sampled residents (Resident #1). Immediate jeopardy began on 06/09/14 when Resident #1 received an incorrect dose of concentrated [MEDICATION NAME] liquid resulting in a significant medication error. Immediate jeopardy was removed on 06/21/14 at 3:05 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective. The findings included: Resident #1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had short term and long term memory problems and was moderately impaired in cognitive skills for daily decision making. Review of the June 2014 recapitulation of physician's orders [REDACTED]. Resident #1's resuscitation status was listed as Do Not Resuscitate. A physician's orders [REDACTED]. Review of the June 2014 Medication Administration Record [REDACTED]. A second entry dated 06/09/14 read [MEDICATION NAME] 100 mg/ 5 ml - give 2.5 mg dose by mouth or per tube every 4 hours PRN pain. The June 2014 MAR indicated [REDACTED] 06/09/14 9:00 PM [MEDICATION NAME] 100 mg/5 ml 2.5 mg, [MEDICATION NAME] 30 mg 06/10/14 8:00 AM [MEDICATION NAME] 100 mg/5 ml 2.5 mg, [MEDICATION NAME] 30 mg 06/10/14 1:00 PM [MEDICATION NAME] 30 mg Review of a Nurse's Note dated 06/10/14 at 3:25 PM by Nurse #1 revealed Nurse Aide (NA) notified the Nurse at 12:50 PM that Resident #1 had a change in condition. Nurse #1 assessed the Resident and observed that her eyes were open with no focus and her respirations were audible while using accessory muscles with periods of apnea (not breathing). Her skin tone was gray/blue with no mottling noted. Nurse #1 notified Resident #1's Power of Attorney (POA) that Resident had taken a sharp decline. Nurse #1 reassessed Resident #1 at 1:00 PM and notified the POA that it appeared that Resident was actively dying. The note also indicated the nurse notified the Physician's Assistant (PA), who was in the facility at the time, of the Resident's condition. Review of a Nurse's Note dated 06/10/14 at 6:45 PM by Nurse #2 revealed the Nurse attempted to administer a PRN dose of liquid [MEDICATION NAME] 2.5 mg to Resident #1 per the request of family for dyspnea (labored breathing) but the Resident spit the medication out. A physician's telephone order dated 06/10/14 read: hold all meds until further notice, discontinue all [MEDICATION NAME] orders, [MEDICATION NAME] (a medication used to reverse the action of narcotic [MEDICATION NAME]) 0.4 mg intramuscularly (IM) now; if respirations fall below 8 to 10 per minute, give [MEDICATION NAME] 0.4 mg IM and call on call physician. Review of the June 2014 MAR indicated [REDACTED] 06/10/14 9:00 PM [MEDICATION NAME] 0.4 mg IM The following medications were documented as held and not administered: 06/10/14 5:00 PM [MEDICATION NAME] 30 mg 06/10/14 9:00 PM [MEDICATION NAME] 30 mg 06/11/14 8:00 AM [MEDICATION NAME] 30 mg Review of a Physician's progress note dated 06/11/14 revealed Resident #1 had a marked change in status with decreased level of consciousness on 06/10/14. The note further revealed the Resident had declined markedly in the last 4 to 6 months and it was difficult to control her behaviors which included striking out at staff when they were trying to care for her. The behavior management team at the facility recommended pain medication as staff thought she might be having discomfort at times and wasn't verbal to tell them. So on 06/09/14 Resident #1 was started on [MEDICATION NAME] 2.5 mg orally twice a day scheduled. Resident #1 received the first dose on the evening of 06/09/14. According to the note, Resident #1 was sleepy all day on 06/10/14 and by late afternoon she was not responsive. The nurses called Resident #1's family because they were concerned she was actively dying. [MEDICATION NAME] was given once the Family Nurse Practitioner (FNP) was alerted of the situation and the possibility of reaction to [MEDICATION NAME] as it was the last new medication started. Resident #1 became slightly more alert and was no longer apneic per nursing report. Her blood pressure (BP) was very low and [MEDICATION NAME] was held the morning of 06/10/14. An interview with Resident #1's physician on 06/20/14 at 11:03 AM revealed she was unsure if the Resident was given too much [MEDICATION NAME] or if it was an adverse reaction but she did have a marked change for the worse after it was given. The physician stated Resident #1 responded positively to the [MEDICATION NAME] and showed some improvement after it was given. She stated she ordered the [MEDICATION NAME] on a trial basis at a very small dose in an attempt to control possible pain that was causing her agitation. The physician stated her main concern was that Resident #1 either had an adverse allergic reaction to the [MEDICATION NAME] or was possibly given too much due to a medication error. An interview on 06/20/14 at 12:35 PM with the Staff Development Coordinator (SDC) and visual inspection of the medication bottle labeled for Resident #1 revealed it was labeled with the resident's name, [MEDICATION NAME] 20 mg/ml (15 ml was listed as quantity dispensed) - administer 0.125 ml = 2.5 mg every 12 hours. The SDC stated she measured the amount remaining in the bottle and there was 7.5 ml of medication in the bottle. The SDC showed surveyor calibrated dose syringes that were available for measuring liquid narcotic medication. A review of the narcotic count sheet with the SDC on 06/20/14 at 12:35 PM revealed a dosage was documented as given on 06/09/14 at 9:30 PM by Nurse #4 and the quantity given was listed as 2.5 ml with 12.5 ml remaining. The next dosage documented as given was on 06/10/14 at 6:45 PM by Nurse #2 and the quantity given was listed as 0.125 ml with 7.5 ml remaining. When asked about the discrepancy between the narcotic count sheet and Resident #1's MAR, she stated Nurse # 5 had documented on the June 2014 MAR indicated [REDACTED]. An interview with Resident #1's physician on 06/20/14 at 2:34 PM revealed Resident #1's baseline condition was a non-verbal, frail woman. She stated when she assessed the Resident on 06/11/14 her level of consciousness was close to her baseline given her cognition was quite poor but her extremities were quite weak. The physician stated it was probably due to the [MEDICATION NAME] dosage, which was a suspected medication error based on the Resident's response to the [MEDICATION NAME]. The physician explained that Resident #1's [MEDICATION NAME] was held because her BP was too low on 06/10/14 and she went into rapid [MEDICAL CONDITION], an abnormal heart rhythm, on 06/12/14. The physician stated the low heart rate was due to the [MEDICATION NAME]. The physician stated there was a direct correlation to the 2 events. The physician further stated that missing a dose of [MEDICATION NAME] might not effect some people but it did Resident #1 because she was so frail. An interview with Nurse #1 on 06/20/14 at 12:10 PM revealed she regularly works the 7:00 AM to 3:00 PM shift as the Resource Nurse on the Unit where Resident #1 lived. Nurse #1 explained that she was responsible for handling emergencies and acute situations with residents. When asked about Resident #1's condition on 06/10/14, Nurse #1 stated the Resident was awake and alert at the beginning of the shift and throughout the morning. She stated the NA who gave Resident #1 her shower commented that she was having a good day. An interview with the PA on 06/20/14 at 3:10 PM revealed she was at the facility on 06/10/14 and she recalled being notified about Resident #1's condition by staff and that they thought the resident's death was imminent. The PA stated she asked staff if the resident needed anything and staff reported the Resident appeared to be comfortable. The PA stated she didn't think the decline was unexpected so she didn't see the Resident or do an assessment. An interview with Nurse #2 on 06/20/14 at 3:37 PM revealed she was the Resource Nurse on 06/10/14 on the 3:00 PM to 11:00 PM shift for the hall on which Resident #1 lived. She stated she checked on Resident #1 every hour and she started having worse dyspnea about 6:30 PM. Nurse #2 stated Resident #1's family asked if she could give the Resident anything to help because she seemed to be in distress and struggling to breathe. Nurse #2 stated she (Nurse #2) asked the Medication Nurse to get a dose of [MEDICATION NAME] for the Resident. Nurse #2 stated she (Nurse #2) attempted to put the liquid medication in the Resident's mouth with a syringe and the Resident spit it out. Nurse #2 stated when the pulled the narcotic count sheet to document the dosage she attempted to give, she realized the dosage that was given on 06/09/14 at 9:30 PM was the wrong dosage. She stated based on the amount that was remaining in the bottle it appeared the wrong dosage was also given on 06/10/14 at 8:00 AM. She stated she immediately notified her supervisor and they both started trying to get in contact with the nurses (Nurse #4 and #5) who had administered the medication on 06/09/14 at 9:30 PM and on 06/10/14 at 8:00 AM. Nurse #2 stated after they spoke with the nurses and confirmed the incorrect dosage was administered, she notified the FNP who was on call and received orders to administer [MEDICATION NAME], which she did. Review of the facility's investigation revealed a written statement by Nurse #4 acknowledging she made a medication error and realized the seriousness of the error. A written statement by Nurse #5 revealed she didn't remember administering [MEDICATION NAME] to Resident #1. An interview with Nurse #5 on 06/21/14 at 10:41 AM revealed she was regularly assigned as the Medication Nurse for Resident #1 and worked on the 7:00 AM to 3:00 PM or the 3:00 PM to 11:00 PM shift. When asked if she could recall the amount of medication that was in the bottle of [MEDICATION NAME] liquid for Resident #1 on 06/10/14 at 7:00 AM, she stated she couldn't remember how much was in the bottle. When asked if she recalled giving a dose of [MEDICATION NAME] to Resident #1 on 06/10/14 at 8:00 AM, Nurse #5 stated she didn't give the Resident a dose of [MEDICATION NAME] because she seemed sleepier than usual. When asked about signing on the MAR indicated [REDACTED]. She stated she didn't sign that she gave it on the narcotic count sheet. Nurse #5 stated when she counted narcotics at 3:00 PM with the nurse who was coming on duty, they realized there had been a medication error and Resident #1 had been given too much [MEDICATION NAME]. When asked if she or the other nurse reported the medication error to a supervisor, she stated she didn't think so. She further stated it was really busy that day and they had a meeting to attend. An interview with Nurse #4 on 06/21/14 at 2:53 PM revealed she was the Medication Nurse for Resident #1 on 06/09/14 for the 3:00 PM to 11:00 PM shift. When asked if she recalled giving [MEDICATION NAME] liquid to Resident #1 on 06/09/14 at 9:30 PM, she stated she put a small amount in a medication cup which was about halfway between the bottom of the medication cup and the 5 ml mark on the cup to approximate 2.5 ml. She stated she thought the dosage was 2.5 ml. She stated she didn't use a syringe to measure the medication and did not realize she had given the wrong dosage until contacted by the nursing supervisor. Nurse #4 stated Resident #1 was sitting in a geri chair when she gave the medication and went to sleep in the geri chair. Nurse #4 stated she and 2 other staff members assisted Resident #1 to bed and she was fighting, pinching and hitting the staff who were trying to transfer her into bed. Nurse #4 stated when she checked on Resident #1 before the end of her shift she was sleeping and was breathing normally. A physician's telephone order dated 06/10/14 read: restart [MEDICATION NAME] if Heart Rate (HR) greater than 110 and systolic blood pressure greater than 100. Vital signs every 3 hours starting at 11:00 PM until 7:00 AM. Review of a Nurse's Note dated 06/10/14 at 11:01 PM by Nurse#2 revealed Resident #1's condition had improved with time and after [MEDICATION NAME] dose. The note further revealed Resident #1 had a possible adverse reaction to meds and suspected overdose. Nurse #2 notified the Resident's physician and the clinician on call, a FNP. Her heart rate (HR) was 80 and her blood pressure (BP) was 102/68. Review of a Nurse's Note dated 06/11/14 at 12:24 AM by Nurse #2 revealed Resident #1 had roused for short intervals the past 2 hours, opened her eyes and followed movement with hand grips strong and attempted to talk. Review of a Nurse's Note dated 06/11/14 at 2:56 AM by Nurse #3 revealed Resident #1 was much more alert, opened her eyes when spoken to, had good grips in bilateral hands and was moving her extremities normally. Her HR was 88 and her BP was 118/69. Review of a Nurse's Note dated 06/11/14 at 6:29 AM by Nurse #3 revealed Resident #1 opened her eyes when spoken to and sat up in bed. Her HR was 84 and her BP was 124/80. Review of a Nurse's Note dated 06/11/14 at 10:13 AM revealed Resident #1 was more alert, opening her eyes and smiling at staff and family that were by the bedside. Her HR was 106 and her BP was 150/88. A physician's orders [REDACTED]. Review of the June 2014 MAR indicated [REDACTED] 06/11/14 1:00 PM [MEDICATION NAME] 30 mg 06/11/14 5:00 PM [MEDICATION NAME] 30 mg 06/11/14 9:00 PM [MEDICATION NAME] 30 mg 06/12/14 2:42 AM [MEDICATION NAME] 25 mg suppository 06/12/14 8:00 AM [MEDICATION NAME] 30 mg 06/12/14 1:00 PM [MEDICATION NAME] 60 mg per tube and [MEDICATION NAME] 30 mg by mouth Review of a Nurse's Note dated 06/12/14 at 1:04 AM revealed Resident #1 vomited a large amount of green liquid and her tube feeding was held. Her HR was 115 and her BP was 147/97. Review of a Nurse's Note dated 06/12/14 at 2:07 AM revealed Resident #1 vomited again and Resident #1 was given a [MEDICATION NAME] 25 mg suppository by Nurse #3, per the physician's standing orders. An attempt was made to contact Nurse #3 but she did not return surveyor's phone call. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of a Nurse's Note dated 06/12/14 at 1:28 PM by Nurse #1 revealed Resident #1 had a HR of 136 and a BP of 207/123 at 7:15 AM - she was given the [MEDICATION NAME] scheduled for 8:00 AM at that time. Resident #1 was reassessed at 9:00 AM - her HR was 132 and her BP was 168/110. Resident #1 had vomited a small amount. Resident #1's physician was at the facility and notified of her condition. Resident #1 was reassessed at 10:00 AM - her HR was 141 and her BP was 168/104. Resident #1's physician was notified and gave orders to administer a second dose of [MEDICATION NAME] 30 mg per tube which was administered at that time. Resident #1 was reassessed at 11:30 AM - her HR was 142 and her BP was 162/110. Resident #1's physician was notified and gave orders to administer [MEDICATION NAME] 60 mg per tube which was administered at that time. Further assessment after administration of the [MEDICATION NAME] revealed Resident #1 had a HR of 137 and BP of 154/108. Resident #1's physician was notified and gave orders to send resident to ER via ambulance and 911 was notified at 1:40 PM of need to transport. Review of an addendum Nurse's Note dated 06/12/14 at 1:48 PM by Nurse #1 revealed Resident #1 had right arm weakness and did not follow command to squeeze the nurse's or POA's hand. After administration of [MEDICATION NAME] 60 mg dose her symptoms improved and she moved her right arm and hand and was able to hold onto nurse's and POA's hand. During an interview with Nurse #1 on 06/20/14 at 12:10 PM she was asked to verify the amount of [MEDICATION NAME] that was given on 06/12/14 and the time it was administered - Nurse #1 reviewed Resident #1's medical record and stated Resident #1 was given [MEDICATION NAME] 30 mg at 7:15 AM, [MEDICATION NAME] 30 mg at 10:00 AM and [MEDICATION NAME] 60 mg at 11:30 AM. Nurse #1 stated she called the physician and notified her that Resident #1's BP and HR were still elevated and the physician called the Resident's POA to ask if he wanted her sent to the hospital. Nurse #1 stated the physician then called and gave orders to send Resident #1 to the ER. Review of a Nurse's Note dated 06/12/14 at 2:55 PM by Nurse #1 revealed Resident #1 left the facility via ambulance at 2:10 PM. An interview was conducted with the Administrator on 06/21/14 at 3:25 PM about the discrepancy in the amount of [MEDICATION NAME] liquid remaining in the bottle labeled for Resident #1 as compared to the narcotic count sheet. The Administrator stated they suspected the amount that was given on 06/10/14 at 8:00 AM may have been more than 2.5 ml. She stated the Pharmacist thought there could have also been some variation in the amount given on 06/09/14 at 9:30 PM that was more than 2.5 ml because the nurse didn't use a syringe. The Administrator stated Nurse #5 had completed training with the DON and the ADON prior to being allowed to return to work. The Pharmacist had provided additional remedial education to Nurse #5 on 06/20/14 and Nurse #5 had difficulty doing the skills validation. The Pharmacist was uncomfortable with Nurse #5 continuing to administer medications so she was terminated on 06/20/14. The Administrator stated Nurse #4 had completed training with the DON and the ADON prior to being allowed to return to work and had also completed additional remedial education with the Pharmacist on 06/20/14. Nurse #4 successfully completed the skills validation with the Pharmacist. The facility's Chief Executive Officer and Administrator were notified of Immediate Jeopardy on 06/20/14 at 5:00 PM for Resident #1. The facility provided a credible allegation of compliance on 06/21/14 at 3:05 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. CREDIBLE ALLEGATION OF COMPLIANCE FOR FREE OF SIGNIFICANT MEDICATION ERRORS Identified Incident of Immediate Jeopardy F333 - Significant Medication Error Resident(s) Identified Resident #1 was discharged to the hospital and will not return to the facility. Other Residents with Potential to be affected by the Immediate Jeopardy Incident Current residents have potential to be affected by the alleged deficient practice. On 06/2014, the Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) reviewed the declining count sheets for every resident with concentrated liquid opioid in the medication carts. There were no residents identified with medication errors. Notification of the Allegation of Immediate Jeopardy and actions taken: On 06/11/14, the Director of Nursing (DON) and the ADON counseled two Licensed Practical Nurses (LPNs) involved in alleged [MEDICATION NAME] administration error for Resident #1. Counseling discussion included the need to use a calibrated oral dosing syringe when measuring/administering concentrated oral liquid opioids. Both nurses were also counseled that if they had any questions in regards to calibrations, they are to contact the pharmacy or their supervisor. Both nurses were suspended for three days and further investigation continued. On 06/13/14 the ADON contacted the North Carolina Board of Nursing (NCBON) and spoke with a NCBON consultant. The ADON was referred to complete a Complaint Evaluation Tool on each nurse involved in the incident. This was done in collaboration with the NCBON Consultant. Immediate Changes to Facility Systems: On 06/20/14, a new policy was approved by the Administrator concerning administration of all concentrated liquid opioids. All medication administration staff members were informed of this new policy on 06/20/14 requiring a nurse cosign with the administering nurse for all concentrated liquid opioids. On 06/20/14 the Facility Administrator, ADON, SDC, and Consultant Pharmacist developed the "Liquid Narcotic and Calculation Review with Return Demonstration In-Service" form. Medication Administration staff received this in-service by the ADON, SDC, or Consultant Pharmacist. Medication Administration staff will not be allowed to continue work until they have completed the "Liquid Narcotic and Calculation Review with Return Demonstration In-Service" and have successfully demonstrated the appropriate procedure to measure and administer a concentrated liquid oral opioid. In-servicing will be provided for all new licensed staff and medications aides at the time of orientation. Skills validation of dosage calculations will be identified by return demonstration by ADON, SDC, or Consulting Pharmacist. [MEDICATION NAME] Concentrate calculation sheet will be added to each med carts narcotic notebook under reference and will be dispensed with each oral concentrated opioid. Immediate jeopardy was removed on 06/21/14 at 3:45 PM. Observations of each medication cart in the facility revealed a reference guide for each type of liquid narcotics in use by the facility with the dosages listed in milligrams and milliliters. Interviews with nursing staff revealed they had received in-service training on 06/20/14 and 06/21/14 regarding the administration of liquid narcotic medications. They explained each medication cart now had a reference guide for dosages and a guide was also included with each container of liquid narcotic medications. They further stated the dosage of the medication required verification of the amount by 2 nurses prior to administration of the medication. They explained that both nurses were required to sign the electronic MAR indicated [REDACTED].