Every finding on record at Pulaski HLTH & Rehab CNTR

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the resident's responsible party of significant weight loss for one of 43 residents, Resident #118. The findings included:A facility policy entitled, Weight Monitoring and Tracking with an effective date of 1/29/2024 was reviewed. The document read in part, The Center has a system in place to weigh, monitor, and track patient's weights. Weights are tracked, monitored, and analyzed by the interdisciplinary team. Under item #8 the document stated, The team will notify the provider and responsible party (RP) of significant weight changes, investigate possible causes of the weight change, discuss interventions, and document a progress note. Resident #118's admission Record indicated the facility admitted the resident on 1/12/2026 with a medical history that included major depressive disorder, bipolar disorder, pneumonia, encephalopathy (any disease, damage, or disorder that changes how the brain works manifested by a change in mental state such as confusion or memory loss), history of stroke. The admission/5-day minimum data set (MDS) assessment with an assessment reference date of 1/19/2026 assigned the resident a brief interview for mental status (BIMS) score of 7 out of 15 indicating severe cognitive impairment. Resident #118 was coded on the MDS as requiring supervision or touching assistance with meals during the lookback period. The document indicated the resident weighed 176 pounds at the time of the assessment and was on a mechanically altered diet. The care plan was reviewed and included a focus with a created date of 1/13/2026, that read, The resident is at risk for weight loss or malnutrition/inadequate hydration related to chronic disease. Interventions included one dated 2/5/2026 that read, Assist as needed at meals. According to the MDS the resident was already getting supervision or touching assistance and the care plan did not specify a change in that level of assistance. The weight record for resident #118 was reviewed. On 1/12/2026 the resident weighed 178 pounds, on 1/14/2026 the resident weighed 175.6 pounds, on 1/22/2026 the resident weighed 170.3 pounds, on 1/29/2026 the resident weighed 166.8, which was significant at 6.29% in less than 30 days, on 2/4/2026 the resident weighed 165 pounds. The progress notes were reviewed. On 2/5/2026 the Registered Dietician entered a Weight Change Note that read WEIGHT WARNING: Value: 165.0 (weight) Vital Date: 2026-02-04 10:23:00.0-5.0% change [ 7.3% , 13.0 ] RDN WT Note: Rsd is (age, gender, height omitted) BMI 30.2-obese I, IBW 110# (IBW 50kg), rsd is on a regular diet-NDD (national dysphagia diet) advanced, Active liquid protein TID (three times daily) with 50 75% PO intake noted. Per wound assessment report 1/28, stage III pressure injury to sacrum-stable. Current interventions appropriate. Medical DX: [NAME] syndrome, ID (intellectual disability) , bipolar, PNA (pneumonia), UTI (urinary tract infection), mood disorder, depression, seizures RX (medications): O2, Lamotrigine, Trazodone, ASA, Lexapro, Atorvastatin, Ativan, Lithium, Risperdal Rsd's estimated needs: 50kg (IBW) x 30-35 kcals= 1500-1750 kcals 50kg x 1.3-1.4g protein= 65-70g protein 1 kcal x 1 mL= 1500-1750 mL water Rsd triggered for a significant WT loss d/t decreased caloric intake with increased energy needs to promote skin maintenance. Recommend continue weekly WTs to establish baseline trend, assist as needed at meals and provider review for appetite stimulant. Will continue to monitor and evaluate WT for any changes, PO (by mouth)/ONS (oral nutritional supplements) intake for adequacy, labs, and skin integrity upon follow up PRN. The provider documented the weight loss during an evaluation of a change in condition on 2/6/2026, no appetite stimulant was discussed in the note. There was no documentation in the record that resident #118's responsible party (RP) was notified of the signficant weight loss. On 8/19/2026 at 3:00 PM this concern was discussed with the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS). They were unable to provide evidence that resident #118's RP was notified of the significant weight loss. On 8/19/2026 at 4:30 PM the survey team met with the Administrator, DON, RDCS and the Regional Director of Clinical Reimbursement. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to consistently implement the comprehensive care plan for one of six residents in the survey sample, resident # 4.The findings included: For resident #4 the facility staff failed to ensure fall mats were in place on each side of the bed per the residents individualized comprehensive care plan. Resident #4's diagnoses included but were not limited to dementia, repeated falls, muscle weakness, anxiety and osteoporosis. On 11/6/25 at 9:15 AM this surveyor visited with resident #4 in their room. The resident was lying in bed and was alert and pleasant. There was no fall mat noted on the left side of the bed where the surveyor stood to speak with resident. The minimum data set (MDS) assessment with an assessment reference date of 10/24/25 assigned the resident a brief interview for mental status (BIMS) score of 2, which is an indication of severe cognitive impairment. The MDS stated the resident #4 did have 2 falls since the prior assessment, one with no injury and one with minor injury.According to the progress notes, resident #4 fell on 8/4/25 at 11:45 AM while toileting independently. On 9/21/25 at 3:45 AM resident rolled out of bed to the floor and sustained a skin tear to the top of the right hand. The progress note dated 9/21/25 at 4:17 AM read, Description of the fall/V/S/injuries if any: Resident attempting to self-toilet, after fall alarm in bed sounded, staff entered room, resident in floor on buttocks, has skin tear to right posterior hand. What Interventions were in place at the time of the fall: bed low to floor, had removed no-slip socks, alarm on and working properly. What are the risk factors that could have contributed to the fall? resident continent and attempting to self-toilet- [NAME] fast. What new Interventions were implemented in response to the fall? concave mattress. Was the Provider/resident and RP notified at the time of the fall? YES. Additional Comments: resident swift in walking. There was no mention of fall mats being in place anywhere in the documentation.The comprehensive care plan included a problem statement that read, The resident is at risk for falls related to weakness and deconditioning with an actual fall. The interventions included an intervention dated 7/18/25 that read, Fall mats on each side of the bed. On 11/6/25 at 10:00 AM this surveyor interviewed Registered Nurse (RN) #3 who stated they were the unit manager. When asked if resident #4 was supposed to have bilateral fall mats they stated, Yes, they should be there. Surveyor and RN #3 went to the resident's room. RN #3 stated, They are both over there. Indicating that both fall mats were on the right side of the bed between the bed and window. This surveyor asked if that was the expectation and RN #3 stated, No, there should be one on each side.The policy entitled, Falls Management Program with an effective date of 1/24/24 was requested and provided. The document read in part, The Center considers all residents to be at risk for falls and provides an environment as safe as practicable for all patients. The Center utilizes a systematic approach with evidence-based interventions to develop individual strategies. Under the heading entitled, Prevention, item #3 read, Incorporate any identified interventions into the care plan as applicable. Under the heading, Fall Occurrence item #3 read, A licensed nurse will review, revise, and implement interventions to the care plan based on: Post Fall Investigation findings, Review of Device Assessment, Review of Fall Risk Scoring Tool.The most recent Device assessment dated [DATE] was reviewed. The only devices listed as currently in use were side rails. The Device assessment dated [DATE] was reviewed. Devices listed as current included bilateral fall mats, chair/bed alarm, side rails, and a specialty bed/mattress. On 11/6/25 at 10:30 AM this surveyor met with the Director of Nursing, (DON) and Regional Director of Clinical Services (RDCS) to discuss this concern. The DON reported that the certified nursing assistant assigned to resident #4 had gotten the resident up to the toilet after breakfast and forgot to put the mat back in place.The survey team met with the Administrator, the DON and the RDCS at 12:22 PM and this concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain a complete and/or accurate clinical record for (1) one of (2) two closed record reviews, Resident #1. The findings included:For Resident #1 the facility staff failed to accurately document a skin assessment and/or nursing progress note on 6/20/25 after an allegation of staff to resident abuse was reported and a nurse performed a skin assessment of the resident. Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, Congestive Heart Failure, Altered Mental Status, Aphasia, Cerebral Infarction, and Cognitive Communication Deficit. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/30/25, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A Skin assessment dated [DATE] read in part, .Large areas of bruising noted to bilateral buttocks/hip areas d/t (due to) medication injections. Generalized bruising noted to bilateral upper extremities from blood draws .No other skin impairments noted at this time. An Encounter Note dated 6/20/25, read in part, .Periods of agitation reported.has had increase in behaviors, has accused the staff of dragging her across floor to cause bruising, bruising is actually from IM (intramuscular) injections. A review of a facility synopsis of events included an investigative reporting statement from registered nurse #2 (RN#2) dated 6/20/25 which read in part, .Skin assessment completed, no new areas were observed. A Skin assessment dated [DATE] read in part, .Bruising noted to bilateral buttocks. no change from previous assessment completed on 6/17/2025. On 11/6/25 at 9:13 AM, surveyor interviewed RN#2 and she informed this surveyor she did a skin assessment on Resident #1 after learning of an abuse allegation. This surveyor inquired about the protocol when conducting a skin assessment after an allegation of abuse and RN#2 stated she did not document it because she did not find anything new, if she had found something new, she would have documented a skin assessment. On 11/6/25 at 9:44 AM, this surveyor interviewed the director of nursing (DON) and she informed this surveyor her expectation when there is an allegation of abuse is a head-to-toe skin assessment to be documented in the clinical record under the assessments tab or in a nursing progress note. This concern was discussed at the pre-exit meeting on 11/6/25 at 12:25 PM with the administrator, director of nursing, and regional director of clinical services. This surveyor requested but did not receive a facility policy regarding accuracy of documentation in the clinical record. This surveyor did receive a facility policy titled Nursing Care & Services which read in part, .Nursing staff will provide nursing care and services following current standards of practice. No further information was provided to the survey team prior to exit on 11/6/25.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure a safe environment as evidenced by the absence of documentation addressing the training, health, and/or vaccinations for an animal/pet (Pet #1) present at the facility. Pet #1 was reported to be one (1) of the five (5) animals/pets to frequent the facility. The findings include: On 7/23/24 at approximately 3:50 p.m., the surveyor knocked on a closed office door at the facility. A dog inside the door was heard to bark. A facility staff member opened the door. The dog could not be seen but was heard to be growling. The dog (Pet #1) was placed in a wire pet kennel. The dog was heard to growl while in the wire pet kennel. Pet #1 had been observed, earlier in the survey, to walk unleashed in the facility with its owner nearby. On 7/23/24 at 4:10 p.m., the surveyor interviewed the facility's Administrator with the Vice-President of Operations present. The Administrator reported the animal/pet in question was considered a center pet. The Administrator reported no injury had ever occurred at the facility related to an animal/pet. The following information was found in a facility policy titled Therapeutic Pets (with an effective date of 1/22/24): - The Recreation Director/staff will ensure any pets and animals integrated into the activity program on a permanent basis are disease free with appropriate documentation on file. Recreation staff will monitor pets and animals and follow safety precautions to ensure patient safety. Pets and animals will be treated humanely and maintained in a safe environment. - Center Pets: . Will be cleared by a veterinarian prior to placement. Examination will include checking for all parasites, diseases, etc. that can be transmitted to humans. Pets and animals will be treated as necessary . Documentation will be kept on file in the recreation department . Dogs: . Will receive obedience training by a certified trainer . Will be treated for fleas and ticks. Pet #1's documentation was a one-page form which did not include the veterinarian's name, address, and/or contact information. This form indicated Pet #1's last Parasite Control was Drontal administered orally on 6/28/23. This form indicated Pet #1's last vaccines were administered on 6/28/23 (10 way and Rabies (3 yr)); the location and route of these vaccines were not documented. No documentation indicating Pet #1 had been cleared by a veterinarian was found by or provided to the surveyor. No documentation indicating Pet #1 had received obedience training by a certified trainer was found by or provided to the surveyor. On 7/24/24 at 11:38 a.m., the surveyor met with the facility's Administrator and a Regional Director of Clinical Services (Administrative Staff #4). The Administrator reported there was no documentation to indicate Pet #1 had been cleared by a veterinarian. The Administrator reported they were still waiting for information from the veterinarian. The Administrator confirmed Pet #1 was not required to be on a leash while in the facility. The Administrator reported Pet #1 would only interact with residents if its owner was present. During this meeting, the absence of documentation of Pet #1 having received obedience training by a certified trainer was discussed. On 7/24/24 at 4:39 p.m., the survey team met with the facility's Administrator, Director of Nursing, and Administrative Staff #4. During this meeting, the Administrator reported no additional documentation related to Pet #1 was available.

Based on observations, staff interview, clinical record review and facility document review, the facility staff failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently for 1 of 20 sampled residents, Resident #21. The findings include: For Resident #21, the facility staff failed to provide a divided plate as recommended by the Certified Occupational Therapy Assistant. Resident #21's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Dementia, Dysphagia, and Cerebral Infarction (stroke.) The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 07/09/2024, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely cognitively impaired. On 07/21/24 at 2:41 PM, surveyor observed Resident #21 sitting in wheelchair in her room with a lunch tray on the over-the-bed table in front of resident. The meal ticket on the tray read in part, .Divided Plate . A regular glass plate was observed to be on the resident's tray. On 07/22/24 at 8:42 AM, surveyor observed Resident #21 in her room sitting in her wheelchair with her breakfast tray on the over-the-bed table in front of her. The meal ticket on the tray read in part, .Divided Plate . A regular glass plate was observed to be on the resident's tray. Surveyor interviewed licensed practical nurse #3 (LPN#3) and she agreed meal ticket read divided plate and stated Resident #21 should have a divided plate and that she would check into it. Surveyor reviewed the physician's orders, the comprehensive person-centered care plan, progress notes, and dietary assessments for Resident #21 on the electronic clinical record and was unable to locate any information about the divided plate for the resident. On 07/22/24 at 9:03 AM, surveyor interviewed Dietary Manager, other staff #2 (OS#2). Surveyor observed Resident #21's meal ticket in his hand and Divided Plate was scratched out with ink. OS#2 stated OT (occupational therapy) told him, resident no longer needed a divided plate. On 07/22/2024 at 9:25 AM, surveyor interviewed certified occupational therapy assistant, other staff #4 (OS#4). OS#4 stated Resident #21 was on therapy caseload approximately two weeks ago and she had a goal for self-feeding. OS#4 stated Resident #21 mostly uses fingers to eat but felt she could benefit from a divided plate when she uses utensils so she would have a wall to scoop against. OS#4 stated she talked with dietary about a divided plate for Resident #21 and dietary told her they did not have enough divided plates for Resident #21 to have one. OS#4 also stated there are several residents here that would benefit from divided plates. Surveyor spoke with OS#4 again at 9:40 AM on 07/22/24 and asked her if she had a note or diet communication slip for the requested divided plate for Resident #21 and she stated she did not write it (divided plate) in her notes or do a diet communication slip/order for the divided plate because dietary had told her they did not have enough divided plates. On 07/22/24 at 9:56 AM, surveyor interviewed Regional Dietary Manager for Aramark Services, other staff #3 (OS#3). She stated someone, jumped the gun and put the divided plate on Resident #21's meal ticket while they (dietary) were waiting to order it. On 07/22/2024 at 10:10 AM, surveyor interviewed the administrator (ADM) and OS#3. ADM stated if someone needed a divided plate, she would have ordered it. On 07/22/24 at 3:25 PM, surveyor interviewed OS#4 again to clarify that she spoke with dietary staff members about divided plate for Resident #21. She stated she spoke to three or four dietary staff in the kitchen at the time she went to the door. This concern was discussed on 07/22/24 at 4:50 PM during the end of day meeting with the administrator, regional director of clinical services, and the director of nursing and again during the end of day meeting on 07/23/2024 at 4:53 PM and the pre-exit meeting on 07/24/24 at 4:40 PM. Surveyor requested and received Resident #21's meal tickets for a variety of days in June 2024 and July 2024 and received a meal ticket dated 7/10/24 that read in part, .Divided Plate . OS#3 stated she was not sure how it (divided plate) got on there today (07/22/2024) and surveyor informed OS#3 it was observed on Resident #21's meal ticket yesterday as well. A review of the policy, Assistive Devices read in part: .It is the center policy to provide assistive devices .1. The Dining Services Director will provide appropriate assistive devices .as indicated . No further information regarding this concern was presented to the survey team prior to the exit conference on 07/24/24.

Based on observation, resident and staff interview, clinical record review and facility document review, the facility staff failed to provide the proper amount of fluid to maintain an appropriate fluid and electrolyte balance for one of 20 current residents in the survey sample, Resident #66 (R 66). The findings included: R 66's diagnoses included but were not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease, essential hypertension and peripheral vascular disease. R 66's most recent minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/25/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating they were cognitively intact. Review of R 66's clinical record indicated they were on a 1,200 ml/day fluid restriction per a physician's order written on 7/5/2024. On 7/23/24 at 10:20 AM this surveyor noted that resident had a measured water pitcher with 900 ml (milliliter) capacity, 300 ml's were remaining, a 20-ounce Styrofoam cup filled with soda (20 ounces = 591.471 ml) and a small plastic cup with approximately 3 ounces of water remaining in it. Surveyor asked resident if they were aware of their 1,200 ml fluid restriction, they indicated that they were not aware of it. When asked what they had to drink for breakfast, they stated, A carton of milk, a cup of coffee and some juice. Resident stated the staff fill up their water pitcher for them twice daily and give them a fresh cup of ice for their soda whenever they ask. On 7/23/24 at 10:40 AM this surveyor interviewed Certified Nursing Assistant (C.N.A.) # 1. When asked how they know when a resident is on fluid restriction they stated, It'll be on their tray cards. C.N.A. #1 could not explain how they monitor fluid restrictions and stated they don't document how much fluid a resident drinks on their shift. On 7/23/24 at 10:45 AM this surveyor interviewed C.N.A. #3. They stated they were not sure how to know if a resident is on fluid restriction, I think I would just ask the nurse. On 7/23/24 at 10:53 AM Registered Nurse #1 was interviewed and stated that fluid restrictions are monitored and documented by the nurses on the Treatment Administration Records (TAR). They could not state why R 66 was on a fluid restriction, It's usually related to a diagnosis like CHF (congestive heart failure). On 7/23/24 at 11:11 AM this surveyor interviewed the Nurse Practitioner (NP) caring for R 66. They stated, It's due to a specific diagnosis but I'll have to look at the chart to make sure what that is. (Resident) knows he/she is on it but is noncompliant with it. Review of the TAR revealed that nurses were signing off that R 66 was on a fluid restriction but there was no where to document the number of ml's provided per shift. There was no indication in the record that resident had been educated or informed about the fluid restriction and no documentation of noncompliance. This surveyor interviewed the Registered Dietician (RD) on 7/23/24 at 12:20 PM. They stated that resident was on the fluid restriction for hyponatremia. They provided a copy of R 66' s' tray card for the day. According to the tray card R 66 was provided with 8 ounces of orange juice, 16 ounces of coffee/tea and 16 ounces of milk for breakfast. That is a total of 1,182.941 ml's. For lunch R 66 tray card indicated they got 16 ounces of milk and 16 ounces of coffee/tea for 946.353 ml's. R 66 was scheduled to get another 16 ounces of milk and 16 ounces of coffee/tea for the supper meal. Surveyor requested and received a copy of the policy entitled, Fluid Restriction with an effective date of 1/29/2024. Under procedure the policy read in part, 2. Provide education to the patient on specific fluid restrictions. 3. Inform the patient of the amount of fluid allowed orally, including ice chips, gelatin, and ice cream. 4. Per the provider's order for daily fluid allowance. Determine the amount of fluids to be provided with each meal, before bedtime and with medication administration. Consideration of patient preferences. On 7/24/24 the surveyor was referred to an addendum of a progress note dated 7/23/24. The addendum was written at 12:42 PM by the NP and read, Resident was admitted and came into the facility with an order for a fluid restriction, resident was aware of the fluid restriction but unsure why. After reviewing records, her CXR (chest x-ray) shows emphysema, no pneumothorax, effusion, infiltrate or edema. Cardiac silhouette normal in size. Her last echocardiogram was on 5/5/21 which showed an EF (ejection fraction) of with normal LV systolic function, normal diastolic function and mild pulmonary hypertension with an RVSP of 45-50. Bony thorax intact. No clinical indications for the fluid restriction. Laboratory results reviewed. On 7/4/24 resident had a low sodium level of 129 (normal is 136-145). The physician was notified and on 7/5/24 ordered a 1,200 ml fluid restriction and weekly lab work. Sodium on 7/11/24 was 130 and on 7/18/24 was 132. Resident was admitted to the facility on [DATE]. This concern was reviewed with the Administrator, Director of Nursing and Regional Director of Clinical Services on 7/24/24 during a meeting with the survey team. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 20 sampled residents (Resident #22). The findings included: For Resident #22, the facility staff failed to obtain a comprehensive metabolic panel (CMP), complete blood count (CBC), and a lactic acid blood level as ordered by the medical provider. Resident #22's diagnosis list indicated diagnoses, which included, but not limited to Polyneuropathy, Chronic Pancreatitis, and Chronic Gout. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/14/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #22's clinical record revealed a medical provider order dated 7/12/24 to obtain a CMP, CBC, and a Lactic Acid level on 7/13/24. Resident #22 was seen by the nurse practitioner (NP) on 7/12/24, the progress note read in part .Resident being seen per nursing request for follow up on cellulitis and for generalized weakness .obtain CBC CMP in am, lactic acid in am . Surveyor reviewed Resident #22's clinical record and was unable to locate the results of the CMP, CBC, and lactic acid blood tests. On 7/23/24 at 2:33 PM, surveyor spoke with the Director of Nursing (DON) who stated they have spoken with the lab and the lab tests were not obtained. Surveyor requested and received the facility policy titled Laboratory/Diagnostic Testing with an effective date of 1/29/24 which read in part .1. A licensed nurse will obtain laboratory, radiology, or other diagnostic services to meet the needs of its patients as ordered by the provider. 2. A licensed nurse will monitor and track all provider ordered laboratory, radiology, and other diagnostic tests; ensure that tests are completed as ordered and communicate results to the provider . On 7/24/24 at 4:40 PM, the survey team met with the Administrator, Regional Director of Clinical Services, and the DON and discussed the concern of the facility staff failing to obtain lab tests as ordered for Resident #22. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/24/24.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure safe and secure storage of medications for one of 20 current residents in the survey sample, Resident #66 (R66). The findings included: R66's diagnoses included but were not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease, essential hypertension and peripheral vascular disease. R66's most recent minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/25/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating they were cognitively intact. On 7/21/24 at 2:20 PM this surveyor noted that R66 had a bottle of Tums, a bottle of saline nasal spray and a partial tube of diclofenac sodium topical gel on their bedside table. They stated these medications are some they had been taking routinely for a number of years and that the nurses, rub that on my legs, I don't know what I'd do without it referring to the diclofenac tube. The clinical record was reviewed on 7/22/24. There were no orders noted for Tums, saline nasal spray or diclofenac sodium. On 7/23/24 this surveyor noted that the medications were no longer on the bedside table and R66 stated, I put them away. When asked if they had a locked box to keep their medications in, they stated, no. When asked if the staff knew they had the medications they sated, I don't know if they do or not but that doesn't matter, they don't need to know it do they? R66 indicated the medications were in their nightstand drawer. On 7/23/24 at 2:46 PM this surveyor interviewed Registered Nurse (RN) # 1. They stated they were not aware of R66 having medications at bedside. When asked what the policy is for medications at bedside they stated, They shouldn't have any medications at bedside. RN # 1 stated, I'll take care of it. On 7/23/24 at 3:20 PM this surveyor requested and received the policy entitled, Self-Administration of Medications at Bedside, with an effective date of 1/29/24, The policy read in part, 1. The patient may request to keep medications at bedside for self-administration in a lock box. 2. Complete Medications Self- Administration Safety Screen assessment. 3. The Interdisciplinary Team will review the assessment together, use clinical judgment to determine if the patient is eligible. 4. If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record. On 7/23/24 at 5:00 PM this concern was discussed during an end of day wrap up meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services. On 7/24/24 at 12:20 PM the Regional Director of Clinical Services stated the medications were removed from the room and the Nurse Practitioner was meeting with R66 to review medications. A progress note dated 7/24/24 at 12:40 PM read, Spoke with resident regarding having medications at bedside. Reviewed facility policy with resident and (omitted) verbalized understanding. Discussed obtaining orders for medications and nursing staff to administer as ordered. Resident agreed. New orders obtained from NP (name omitted) for orders for PRN voltaren gel, nasal saline spray, fluticasone spray, and tums. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for 1 of 20 sampled residents, Resident #25. The findings included: For Resident #25, the facility staff failed to follow provider orders for the administration of the medications, Invanz and Culturelle for 14 (fourteen) days. Invanz is an antibiotic indicated for the treatment of moderate to severe infections, Culturelle is a probiotic used to maintain digestive health. Resident #25's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 Diabetes Mellitus, Age-Related Physical Debility, Heart Failure, Overactive Bladder, Chronic Kidney Disease, and Urinary Tract Infection. Resident #25's most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/11/24 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating the resident is severely cognitively impaired. A provider's progress note dated 7/5/24, read in part, .SUMMARY OF VISIT: Resident is being seen today per nursing request for UA (urinalysis) results, final urine culture indicates ESBL (extended spectrum beta-lactamase). Orders for contact precautions, Invanz 1 GM (gram) IM (intramuscular) QD (once a day) x 14 days, Culturelle 1 tab (tablet) po (by mouth) BID (twice a day) x 14 days . A review of Resident #25's July 2024 MAR (medication administration record) revealed Invanz and Culturelle were administered for 10 days. Resident #25's provider orders included an order dated 7/5/24 to give Culturelle for 10 days and Ertapenem Sodium Solution Reconstituted (Invanz) for 10 days. According to the provider's orders and the July 2024 MAR, the medications were not given as ordered for 14 days. On 7/24/24, surveyor interviewed the nurse practitioner (other staff #1) and she stated she did direct staff to administer the Invanz and Culturelle for 14 days. She stated staff informed her the order was transcribed incorrectly to be administered for 10 days and she provided a new order for an additional 4 days of the medications on 7/23/24. On 7/24/24 at 10:03 AM, surveyor interviewed director of nursing (DON) and she stated the order was entered incorrectly and agreed that was why 4 more days were added to Resident #25's treatment on 7/23/24. This concern was discussed on 7/23/24 at 4:53 PM at the end of day meeting with the administrator, director of nursing and the regional director of clinical services and again at the pre-exit meeting on 7/24/24 at 4:40 PM. Surveyor requested and received the facility policy titled, Non-Controlled Medication Orders, that read in part, .I. Elements of the Medication Order 1. Medication orders specify the following .f. Quantity or duration (length) of therapy .III. Documentation of the Medication Order .F. Completing Documentation .Transcribe newly prescribed medications on the MAR .After completion, document each medication order entered on the appropriate form . No further information regarding this concern was presented to the survey team prior to the exit conference on 07/24/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to act upon drug regimen review recommendations for 2 of 5 residents selected for drug regimen review (Resident #32 and Resident #54). The findings included: 1. For Resident #32, the facility staff failed to provide evidence of the 8/26/23, 9/26/23, 10/27/23, 1/26/24, and 3/25/24 drug regimen reviews being acted upon by the medical provider. Resident #32's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Anxiety Disorder, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 indicating the resident was severely cognitively impaired. Documentation within Resident #32's clinical record indicated drug regimen reviews (DRRs) were completed on 8/26/23, 9/26/23, 1/26/24, and 3/25/24, each with pharmacist recommendations. Surveyor was unable to locate the recommendation reports in the resident's clinical record. A 10/27/23 DRR read in part This resident is on an antipsychotic medication and a current AIMS [Abnormal Involuntary Movement Scale] could not be located in the chart .AIMS should be done within the first 30 days of either admission or initiating therapy, then at least every 6 months after that . The medical provider reviewed the 10/27/23 DRR but failed to address the recommendation for an AIMS test. The only AIMS test located in Resident #32's clinical record was dated 6/20/24. On 7/23/24 at 11:25 AM, surveyor spoke with the Director of Nursing (DON) and requested the 8/26/23, 9/26/23, 1/26/24, and 3/25/24 DRRs and any evidence of an AIMS test being completed prior to 6/20/24. The DON returned to the surveyor at 2:33 PM and provided copies of the requested 8/26/23, 9/26/23, 1/26/24, and 3/25/24 DRRs which had not been reviewed or signed by the medical provider. The DON stated the provider also failed to address the pharmacist's recommendation on the October DRR and there were no AIMS tests completed prior to 6/20/24. Surveyor requested and received the facility policy titled Medication Regimen Review with an effective date of 1/29/24 which read in part, .The physician is to review and sign the patient's individual MRR [medication regimen review] and document that he/she has reviewed the pharmacist's identified irregularities within 30 days of receipt . On 7/23/24 at 4:53 PM, the survey team met with the Administrator, Regional Director of Clinical Services, and the DON and discussed the concern of the medical provider failing to address Resident #32's DRRs. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/24/24. 49622 2. For Resident #54, the facility staff failed to provide evidence of the 1/26/24 and 3/25/24 drug regimen reviews being reported to and acted upon by the medical provider. Resident #54's diagnosis list indicated diagnoses, which included, but not limited to, Zoster Encephalitis, Hemiplegia and Hemiparesis, Aphasia, Peripheral Vascular Disease, Depression, Anxiety, Mixed Receptive-Expressive Language Disorder, and Cognitive Communication Deficit. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 indicated the resident had severely impaired decision-making and is rarely/never understood. Surveyor spoke with the Director of Nursing (DON) on 7/23/24 and requested the drug regimen review recommendation reports completed by the pharmacist for Resident #54. On 7/24/24 at 8:00 AM, the DON provided copies of the requested drug regimen reviews. The Consultant Pharmacist Recommendation to Physician reports dated 1/26/24 and 3/25/24, had not been signed by the medical provider indicating review. The 1/26/24 Consultant Pharmacist Recommendations to Physician read in part, .This resident is taking Depakote routinely. The recommended routine lab work includes VPA (valproic acid) level and Ammonia level . The lab results could not be located on the clinical record, indicating the January recommendation was not addressed. The 3/25/24 Consultant Pharmacist Recommendation to Physician read in part .The resident has been taking Omeprazole 20 mg (milligrams) QD (once a day) since 9/1/2023 without a dose reduction. Please consider a trial dose reduction to Omeprazole 10 mg . A provider order decreasing the dose of Omeprazole could not be located, indicating the March recommendation was not addressed. On 7/24/24 at 9:59 AM, surveyor discussed these findings with the DON, and she stated they could not be found. This concern was discussed on 7/24/24 at 4:40 PM during the pre-exit meeting with the administrator, regional director of clinical services, and the director of nursing. Surveyor requested and received the facility policy titled Medication Regimen Review which read in part The drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist .The physician is to review and sign the patient's Individual MRR (medication regimen review) and document that he/she has reviewed the pharmacist's identified irregularities within 30 days of receipt . No further information regarding this concern was presented to the survey team prior to the exit conference on 7/24/24.

Based on clinical record review and facility document review, the facility staff failed to ensure timely revision of the comprehensive plan of care for 1 of 20 current sampled residents, Resident #53. The findings included: For Resident #53, the facility staff failed to revise the person-centered care plan to discontinue the need for thickened liquids per the physician's order. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Dysphagia, Transient Ischemic Attack (TIA), and Cognitive Communication Deficit. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/23/2024, assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating Resident #53 was moderately impaired in cognition. Resident #53's physician's orders included an active order dated 11/14/2023, which read in part, Regular diet .Thin Liquids consistency . Surveyor reviewed Resident #53's comprehensive care plan with a revision date of 07/01/2024, that read in part, Focus .on a mechanically altered diet with thickened liquids .Revision on: 11/14/2023 .Goal .Revision on: 07/01/2024 .Interventions .therapeutic diet as ordered .Created on: 05/30/2023 . Further review of the clinical record revealed a Skilled Note, dated 06/15/2023, that read in part, .Swallow study .now on thin liquids . Further review of physician's orders revealed a physician's order with a start date of 06/15/2023 that read in part, .Regular diet .Thin Liquids consistency . This concern was discussed at the end of day meeting on 07/23/24 at 4:53 PM with the administrator, director of nursing, and regional director of clinical services and again at the pre-exit meeting on 07/24/24 at 4:40 PM. Surveyor requested and received the facility policy titled Care Planning which read in part, .5. Care plans will be updated on an ongoing basis as changes in the patient occur . No further information regarding this concern was presented to the survey team prior to the exit conference on 07/24/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) notification for 1 of 3 residents selected for SNF Beneficiary Notification Review (Resident #98). The findings included: For Resident #98, the facility staff failed to provide a SNF ABN notification when the resident was discharged from Medicare Part A services with skilled benefit days remaining while continuing to reside in the facility. Resident #98's diagnosis list indicated diagnoses, which included, but not limited to Pneumonitis, Dysphagia, Generalized Muscle Weakness, and Dementia. The minimum data set (MDS) with an assessment reference date (ARD) of 1/27/24 assigned the resident a brief interview for mental status (BIMS) summary score of 1 out of 15 indicating the resident was severely cognitively impaired. Resident #98's clinical record included a progress note by the discharge planner dated 3/04/24 10:16 AM which read in part, SW [social worker] [name omitted] spoke to patient's POA [power of attorney] [name omitted] to issue NOMNC [Notice of Medicare Non-coverage] with LCD [last covered day] 3/08/24 and converting to LTC [long term care] 3/09/24. Appeal rights were went [sic] over and POA declined wanting to appeal. SW [name omitted] to have business office to call POA to go over private pay prices and if patient would be eligible for Medicaid . Surveyor requested to review notices that were provided to Resident #98's POA when discharged from Medicare Part A services. Surveyor received a copy of a NOMNC indicating skilled services would end on 3/08/24 and signed by the POA on 3/04/24. On 7/24/24 at 1:58 PM, surveyor spoke with the SW who stated a SNFABN was not provided because Resident #98 went from skilled care to private pay receiving comfort care. Surveyor requested and received the facility policy titled Advanced Beneficiary Notice (ABN) with an effective date of 4/01/22 which read in part 3. The ABN for Part A is used when a patient is coming off of a Part A stay, has days left in the benefit period and is remaining in the Center . On 7/24/24 at 4:40 PM, the survey team met with the Administrator, Regional Director of Clinical Services, and the Director of Nursing and discussed the concern of Resident #98 not receiving a SNFABN. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/24/24.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide services that met professional standards of clinical practice for 1 of 20 residents, Resident #21. The findings included: For Resident #21, the facility staff failed to transcribe a verbal medical provider order for the administration of ten (10) units of insulin on 07/13/2024 and failed to document the administration of the insulin. Resident #21's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Presence of Cardiac Pacemaker, and Cerebral Infarction (stroke). The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 07/09/2024, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely cognitively impaired. A review of the medication administration record (MAR) for July 2024 revealed on 07/13/2024 that Resident #21's BS (blood sugar) was 410 and the MAR was coded as, 9 (nine), which indicated, 9=other/see progress note. A review of the Orders Administration Note dated 07/13/2024, read in part, .Lyumjev KwikPen Subcutaneous Solution Pen-injector 100 (one hundred) UNIT/ML (milliliter) Inject as per sliding scale .401+ Notify MD (medical doctor) if greater than 400 .Notified [name omitted], NP (nurse practitioner) advised to give 10 U (units) . Surveyor reviewed Resident #21's clinical record and was unable to locate a provider order or documentation of administration of Lyumjev insulin. On 07/23/24 at 9:30 AM, surveyor interviewed licensed practical nurse #5 (LPN#5) and director of nursing (DON). LPN#5 stated she gave Resident #21 the 10 U of insulin after speaking with the NP and she thought the note would verify that she gave it. Surveyor asked the process for giving medication when there was not an order as the BS of 410 was outside of the parameter. LPN#5 stated she would have notified her supervisor and put in a note. Surveyor asked what was required when there was no order, as there was no documentation to verify the medication was given, the time of the administration or the amount. The DON stated a verbal order should have been entered and this would have allowed it to have been documented as administered on the MAR. This concern was discussed on 07/22/24 at 4:50 PM during the end of day meeting with the administrator, regional director of clinical services, and the director of nursing and again during the end of day meeting on 07/23/2024 at 4:53 PM and the pre-exit meeting on 07/24/24 at 4:40 PM. Surveyor requested and received the facility policy titled, Non-Controlled Medication Orders, that read in part, .III .B. New Verbal Orders .The nurse documents the verbal order .on the .electronic medical record .F. Completing Documentation .Transcribe .medications on the MAR . Surveyor also requested and received a facility policy titled, Administration Procedures for All Medications, that read in part, .III .a. Check the MAR .for the order .IV .7. After administration .and document administration in the MAR . Surveyor requested and received a facility policy titled, Nursing Care & Services, that read in part, .Nursing staff will provide nursing care and services following current standards of practice recognized by .Procedure 1. The center will utilize .and/or Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff as a reference for nursing services and skills not otherwise provided in the Policies and Procedures Manuals. On 07/23/24 at 4:33 PM, DON brought surveyor copies of requested pages from the facility copy of Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff, (February 7, 2022 ) located at the nurse's station for reference, that read in part, .Chapter 4 .Telephone and Verbal orders .when receiving a TO (telephone order) or VO (verbal order), enter the complete order into the computer .Chapter 20 .use the MAR to prepare and administer medications .ensure that the MAR clearly shows .the dosage, route .Document the administration of each medication on the MAR as soon as you give it . The DON informed surveyor facility staff use the MFA (Medical Facilities of America) policies first and then go to [NAME] & [NAME]. No further information was provided to the survey team prior to the exit conference on 07/24/2024.

Based on observations, interviews, and document review, the facility staff: (a) failed to ensure food items were stored in a manner to promote food safety for one (1) of the two (2) resident refrigerators on the resident units and (b) failed to ensure the ice machine, located in the kitchen, was clean and in a safe operating condition. The findings include: The facility staff failed to ensure resident food items kept in refrigerators on the nursing units were correctly labeled and stored. On 6/21/23 at 4:35 p.m., the surveyor observed storage of residents' food items on the nursing units with Licensed Practical Nurse (LPN) #1. The following food items were observed: - (a) a small bag of sliced apples was not labeled with name and/or date; - (b) a half of a sandwich dated 6/12 (provided by the facility) was still in the pantry refrigerator; - (c) a small, opened bottle of store-bought iced tea was not labeled with a name and/or date; - (d) a salad dated 6/5/23 was still in pantry refrigerator; - (e) a bowl of mixed fruit containing strawberries and melon was not dated. All the aforementioned foods were immediately tossed by LPN #1. The following information was found in a facility policy and procedure titled Outside Food for Patients (with an effective date of 11/1/19): 1. Prepared/ready-to-eat outside food that needs refrigeration may be placed in the refrigerator at the nurse's station, if there is space, for a short period of time, not to exceed three (3) days. 2. The items must be labeled and dated with the patient's name, room number, and the use-by-date. On 6/20/23 at 2:15 p.m., the surveyor, with Staff Member (SM) #6 (a dietary employee) present, noted one of the drainage pipes from the ice machine in the kitchen had water running back up the underside of the drainage pipe; the underside of the drainage pipe was also noted to have a black substance which ran the length of the drainage pipe to the pipe elbow connector. The Maintenance Director was asked to look at the ice machine. The Maintenance Director acknowledged the aforementioned observations. The Maintenance Director reported the drain in question was coming from the lower ice storage bin. On 6/20/23 at 3:45 p.m., the surveyor, with the Maintenance Director, observed the aforementioned ice machine drainage pipe. The Maintenance Director reported the drainage pipe had been cleaned. The Maintenance Director repositioned the pipe to allow it to drain freely; when repositioned pulled water in the tube was observed to flow into the floor drain. The Maintenance Director provide the Installation Owner/Operator Use and Care Manual for the ice machine to the surveyor. This manual included the following information: Follow these guidelines when installing drain lines to prevent water from flowing back into the ice machine and storage bin: Drain lines must have a 1.5 inch drop per 5 feet of run (2.5 cm per meter), and must not create traps. On 6/20/23 at 5:16 p.m., The Maintenance Director reviewed the aforementioned information. The Maintenance Director confirmed the pipe had shifted limiting the flow of the water from the drain; the Maintenance Director acknowledged some pooled water had drained from the drain pipe when it was repositioned. On 6/23/23 at 12:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Regional Director of Clinical Services. During this meeting, the surveyor discussed (a) the observations of improperly label resident food items in one (1) of the resident refrigerators on the nursing unit and (b) the observations of the ice machine drainage pipe being incorrectly positioned and noted to have a black substance on the drainage pipe.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 30 residents in the survey sample, Resident #92. The findings included: For Resident #92, the facility staff failed to administer Phenobarbital as ordered by the medical provider on two separate occasions. Phenobarbital is a medication used to control seizures. Resident #92's diagnosis list indicated diagnoses, which included, but not limited to Bilateral Osteoarthritis of the Knee, Somatization Disorder, Chronic Post-Traumatic Stress Disorder, History of Traumatic Brain Injury, and Seizures. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 5/31/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #92's comprehensive person-centered care plan included a focus area stating the resident had a risk for complications secondary to a convulsive disorder with an intervention to administer medication as ordered. On 6/22/23 at 2:30 pm, surveyor spoke with Resident #92 who stated they missed the first few doses of their seizure medication following admission to the facility. Resident #92's physician's orders included an order dated 5/24/23 for Phenobarbital 100 mg two tablets one time a day for seizures. According to Resident #92's May 2023 Medication Administration Record (MAR), the resident did not receive the Phenobarbital on 5/25/23 and 5/26/23, for each administration a 9 was documented indicating Other/See Progress Notes. A nursing progress note dated 5/25/23 at 10:30 am stated the Phenobarbital was not available from the pharmacy and was not stocked in the Omnicell (the facility in-house medication supply). A 5/26/23 10:39 am nursing progress note stated the Phenobarbital was not available from the pharmacy and a script was faxed. On 6/23/23 at 10:11 am, surveyor spoke with registered nurse (RN) #1, the writer of the 5/25/23 nursing note, who stated Resident #92's Phenobarbital had not arrived from the pharmacy and was not stocked in the Omnicell. RN #1 stated they contacted the pharmacy and was told the medication was out for delivery that day. RN #1 stated they notified the provider but could not remember who or what was said in response. On 6/23/23 at 9:45 am, surveyor spoke with Resident #92's physician who stated they could not get the Phenobarbital from the pharmacy at first, but the family brought the medication to the facility. Surveyor asked if the two missed doses could have caused the resident's seizure on 5/27/23, the physician stated it may have increased the likelihood if in fact the resident were having seizures. Physician further stated they were not sure if the resident was having seizures or pseudo-seizures. On 6/23/23 at 10:24 am, surveyor spoke with the Director of Quality (DQ) for the facility pharmacy who stated the order for Phenobarbital was entered into Resident #92's clinical record on admission on 5/24/23 however the order was not transmitted to the pharmacy because it required a valid script. DQ stated the pharmacy received a script for the Phenobarbital on 5/29/23 and the medication was dispensed with the evening delivery on 5/29/23. Surveyor reviewed the facility Omnicell in-house medication supply inventory and Phenobarbital was not available. Surveyor requested and received the facility policy entitled Medication Management/Medication Unavailability with a revised date of 4/21/22 which read in part .3. If medications are determined to be unavailable for administration, licensed nurse will notify the provider of the unavailability. Licensed nurse will document notification to the provider of the unavailability in the medical record. Licensed nurse will notify provider of the unavailability of medication and request an alternate treatment if possible. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures. On 6/23/23 at 12:45 pm, the survey team met with the administrator, director of nursing, and the regional nurse and discussed the concern of Resident #92 not receiving Phenobarbital as ordered on 5/25/23 and 5/26/23. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/23/23.

Based on observations, interviews, and document reviews, the facility staff failed to provide care and/or treatment according to medical provider orders for three (3) of 30 sampled residents (Resident #101, Resident #32, Resident #301). The findings include: 1. LPN #7 initiated cardiopulmonary resuscitation (CPR) on a resident (Resident #101) who had an active Do Not Resuscitate (DNR) order. Resident #101's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. Resident #101 was documented as able to make self understood and as able to understand others. Resident #101's Brief Interview for Mental Status summary score was documented as 15 out of 15; this indicated intact and/or borderline cognition. Resident #101 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During a telephone interview on the afternoon of [DATE], Licensed Practical Nurse (LPN) #7 reported they found the resident unresponsive sitting semi-up right on the floor. Resident #101 was assessed to be not breathing and without a pulse. LPN #7 confirmed they started cardiopulmonary resuscitation (CPR) and called Emergency Medical Services (EMS). CPR was not successful. LPN #7 reported that information provided during report indicated Resident #101 was a full code. LPN #7 reported EMS arrived at the facility and contacted a medical provider at a local emergency department to get orders to stop CPR. LPN #7 reported it wasn't until after CPR was stopped that it was discovered that Resident #101 had a DNR order. Resident #101's clinical documentation indicated CPR was attempted when the resident was found unresponsive, pulseless, and not breathing. Resident #101's clinical record indicated an active DNR order was in place at the time CPR was started when the resident was discovered unresponsive, pulseless, and not breathing. The following information was found in a facility policy and procedure titled Cardio-Pulmonary Resuscitation (CPR) (with an effective date of [DATE]): Cardio-Pulmonary Resuscitation (CPR) will be initiated as a resuscitation procedure to restore breathing and/or heartbeat if any patient is found to be in cardiopulmonary arrest, EXCEPT where the patient's physician has specifically and appropriately documented a DNR order in the patient's permanent medical record. On [DATE] at 12:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Regional Director of Clinical Services. During this meeting, the surveyor discussed LPN #7 providing CPR, to Resident #101, when the resident had a current, active DNR order. 28567 2. For Resident #32, the facility staff failed to administer the residents evening medications on [DATE] per the providers orders. Resident #32's diagnoses included, but were not limited to, Parkinson's disease, diabetes with neuropathy, muscle weakness, essential hypertension, and anxiety disorder. Section C (cognitive patterns) of Resident #32's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Indicating this resident was alert and orientated. Resident #32's comprehensive care plan included the intervention administer medications as ordered. Resident #32 reported to the facility staff that Licensed Practical Nurse (LPN) #2 had not administered their evening medications on [DATE]. [DATE] 2:37 p.m., Resident #32 stated to the surveyor that LPN #2 did not give them their nighttime medications and the Director of Nursing (DON) took care of the issue. Resident #32 was unsure of the date when interviewed by the surveyor. A review of Resident #32's electronic medication administration records (eMARs) revealed that LPN #2 had documented that they had administered all of Resident #32's evening medications on [DATE]. Administrator stated that they had investigated the residents allegation and they had discovered during their investigation that LPN #2 had documented for the residents narcotic Alprazolam on the eMAR, but they had not signed out this narcotic on the controlled drug administration record. With this information they were able to verify that this resident did not receive their medications. The facility staff provided the surveyor with an employee corrective action document and a medication error report both dated [DATE] regarding this issue. LPN #2 had signed the corrective action document on [DATE] but did not sign the medication error report. LPN #2 no longer worked at the facility. [DATE] 5:10 p.m., the issue regarding Resident #32's medications was reviewed with the Administrator and Nurse Consultant. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #301, the facility nursing staff administered 1000 mcg (microgram) of B12 when the provider order was for 100 mcg of B12. [DATE] 8:10 a.m., the surveyor observed Licensed Practical Nurse (LPN) #4 prepare and administer Resident #301's morning medication to include their B12. LPN #4 obtained 1000 mcg of B12 from the stock medication supply in the medication cart and administered this to Resident #301. [DATE], the surveyor reviewed Resident #301's medication orders. The clinical record included a provider order dated [DATE] for B12 100 mcg's by mouth in the morning. [DATE] 10:15 a.m., the surveyor and LPN #4 checked the medication cart for the B12. LPN #4 pulled the B12 bottle from the medication cart and confirmed the providers order read 100 mcg's and the bottle read 1000 mcg's. LPN #4 stated they did not have another bottle of B12 on the medication cart. [DATE] 10:25 a.m., call placed to facility pharmacy who confirmed the B12 was available in a 100 mcg dosage. [DATE] 5:10 p.m., end of the day meeting with the Administrator and Nurse Consultant. The issue with the B12 dosage was reviewed. [DATE], the facility provider changed the dosage of B12 to 500 mcg's in the morning due to B12 deficiency. [DATE] 8:52 a.m., the Director of Nursing (DON) provided the surveyor with a copy of a policy titled, Administration Procedures for All Medications. This policy read in part, .Prior to removing the medication from the container. Check the label against the order on the MAR . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, and during the course of a complaint investigation, the facility staff failed to follow physician's orders for 1 of 14 residents in the survey sample, Resident #12. For Resident #12, the facility staff failed to follow the physician's order for the resident's code status of do not resuscitate (DNR). This was a closed record review. The findings included: Resident #12's diagnosis list indicated diagnoses, which included, but not limited to Congestive Heart Failure, Type 2 Diabetes Mellitus, Nonalcoholic Steatohepatitis, Portal Hypertension, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 indicating Resident #12 was severely cognitively impaired. Resident #12's physician's orders included an order dated [DATE] 5:49 pm stating Code Status DNR. This order was created and confirmed in the resident's electronic medical record by registered nurse (RN) #3 and electronically signed by the attending physician on [DATE] at 7:42 pm. Resident #12's clinical record also included a completed Virginia Department of Health Durable Do Not Resuscitate Order form dated [DATE] and signed by the resident, the resident's spouse, and a physician. A change of condition progress note by RN #3 dated [DATE] at 1:48 pm read At 1315 (1:15 pm), pt (patient) was sitting up in wheelchair with head slumped forward. CNA (certified nursing assistant) attempted to rouse pt with no success. Undersigned entered room, attempted sternal rub with no success. Code Blue was called at that time. Pupils unresponsive to light. BG (blood glucose) 107 92% on O2 (oxygen) via rebreather at 12 l/m (liters per minute). BP (blood pressure) ,d+[DATE], HR (heart rate) 99 and a thready pulse. 1322 (1:22 pm): 22 G (gauge) IV started in R (right) hand, NS (normal saline) started on gravity flow. 1324 (1:24 pm): ,d+[DATE], 100% O2 72 pulse, 10 RR (respiratory rate). 1326 (1:26 pm): EMT arrived and continued care. IO (intraosseous infusion) started in right shin with NS via EMT. (Spouse) (name omitted) and (adult child) (name omitted) made aware. A physician's note dated [DATE] at 12:22 pm read in part Patient had been progressing well but was found unresponsive on the 15th by nursing staff. Patient was subsequently transferred to (name omitted) ER where (he/she) was admitted to the ICU for a cardiovascular arrest and questionable stroke. On [DATE] at 10:57 am, surveyor spoke with RN #3 regarding Resident #12. RN #3 stated they found Resident #12 in wheelchair with head slumped over with a weak thready pulse, they did a sternal rub and told the CNA to call a Code Blue and a CNA called 911. RN #3 stated licensed practice nurse (LPN) #2, LPN #4, and RN #4 responded and assisted the resident to the ground and a CNA brought in the crash cart. RN #3 stated LPN #4 was pulling supplies from the crash cart, RN #4 started an IV, a non-rebreather oxygen mask at 12 l/m was applied and LPN #2 did a short round of chest compressions. RN #3 stated they then got a weak thready pulse. EMTs arrived in 10 to 15 minutes and took over care, non-rebreather mask was switched to an ambu bag and RN #3 provided the ventilation until the resident entered the ambulance. RN #3 stated EMTs never did chest compressions or shock the resident. When asked why the code was started, RN #3 responded I did not check (his/her) code status. RN #3 further stated at one point they did not have paper work for the resident to be a DNR and the paper work came through a few days before and they were unaware. On [DATE] at 11:38 am, surveyor spoke with LPN #2 who stated they responded to the Code Blue call and Resident #12 was blue, not breathing and they could not find a pulse and did one round of chest compressions and then got a pulse. Surveyor asked why they coded the resident and LPN #2 stated because a Code Blue was called. On [DATE] at 11:53 am, surveyor spoke with the administrator who stated Resident #12's completed DDNR was not given to the facility until [DATE] following the facility social worker's request. Administrator stated Resident #12's spouse had taken the DDNR form out of the facility and had the resident's physician sign it. On [DATE] at 10:37 am, surveyor spoke with the director of nursing (DON) regarding Resident #12's code. The DON stated the facility did not discover Resident #12 was a DNR until the resident was at the hospital. The DON stated when Resident #12 was admitted , they were told the resident was a DNR but then the social worker discovered there was no signed DDNR and the resident had to go back to being full code until the spouse brought the DDNR in on [DATE]. DON stated they immediately began educating staff on the policy and where to locate a resident's code status in point click care (PCC) (electronic medical record system) and a PIP (process improvement project) was initiated on [DATE]. Surveyor received a copy of the PIP dated [DATE] for the project entitled Identification of resident code status and process for initiating CPR, if indicated with a completion date of [DATE]. Facility provided a copy of an Employee Corrective Action form dated [DATE] which read in part Describe specific facts including date, time, what happened, witness: CNA called nurse to room of patient (Resident #12) who was found unresponsive and slumped over in WC (wheelchair). Assessment made and CPR started, patient was a DNR and the order was not verified. Patient sent out to hospital . Describe the impact the infraction had on the patient, customer, or business: 1) Patient should not have been coded per (his/her) request and MD orders which resulted in transfer to hospital and prolonging (his/her) life. 2) Nurse to always check order prior to starting CPR. Surveyor was provided a copy of a report sheet page with multiple residents listed including Resident #12. Resident #12's code status was documented as DNR on the form. On [DATE] at 2:25 pm, the administrator stated the copy was from [DATE]. Surveyor requested and received the facility policy entitled Do Not Resuscitate which read in part: Policy: CPR (cardio-pulmonary resuscitation) will not be initiated when there is a valid Do Not Resuscitate (DNR) order located on the patient's permanent medical record. Procedures: 2. A valid DNR order by the attending physician must be in writing, signed and appropriately dated: a valid DNR order may be a fax. A verbal DNR order is not a valid DNR order 4. A Virginia Department of Health Durable Do Not Resuscitate (DDNR) Order form is a valid order Surveyor also requested and received the facility policy entitled Cardio-Pulmonary Resuscitation (CPR) which read in part: Policy: Cardio-Pulmonary Resuscitation (CPR) will be initiated as a resuscitation procedure to restore breathing and/or heartbeat if any patient is found to be in cardiopulmonary arrest, EXCEPT where the patient's physician has specifically and appropriately documented a DNR order in the patient's permanent medical record. Procedure: 1. Validate code status. On [DATE] at 6:37 pm, survey team met with the administrator, DON, and regional nurse consultant and discussed the concern of staff failing to follow the physician's order for DNR for Resident #12. No further information was provided regarding this concern prior to the exit conference on [DATE]. This was a complaint deficiency.

Based on observations, interviews, and policy review, the facility failed to follow hand hygiene protocol for one resident (R146) of three residents observed during medication administration. This deficient practice increased the risk for spread of infection for these residents. The facility's Administration Procedures for All Medications Policy, dated 09/2018 and provided by the facility, read, in pertinent part, Medications will be administered in a safe and effective manner; and Administration: 3. Cleanse hands using antimicrobial soap and water or facility approved hand sanitizer before beginning a med pass, before handling medication, and before contact with a resident. R146 was admitted to the facility on [DATE], according to the undated Admission Record found in the electronic medical record (EMR) under the Admissions tab, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] According to R146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 09/14/21, R146 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 99. The MDS indicated the resident had both short and long-term memory deficits. The assessment indicated R146 received 51 percent or more of his daily caloric intake via his gastrostomy (g, a tube inserted through the wall of the abdomen directly into the stomach)-tube. R146's Order Summary Report, dated 11/18/21 and located in the EMR under the Orders tab, indicated the resident was to receive [MEDICATION(S)] 600 milligrams (MG) (a capsule) via g-tube three times daily. Licensed Practical Nurse (LPN) 2 was observed administering R146's medications on 11/17/21 at 9:42 AM. LPN2 dispensed the resident's [MEDICATION(S)] capsule into a medication cup with three other medications (all in tablet form). After dispensing all the resident's g-tube medications into the medication cup, LPN2 removed the [MEDICATION(S)] capsule from the medication cup, touching the outside of the [MEDICATION(S)] capsule as well as the other medication tablets, without first sanitizing her hands or putting on gloves. The capsule was opened with the nurse's bare fingers and the contents of the capsule was placed back into the medication cup with the resident's other g-tube medications prior to administration. During an interview on 11/17/21 at 10:09 AM, LPN2 stated, When I pulled the capsule out [of the medication cup] I didn't touch the medicine, so I didn't put on gloves. During an interview on 11/17/21 at 10:35 AM, the Director of Nursing (DON) stated, She [LPN2] should not have been touching anything with her bare hands when passing meds [medications].

Based on facility policy, clinical record review, and staff and family interviews, the facility failed to ensure family of one resident of five residents (Resident (R) 19) reviewed for advanced directives was adequately informed to make decisions related to the resident's code status. Code status options were not reviewed with R19's Resident Representative (RP)/Power of Attorney (POA) to determine the resident's wishes related to Cardio-Pulmonary Resuscitation (CPR). The findings include: The facility's Advance Directives Policy, provided to the survey team and dated [DATE], read, in pertinent part, Documents of declaration for advance directives that are approved by state law (i.e. Living Wills, Durable Powers of Attorney and/or Agents for Healthcare Decisions/Healthcare Power of Attorney, appointments for anatomic al gifts/organ donations) will be placed in the medical record as provided by the patient or legally designated representative. R19 was admitted to the facility on [DATE], according to the undated Admission Record found in the Electronic Medical Record (EMR) under the Admissions tab, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] According to R19's Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE], R19 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident could not complete the interview. The MDS indicated the resident had both short and long-term memory deficits, and her cognitive skills for daily decision making were severely impaired. R19's MFA Policies Governing the Implementation of Self-Determination Rights Form, signed by the resident's POA, dated [DATE] (almost two months after the resident's admission to the facility), and provided to the survey team by the facility, indicated the resident had an Advance Medical Directive and the directive was in the resident's medical file. R19's Durable, General Power of Attorney and Advance Medical Directive, dated [DATE] and located in the EMR under the Miscellaneous tab, documented the resident's wishes were my dying shall not be artificially prolonged under the following circumstances, and do hereby declare that if at any time I should (1) have a terminal condition, (2) be comatose with little likelihood of recovery, (3) be in a persistent vegetative state, or (4) have any medical condition or disease from which recovery is unlikely and death or prolonged suffering leading to death is likely, based on then prevailing medical knowledge and treatment, and my attending physician(s) has (have) conferred with my agent and confirmed his/her/their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .,d+[DATE], A-F, H, K, and L. R19's Order Detail Report, dated [DATE] and located in the EMR under the Orders tab, indicated the resident's code status was Full Code. During an interview on [DATE] at 4:59 PM, the Director of Nursing (DON) confirmed an Implementation of Self Determination of Rights Form had not been completed for R19 upon admission per facility protocol, and she stated the resident's Responsible Party would be in to the facility the next morning to fill out the paperwork. A Communication Progress Note, dated [DATE] and found under the Progress Notes tab in the EMR, read, in pertinent part, DP/SW [Discharge Planner/Social Worker, Director of Social Services (DSS)] spoke with patient's [niece] in regards to code status. Patient has completed advance directives listing [niece] as appointed to make decisions if patient unable. DP/SW asked if patient's heart was to stop beating does she want chest compressions done and niece states no. Niece does want patient to be a DNR [Do Not Resuscitate]. During an interview on [DATE] at approximately 3:00 PM, the DSS stated R19's POA was in the facility the previous evening to sign advanced directive paperwork, and indicated she wanted to have the resident be a DNR. She stated R19's POA indicated she did not know where the facility got the idea that the resident was to be full code. During an interview on [DATE] at 3:51 PM, R19's POA stated she wanted R19 to be a DNR according to the resident's wishes. R19's POA stated the facility had not spoken to her about the resident's code status prior to [DATE]. R19's POA indicated the resident's Advance Directives had been provided to the facility upon admission, and that she assumed the Advance Directives were enough to show the resident's code status was to be DNR. She stated, I don't remember having any conversation about CPR with facility at all.

Based on facility policy, clinical record review, and staff interview, the facility failed to ensure timely reporting of allegations of abuse for one of one abuse report reviewed. An allegation of verbal abuse occurred in the presence of staff, in which Resident (R) 78 verbally abused R242, and the allegation was not reported to administration. The findings include: The facility's Abuse/Neglect/Misappropriation/Crime Policy, provided directly to the survey team and dated 01/23/20, read, in pertinent part, The Administrator will ensure the timely reporting, investigating, and follow-up reporting of incidents of alleged/suspected patient abuse, neglect, mistreatment, exploitation, or crime against a patient to the State Agency and any other appropriate authorities. R78 was admitted to the facility on [DATE], according to the undated Admission Record found in the Electronic Medical Record (EMR) under the Admissions tab, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R78's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/27/21, R78 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS indicated the resident was not having behaviors during the assessment reference period prior to the assessment date of 10/27/21. R78's Behavior Care Plan, dated 03/31/21, located in the Electronic Medical Record (EMR) under the Care Plan tab, read, in pertinent part, The resident exhibits adverse behavioral symptoms r/t [related to] dementia, severe anxiety, refusal of care, yelling, cursing at staff, and delusions. Interventions included administer medications as ordered and monitor for side effects and effectiveness. R78's Behavior Progress Note, dated 07/20/21 and located in the EMR under the Progress Notes tab, read, in pertinent part, Resident verbally abusive toward roommate when [R242] asked CNA [Certified Nursing Assistant] to turn on air conditioner. [R78] called [R242] a pain pill seeking [OBSCENITY] . I'm going to beat your ass. [R242] verbalized fear of [R78]; and [R242] was moved to another room; and Resident no longer aggressive but pleased to have room back to herself. R242's clinical record was reviewed and indicated no documentation of the 07/20/21 event. Review of R242's MDS revealed that R242 was discharged from the facility on 08/07/21. The nurse who documented the incident was not available for interview. During an interview with the Administrator on 11/18/21 at 1:41 PM, R78's 07/20/21 Progress Note was reviewed, and the administrator stated the allegation of abuse was not reported to her per facility policy. She stated her expectations was the incident should have been reported to her immediately. During a follow-up interview with the Administrator on 11/18/21 at 2:14 PM, she stated, If someone says something (makes an allegation of abuse), that is to be reported to the charge nurse, then the Charge Nurse reports to the Unit Manager or the DON (Director of Nursing), then they (the Unit Manager of the DON) would notify me. Or they (staff) can just call me. The Administrator stated, (The DON) was not aware of this, either.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of nursing practice for 2 of 25 residents, residents #16 and #10. 1. For resident #16, the facility staff (a) administered the medications [MEDICATION NAME] without a physicians order and (b) failed to obtain the physician ordered labs H&H (hemoglobin & hematocrit). Regarding the medications administered without an order, the physician ordered Resident #16 to be transported to the hospital for evaluation and the reason documented on the telephone order was acute change in respiratory status. Resident #16 was subsquently admitted to the hospital and [DIAGNOSES REDACTED]. 2. For resident #10, the facility staff administered the medication [MEDICATION NAME] for a pulse < (less than) 60 on 2 separate occasions. The findings included: 1. a. For resident #16, the facility staff administered the medications [MEDICATION NAME] without a physicians order.Regarding the medications administered without an order, the physician ordered Resident #16 to be transported to the hospital for evaluation and the reason documented on the telephone order was acute change in respiratory status. Resident #16 was subsquently admitted to the hospital and [DIAGNOSES REDACTED]. Reference: Nursing 2009 Drug Handbook, [MEDICATION NAME] a schedule II narcotic and is classified as an opioid [MEDICATION NAME] and is used to treat moderate to severe pain. The half life is 2 to 3 hours duration 4-24 hours (753). Contraindications and cautions: Use with caution in patients with severe [MEDICAL CONDITION] (755). Adverse reactions include: Sedation, [MEDICAL CONDITION](fast heartrate), urine retention, and respiratory depression. (754-55) Reference: Nursing 2009 Drug Handbook, [MEDICATION NAME] is classified as an antidepressant. The half life is 18-24 hours, duration is unknown (605). Adverse reactions include: Weakness, [MEDICAL CONDITION] urine retention, and [MEDICAL CONDITION] (605). Reference: Fundamentals of Nursing, "Standards are those actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administrations. All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six right of medication administration include the following:" 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Once you determine that the information on the MAR indicated [REDACTED]. (841). "A medication error is any event that could cause or lead to a client receiving inappropriate medication therapy...most medication errors occur when a nurse becomes distracted or fails to follow routine procedures..." (841). Resident #16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) completed on this resident was a quarterly assessment with an ARD (assessment reference date) of 04/20/10. This assessment had the resident coded as having problems with short term memory but no problems with long term memory and as modified independence in cognitive skills for daily decision making. Section C (communication/hearing patterns) was coded 0/0 to indicate the resident had no problems making self understood or understanding others, section V (vision patterns) was coded 0 to indicate the resident had adequate vision (sees fine detail), section N (activity pursuit patterns) indicated the resident was awake all or most of the time in the morning, afternoon, and evening, and section P (special treatments and procedures) had the resident checked as receiving oxygen therapy. On 02/28/11 a review of resident #16's clinical record was completed. During this review a nurse's entry labeled "Late entry from 05/26/10" and dated 05/27/10 at 3:55 p.m., was noted in the progress note section of the resident record. This nurse's note was written by LPN (licensed practical nurse) #5 and read as follows: "At approximately 8:35 pm, while pulling medications at resident came up the medication cart and requested I label a bottle drink with name and date and place in refrigerator. I stopped pulling medication and without labeling the drugs I locked the cart and went to place the drink in the refrigerator. While in the kitchen I got 2 orange juice with sugar for a resident whose insulin level had dropped. After taking care of the resident whose insulin had dropped I returned back to the cart and started to give the last 3 patients their medication. Mrs. (name omitted) (Resident #16) was the 1st patient I came to and I had labeled her cup with Ambien, which I was waiting for pharmacy to deliver. Looking at her screen (computer) I saw [MEDICATION NAME] as the 1st medication that came up and when I looked at the medication I had pulled I saw a cup with [MEDICATION NAME] and 2 other pills. I mistakenly thought that I had labeled an additional cup for the Ambien, since I was waiting for pharmacy. I took the medications, [MEDICATION NAME], and MS-Contin by mistake to Mrs. (name omitted). I discovered the error when I went to administer the next resident's medication. I immediately went to Mrs. (name omitted) room and asked her if she recognized the medication that I had given her. She stated that she recognized the [MEDICATION NAME] and thought that Dr. (name omitted) had changed her medication, since they had discussed that earlier. I explained to Mrs. (name omitted) that I had inadverntly given her the wrong medication and informed her of those medications. She stated that she did not have any allergies and would probably sleep good that night. I apologized and told her that I was going to call Dr. (name omitted) and get directions on how to proceed. I called Dr. (name omitted) and advised him of the medication error. Dr. (name omitted) advised that we monitor Mrs. (name omitted) through the night for any adverse reaction. After speaking with Dr. (name omitted) I called (name omitted), on call supervisor, and informed her of the medication error. (Name omitted) reiterated that we continue to monitor Mrs. (name omitted) through the night. I immediately went to Mrs. (name omitted) and told her Dr. (name omitted) direction and asked her to please use her call light if she had any ill effects. I failed to notify Mr. (name omitted) because I thought Mrs. (name omitted) was her own responsible party." (sic) On 05/26/10 at 10:52 p.m., RN (registered nurse) #10 documented on the eMAR that resident #16 had refused her Ambien. There was no documentation in the clinical record indicating the resident had been administered any other routine or prn (as needed) medications that night. On 05/27/10 resident #16 was administered the following am medications-[MEDICATION NAME] ([MEDICATION NAME]/Proton pump inhibitor), Acetyl L [MEDICATION NAME] (amino acid supplement), Cranberry Capsule's (herbal supplement), Delta D3 (vitamin D supplement), DHEA (endogenous (made in the human body) hormone), [MEDICATION NAME] (stool softener), Folic Acid (vitamin), Klor Con (potassium), [MEDICATION NAME] (adrenocorticoid), and Vitamin B12 (vitamin supplement). The MayoClinic website was used as a reference for the medications Acetyl L [MEDICATION NAME], Delta D3, and DHEA and The Nursing 2009 Drug Handbook was used as a reference for the medications [MEDICATION NAME], Cranberry Capsules, [MEDICATION NAME], Folic Acid, Klor Con, [MEDICATION NAME], and Vitamin B12. On 05/27/10 at 7:30 a.m. LPN #2 transcribed a physician's telephone order to "Hold [MEDICATION NAME] today..." the reason given was documented as change in LOC (level of consciousness). The following medication was documented as administered at noon on 05/27/10-Acetyl L [MEDICATION NAME]. Between 4:30 p.m. and 5:30 p.m. the following documentation was made by the nursing staff-Acetyl L [MEDICATION NAME] (held evening dose-lethargic), Delta D3 (lethargic), DHEA (lethargic), [MEDICATION NAME] (lethargic). The nursing staff had obtained an order at 2:01 p.m. to hold medications today (05/27/10). Reference: Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health. Lethargy is defined a (a) Lowered level of consciousness marked by listlessness, drowsiness, and apathy (b) A condition of indifference (1022). The resident's BS (blood sugar) was documented as 98 at 7:00 a.m. and 119 at 12:00 p.m. The nursing staff had signed for the BS at 4:30 p.m. but the surveyor could find no documentation indicating the results, BS at 7:58 p.m. was documented as 133, no sliding scale insulin coverage was documented as given for any of these administration times. Further review of the clinical record produced the following documentation. Physician documentation: 1. Progress Note dated 05/19/10-"Pt is seen today. She has been having some decreased O2 (oxygen) sats. The student has heard some decreased breath sounds in the left lung. We did proceed with a chest x-ray. This revealed a large pleural effusion." Past Medical History: "She did have a pleural effusion which resolved itself. This was associated with pneumonia." Assessment and plan."Pleural effusion. Set up for thoracentesis..." 2. Progress note dated 05/26/10 (date of medication error) completed by Dr. (name omitted). "Pt denies needs/complaints today. Pt. states urine this morning was dark and odorous..." Vital signs: "B/P 98/60, T (temp)-100, R (respirations)-16, O2-95%. General "Pt (patient) is A&Ox3 (alert and orientated X3 (person, place, and time)..." Labs/Test "Pleural fluid analysis 5/21-negative for malignant cells..." Nursing documentation: 1. 05/26/10 10:52 p.m., RN #10-"Refused" there was no mention as to what was refused and the surveyor could find no documentation in the clinical record regarding this entry. 2. 05/27/10 8:16 a.m., RN #5-"100.0-74-16-98/60-95%. Resident has rested quietly this shift, no acute distress noted...No complaints this shift. Call light in reach." 3. 05/27/10 12:12 p.m., LPN #2-"Refused resident's appetite poor." 4. 05/27/10 2:01 p.m., LPN #2-"Order received to hold medication today." 5. 05/27/10 5:02 p.m., LPN #2-"Resident very drowsy this AM, speech slurred, VS (vital signs) 97.2, 109, 20 117/78 Sat 90%, notified Dr. (name omitted) order received to HOLD [MEDICATION NAME] for today. At 10:30 am order received to monitor VS every hour for 24 hours. VS monitored as order, at 2pm resident husband notified this nurse that resident having tremors in left arm and leg, and resident unable to void, this nurse noted tremor in right hand, resident easy to awake, denies pain, note pulse increased, paged Dr. (name omitted). Order received to straight cath to check for [MEDICAL CONDITION]. Resident cathed with 300 cc (cubic centimeters) of clear yellow urine returned. Notified Dr. (name omitted), order received to continue to monitor urinary output if unable to voice (void) insert Foley Cath, encourage resident to drink." 6. 05/27/10 5:43 p.m., LPN #2-"Patient lethargic, rouses to loud verbal stimulus. Husband is in at bedside and monitoring patient. Respiration decreased to 5/min. while resting with eyes claosed (closed). O2 sat decreased to 78% and increased to 98% when patient awake, One min. continuous monitoring has saturation ranging from 78%-93%. Venti (face) mask in use. Pulse 120 apical per min. Current Blood sugar 133. Order obtained via telephone from Dr. (name omitted) to send to (name omitted) hospital for further evaluation. Will call report to (name omitted) hospital ER (emergency room )." Note cosigned by RN #11. 7. 05/27/10 7:24 p.m., RN #11-VS a. 1530 (3:30 p.m.) 98.3-117-7-103/73-97% b. 1630 (4:30 p.m.) 117- 5- 99/74- 95% c. 1730 (5:30 p.m.) 118-6-116/85-95% On 05/27/10 RN #11 transcribed a physician's telephone order to "Transport to (name omitted) hospital for evaluation." The reason documented on this telephone order by the nursing staff was "Acute change in resp. (respiratory) status." On 05/27/10 resident #16 was admitted to the ICU (intensive care unit) of (name omitted) hospital. A review of Resident #16's POS (physician order [REDACTED].#16. This order was electronically reviewed and approved on 04/07/10 by Dr. (name omitted). Therapy documentation: 05/28/10 7:45 a.m., other staff #3 had documented a rehab discontinue note for PT (physical therapy) in the resident's clinical record. This note had been struck through on 06/29/10 at 1:16 p.m., this entry read in part: "...Pt. (patient) was d/ced (discharged ) from facility d/t (due to) admission to ICU as a result of medication error. Pt. was observed prior to d/c from facility and noted to have slurred speech, inability to maintain sats WNL (within normal limits) w/out (with out) frequent cues to breath, eyes unable to remain open for more than approx. 15 seconds at a time. Pt. very lethargic and husband at bedside. Prior to this episode she had improved w/ (with) all aspects of P.T." Other staff #4, who was the rehab manager, was interviewed on 02/28/11 at approximately 1:55 p.m., and was asked about the PT entry and why it was struck through. The Rehab Manager stated she did random audits and when doing an audit she noted the above entry. She stated she talked to other staff #3 about the entry and explained to other staff #3 that she was not qualified to make clinical conclusions. The Rehab Manager stated other staff #3 agreed with her and struck through the note and made another entry. Other staff #3 was out on medical leave and was unable to be interviewed. On 02/28/11 the DON (director of nursing) was asked if she was aware of medication error involving resident #16. The DON stated she was not aware of one but would check. On 02/28/11 the DON gave to the surveyor a copy of a medication error report dated 05/26/10. This medication error report had been completed by LPN #5. This report read in part: Medication [MEDICATION NAME] medication(s) given [MEDICATION NAME] (MS Contin) ER (extended release) 60mg and [MEDICATION NAME] 50mg. On 02/28/11 at approximately 12:00 p.m., the surveyor reviewed the hospital documentation from the resident's admission on 05/27/10. History & Physical Exam-Dated 05/27/10 1. Chief complaint: "I was given the wrong medication in the Rehab Center." 2. History of Present Illness: "The patient is a [AGE] year old Caucasian female who presented from (name omitted) Rehab Center stating she was given [MEDICATION NAME] mg and [MEDICATION NAME] 50 mg last night. She had never taken this medication before and it was the wrong medication ... According to patient's husband who was sitting at bedside, said that since she took that medication this morning, she cannot stay awake, and her urine output has decreased. She had a straight cath at the rehab center of about 300 cc was taken out. He also described her breathing as "Cheyne-Stokes" kind of breathing and saturation has kind of decreased ...Creatinine (renal (kidney) excretory function) about a week ago was 1.3. Creatinine now is 1.9." 3. Review of systems. "Respiratory: Patient admits to having labored breathing." 4. Physical Exam: "Temperature 97.6, pulse 112, respirations 16, blood pressure is 116/37." 5. General: "Patient is alert, awake, oriented and does not appear to be in any acute distress. Patient looks somewhat drowsy." 6. Impression: "Medication toxicity, pleural effusion, respiratory distress, hydration, urinary tract infection, history of shingles, renal lupus, [MEDICAL CONDITION] lupus, rule out [MEDICAL CONDITION] malignancy." 7. Plan: "Will give IV hydration, normal saline at 75 ml per hour. [MEDICATION NAME] 2 grams IV piggyback daily. Will give finger stick at 6H with moderate Insulin coverage. Will consult radiology for possible thoracocentesis..." 8. Conclusion: "The patient is hemodynamically stable. She does not seem to be in acute respiratory distress. Again, will bring patient to Intensive care unit to monitor for [MEDICAL CONDITION]. Also, will place a Foley catheter to monitor renal function and urine output." Reference: Fundamentals of Nursing, defines Cheyne-Stokes respirations as "Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes." (650). While in the ER the patient received the following treatment: Lab work (CBC, Urine), chest x-ray, IV's of NS (normal saline) started at 75 ml/hour, and an EKG (electrocardiography). Resident #16 was admitted to (name omitted) hospital on [DATE] and placed in the ICU on O2 (oxygen) to keep O2 saturations > (greater than) 90%, IV fluids NS at 75 ml/hour, [MEDICATION NAME] (antibiotic) 2 grams IV daily (urinary tract infection), monitoring of BS (blood sugars), lab work (CBC, Cardiac Test (BNP), CMP), Radiology consult, and foley catheter placement. The admitting [DIAGNOSES REDACTED]." Progress note (no date) dictated on 05/28/10 at 7:45 a.m., "The patient is much more awake this morning. It appears that the medication is weaning out of her body gradually. We are hydrating her gently and her Creatinine is now 1.5. After two episodes of nausea and vomiting, we started her on [MEDICATION NAME]. Patient has no labored breathing. Again, chest x-ray from last night did show a pleural effusion on the left side. Will go ahead and get radiology consult with Dr. (name omitted) and see if thoracentesis is warranted at this time ...Nurses report no acute changes in the last 24 hours." Assessment: "Patient is a [AGE] year old Caucasian female who presented from (name omitted) Rehab Center to (name omitted) hospital with chief complaint of being give [MEDICATION NAME], which she hasn't taken in the past and resulted in sedation and respiratory distress." Impression: 1. Drug intoxication, resolved 2. Left pleural effusion 3. [MEDICAL CONDITION] 4. Urinary tract infection 5. Nausea and vomiting 6. Lupus [MEDICAL CONDITION] Discharge Summary dated 05/28/10 listed the following discharge diagnoses. 1. Medication toxicity-resolved 2. Left pleural effusion 3. Urinary tract infection 4. Acute on [MEDICAL CONDITION] 5. Lupus [MEDICAL CONDITION] 6. Pulmonary lupus 7. Shingles Hospital Course: "This [AGE] year old Caucasian female who presented to (name omitted) hospital with chief complaint that patient was wrongly given [MEDICATION NAME] which she was not prescribed. After taking the medication, the patient became very sleepy and was in some respiratory distress. According to patient's husband she was having some Cheyne-Stokes breathing. The patient was admitted to the intensive care unit. The patient was put on IV hydration. The patient was found to have acute on chronic [MEDICAL CONDITION]. The patient was hydrated. Patient is much alert today. Patient had a thoracentesis done about a week ago. Repeat chest x-ray showed the patient does have a pleural effusion on the left lung and chest ultrasound was done and 200cc of fluid was taken out today. The patient seems to be much better. She is much alert, awake compared to what she was yesterday. She does not seem to be in any [MEDICAL CONDITION]. She does not seem to be in any acute distress. Her blood pressure is stable. Vitals are stable ...Nurses report no acute changes in the last 24 hours. Patient's urine output is good. Will go ahead and discharge patient back to (name omitted) Rehabilitation to follow up with Dr. (name omitted) and continue with physical therapy." Radiology: "Chest x-rays shows reaccumulation of the left pleural fluid noted on the chest x-rays. Repeat chest x-rays after thoracentesis showed improved aeration to the left base, no mediastinal shift and no pneumothorax was noted. " Cardiology: "EKG, no ST wave changes." Conclusion: "Patient is clinically and hemodynamically stable and not in acute distress. Will continue with plan as stated above and transfers patient to nursing home." Resident #16 was readmitted to the nursing center on 05/28/10. The readmission note was dated 05/29/10 at 7:45 a.m. and was documented by RN #12. This admission note read in part "A [AGE] year old female admitted to 17 (room) and Dr. (name omitted) services. Admission [DIAGNOSES REDACTED]. Respirations even and non- labored. Nasal O2 (oxygen) at 2liters per minute in use ...No c/o (complaints of) pain ...Vital signs 97.9-77-18-109/68-93%." Readmit note made by Dr. (name omitted) dictated on 05/31/10. "(Name) resident #16 returns to our facility after being admitted for accidental [MEDICATION NAME] administration. She developed some moderate [MEDICAL CONDITION] secondary to respiratory depression. She was sent to the hospital. Pleural effusion had returned. This was tapped. Again it was borderline for transudant exudates. She also had a UTI (urinary tract infection) that was sensitive to [MEDICATION NAME]. She was placed on [MEDICATION NAME] for the UTI and questionable pneumonia...Assessment and Plan #3) Accidental [MEDICATION NAME] administration with subsequent hypercapnea and decreased O2 secondary to decreased respiratory drive, now resolved...The patient will be readmitted and followed from here. She did have a pleural effusion. This will be followed also." On 02/28/11 at approximately 1:20 p.m., a meeting was held with the administrator, nurse consultant, and DON (director of nursing). During this meeting the administrative staff was notified that the office of OLC had received a complaint regarding the administration of the wrong medication and hospitalization of resident #16. The above findings were reviewed with the management team at this time. The management team was also asked if LPN #5 was still employed at the facility. The management team replied that LPN #5 had resigned. No further information was given to the survey team prior to the exit conference. On 06/07/10 at 7:54 a.m., other staff #1 documented a late entry that read, "Mrs. (name omitted) (resident #16) was discharged on [DATE] with Home Health PT & OT (occupational therapy) through (name omitted) HH (home health). A wheelchair, 3 in 1 bsc (bedside commode), sliding board, and Oxygen were ordered for the patient. Discharge instructions and prescriptions were sent with patient." This is a complaint deficiency. 1. b. For resident #16, the facility staff failed to obtain the physicians ordered labs H&H (hemoglobin and hematocrit). Reference: Diagnostic and Laboratory Test Reference, the lab tests Hemoglobin is used to measure the total amount of Hemoglobin in the peripheral blood, which reflects the number or red blood cells in the blood. Hemoglobin serves as a vehicle for oxygen and carbon [MEDICATION NAME] transport (521). The lab test Hematocrit is used to measure the percentage of the total blood volume that is made up by red blood cells. Decreased levels indicate [MEDICAL CONDITION] (518). On 02/28/11 a review of resident #16's clinical record was completed. During this review a physician's telephone order dated 03/08/10 was noted. This physicians telephone order read, "H&H (hemoglobin & hematocrit) q (every) wk (week) on Thursday fax results to pharmacy." This physicians order had been transcribed by LPN #2. The order was changed to a weekly CBC (complete blood count) on 05/12/10. Review of the clinical record was unable to produce any lab results for the H&H on the following Thursday's-March 18, April 15, or May 6, 2010. On 02/28/11 the DON (director of nursing) was asked by the surveyor about the missing H&H labs. The DON stated she would see what she could find. On 02/28/11 at approximately 1:20 p.m., a meeting was held with the administrator, nurse consultant, and DON (director of nursing). During this meeting the administrative staff was notified of the missing lab results for the H&H. No further information was given to the survey team prior to the exit conference. This is a complaint deficiency. 2. For resident #10, the facility staff administered the medication [MEDICATION NAME] for a pulse < (less than) 60 on 2 separate occasions. Reference: Nursing 2009 Drug Handbook, [MEDICATION NAME] is classified as a cardiac glycoside and is used to treat heart failure, [DIAGNOSES REDACTED], and [MEDICAL CONDITION] (446). Alert: Excessively slow pulse rate (60 beats/per minute or less) may be a sign of [MEDICATION NAME] toxicity. Withhold drug and notify prescriber (449). Contraindications and Cautions: Use with extreme caution in elderly patients (448). Reference: Fundamentals of Nursing, "Unexpected outcomes...apical pulse is less than 60 beats/min ([MEDICAL CONDITION]). Assess for the presence of factors that may alter heart rate (e.g., [MEDICATION NAME] or other cardiac medications). It may be necessary to withhold prescribed medications until the physician can evaluate the need to adjust the dose." (642-43). Resident #10 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) completed on this resident was a significant change in status assessment/readmission assessment with an ARD (assessment reference date) of 02/09/11. This assessment had the resident as scoring 3 of 15 in section C (cognitive patterns). On 02/24/11 a review was completed of resident #10's clinical record. During this review a physicians order was noted on the residents POS (physician order [REDACTED]. Further review of the clinical record produced pulses obtained by the nursing staff. The pulse was recorded as 55 on 02/05/11 and as 58 on 02/06/11. LPN (licensed practical nurse) #2 had documented she had administered the medication [MEDICATION NAME] on both days. On 02/24/11 at approximately 2:40 p.m., an end of the day meeting was held with the administrator, nurse consultant, and DON. During this meeting the administrative staff was notified that the resident had received the medication [MEDICATION NAME] on 2 separate occasions when her pulse was < 60. The DON was asked if she knew why the resident should have not have received the medication [MEDICATION NAME] for a pulse < 60 to which she replied it was a "Courtesy to hold Dig. ([MEDICATION NAME])" if the pulse is < 60. On 02/25/11 a physician's telephone order was noted on the resident's clinical record. This order was dated 02/24/11 and read "[MEDICATION NAME] level, continue [MEDICATION NAME] as ordered, Check pulse before giving. Hold for < 60." This order had been transcribed by RN (registered nurse) #2. On 02/25/11 at approximately 10:10 a.m., the DON gave to the surveyor a copy of the [MEDICATION NAME] level obtained on 02/24/11. The results were documented as 1.2, reference range 0.9-2.0. The last documented pulse was on 02/22/10 and was 68. On 02/28/11 at approximately 9:40 a.m., LPN #2 was asked by the surveyor if she took a pulse when administering the medication [MEDICATION NAME]. LPN #2 stated she did take a pulse even when it wasn't ordered by the physician. LPN #2 also stated she knew the medication [MEDICATION NAME] was supposed to be held if the pulse was < 60. LPN #2 then stated "If it's ordered that way and it's not always ordered." No further information was given to the survey team prior to the exit conference. Works Cited: Lippincott, Williams, and Wilkins. Nursing 2009 Drug Handbook. 29th ed. Philadelphia: Wolters Kluwer. 2009. Perry, Anne and Patricia Potter. Fundamentals of Nursing. 6th ed. St. Louis: Mosby. 2005.

Based on observation, staff interview, and clinical record review, the facility staff failed to follow professional standards of practice for 1 of 7 residents, Resident #102. The findings include: The facility staff failed to ensure a physician order [REDACTED]. (An electronic medication administration system.) Resident #102 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Resident #102 was observed receiving her medications on 4/5/11 at around 10:25 a.m. One of the medications she was observed taking was [MEDICATION NAME] 250 milligrams (mg). [MEDICATION NAME] is an over the counter [MEDICATION NAME] that helps promote intestinal health, and maintain bowel function. During the reconciliation of the medications observed given and the physician's order [REDACTED].* (for) 2 weeks. The nurse consultant was made aware of the findings and stated she would check on it. On 4/5/11 at around 1:00 p.m. the director of nursing (DON) handed the surveyor a nurse ' s note dated 4/5/11 at 12:42 p.m. which stated, " Spoke with _______ (physician name) regarding [MEDICATION NAME]. New order to continue per current schedule. RP (responsible person) aware. " The surveyor was also handed a physician order [REDACTED]. " The DON also stated that there were no further [MEDICATION NAME] physician order [REDACTED]. The following information is provided in Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360, " A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician ' s or health care provider ' s complete order on the appropriate medication form, the MAR (medication administration record). The MAR indicated [REDACTED]. When transcribing orders, ensure the names of medications, dosages, routes and times are legible. The nurse checks all orders for accuracy and thoroughness. " The nurse consultant was interviewed on 4/6/11 at around 10:00 a.m. She stated she did not think the physician order [REDACTED]. The facility management team was made aware of the findings on 4/5/11 at around 4:27 p.m.

Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician orders [REDACTED]. The findings include: The facility staff failed to give [MEDICATION NAME] (a [MEDICATION NAME] which promotes intestinal health) as ordered by the physician to Resident #102. Resident #102 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Resident #102 was observed receiving her medications on 4/5/11 at around 10:25 a.m. One of the medications she was observed taking was [MEDICATION NAME] 250 milligrams (mg). During the reconciliation of the medications observed given and the physician's order [REDACTED].* (for) 2 weeks. The nurse consultant was made aware of the findings and stated she would check on it. On 4/5/11 at around 1:00 p.m. the director of nursing (DON) handed the surveyor a nurse ' s note dated 4/5/11 at 12:42 p.m. which stated, " Spoke with _______ (physician name) regarding [MEDICATION NAME]. New order to continue per current schedule. RP (responsible person) aware. " The surveyor was also handed a physician order [REDACTED]. " The DON also stated that there were no further [MEDICATION NAME] physician order [REDACTED]. The following information is provided in Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360, " A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician ' s or health care provider ' s complete order on the appropriate medication form, the MAR (medication administration record). The MAR indicated [REDACTED]. When transcribing orders, ensure the names of medications, dosages, routes and times are legible. The nurse checks all orders for accuracy and thoroughness. " The physician was interviewed on 4/6/11 at around 10:35 a.m. He stated that the [MEDICATION NAME] would not hurt the resident and " may help her with what ' s going on " . The facility management team was made aware of the findings on 4/5/11 at around 4:27 p.m.