Every finding on record at Regalcare at Taunton

Based on observations, interviews, and record review, the facility failed to ensure a clean and homelike environment was provided for residents on two floors (first and second floor), out of two floors. Specifically, the facility failed to:1. Provide clean, comfortable dining chairs in good repair for residents in the dining room areas on the first and second floors;2. Ensure air conditioners were maintained and cleaned to prevent dust, debris, and dirt from forming on the filter and the unit in resident rooms on the first and second floor; and 3. Ensure floor mats (padded mats to prevent injury from falls) in resident rooms were clean and in good repair on the second floor.Findings include: Review of the facility's policy titled Resident Home, dated 2022, indicated but was not limited to the following:-The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. 1. On 6/24/26 at 9:00 A.M., the surveyor observed three residents sitting in the first-floor dining room watching television and talking. The surveyor observed 6 out of 9 dining room chairs with over 50 percent of the seated surface area torn and ripped. During a tour of the second floor on 6/25/26 at 7:56 A.M., the surveyor observed two residents in the dining room area sitting and talking. The surveyor observed 5 out of 8 dining room chairs in disrepair including the padded seat area ripped and peeling with the protective vinyl covering missing from the surface areas. During an observation with an interview on 6/25/26 at 9:51 A.M., the surveyor observed a family member visiting with a resident in the first-floor dining room. The family member was sitting in one of the dining room chairs in disrepair. The family member said the condition of the chairs has been poor since her mother was admitted to the facility approximately six months ago. She said sometimes she leaves and there are pieces of the chair still stuck to her because the vinyl is peeling off. She said she would not have these chairs in her home, and she said she has had conversations with staff about the condition of the chairs a couple times, so she is certain they are aware of the disrepair. During an interview on 6/25/26 at 8:00 A.M., Maintenance Staff #1 said there was no maintenance director working at the building currently and he was responsible for the maintenance of the building. He said he checks the logs on each floor daily and addresses those issues. He said if the issue is not identified by staff on the log or verbally then he does not have time to identify other issues because he is very busy fixing the already identified repairs needed. He said he has not noticed the chairs in disrepair in the dining area but spends more time in resident rooms. Review of the first and second floor maintenance logs failed to indicate the dining room chairs were identified as a request by staff to need repair. During an interview on 6/25/26 at 11:44 A.M., the Administrator said he expects staff to bring concerns like this to his attention. He said the dining room is used by residents for multiple meals on both floors and he was not aware of how badly they were in disrepair. He said he expects the furniture in the building to be clean, comfortable, and homelike. 2. On 6/24/26 at 9:00 A.M., the surveyor observed the following rooms on the first floor to have air conditioners containing black spots inside of the slotted vents, buildup of debris and dust on the filter, and orange water marks inside of the air conditioner installed in the window: Rooms: 101, 102, 103, 105, 106, 107, and 108. On 6/25/26 at 8:23 A.M., the surveyor observed the following rooms on the second floor to have air conditioners with black circular spots inside of the slotted vents, buildup of debris and dust on the filter and brown and orange spots on the vents of the air conditioner units in the windows: Rooms: 201, 203, 209, 212, 216, 219, 221, 224, and 226. During an interview on 6/25/26 at 9:46 A.M., Maintenance Staff #1 said he cleans the air conditioners before they are installed. He said this year the air conditioners were installed at the end of April and beginning of May for the first and second floors. He said he installed nine air conditioners at a time. He said he does not have a process to clean the air conditioners throughout the summer when they are being used. He said if someone tells him they are dirty he will clean the filter but otherwise housekeeping is responsible. During an interview on 6/25/26 at 11:19 A.M., Housekeeping Staff #5 said she cleans the rooms but does not clean the inside of the air conditioner. She said she will wipe down the outside but does not clean the filter or vents. She said she would not know how to take the filter out and put it back in. She said maintenance would be responsible for this. She said her manager was unavailable for interview but was able to say no housekeeping staff are cleaning the air conditioner units. During an interview on 6/25/26 at 11:23 A.M., Housekeeping Staff #2 said she and the staff in the department will wipe down the air conditioner but do not clean the vents or filters. She said she was not sure who did this but believed the Maintenance department was responsible. During an interview on 6/25/26 at 11:27 A.M., Housekeeping Staff #1 said he could see the debris, dust, and dirt in the air conditioner in room [ROOM NUMBER] and said he does not clean the air conditioners in the resident rooms. During an interview on 6/25/26 at 11:43 A.M., Maintenance Staff #1 said he has worked at the building for many years and does not have a process in place for cleaning the air conditioner units in the windows. He said he would depend on someone telling him if they are in need of repair. During an interview on 6/25/26 at 11:44 A.M., the Administrator said the Maintenance department is responsible for cleaning the air conditioners and does not know if this was clarified with the maintenance staff since the director position has been vacant. He said there should be a process in place, and each air conditioner should be cleaned regularly. He said there should be a process for identifying when the air conditioners were last cleaned and when they are due for preventative maintenance and cleaning. He confirmed visually seeing the black dots and debris on the air conditioning units. 3. On 6/25/26 at 8:23 A.M., the surveyor observed the following concerns with fall safety mats on the second floor:-room [ROOM NUMBER]A fall mat to the right side of the resident's bed was on the floor with torn pulled back edges exposing foam on the top and bottom right, as well as cracks in the vinyl like covering on the body of the mat.-room [ROOM NUMBER]A fall mat to the right of the resident's bed was on the floor with a torn area exposing approximately 1.5 centimeters (cm) of foam with peeled back edging and a torn right lower corner with lifted and peeled back vinyl covering exposing foam.-room [ROOM NUMBER]B fall mat to the right side of the resident's bed was with right and left lower corners of the mat with peeled back torn vinyl covering and missing pieces of foam exposed.-room [ROOM NUMBER]B fall mat to the left side of the resident's bed with multiple slits and cracks on the left side of the mat, a missing piece of vinyl covering at the left middle of the mat exposing 1-2 cm of foam and on the right side of the mat a large tear that ran the length of the mat with peeled up edges exposing approximately 4-5 cm of foam at its widest point and tapering down to about 0.5 cm of foam. The fall safety mats have exposed foam, are torn and frayed resulting in a possible infection control and safety hazard as well as not being homelike in appearance and in good repair. During an interview on 6/25/26 at 10:54 A.M., the Maintenance man said he keeps the fall mats downstairs in storage and brings them up when nursing requests them. He said he believes housekeeping cleans them and nursing monitors them. He said once they are in the rooms he is no longer responsible for them, but if nursing needed a new one because one is torn or ripped, they would typically contact him for a replacement. He said in the past they had purchased new ones, but he isn't sure how long ago that was. He said he checks the maintenance logs frequently throughout the day to complete the requested tasks. Review of the Maintenance Logs from the second floor failed to indicate the staff placed the fall mats on the log for repair or replacement in the last two months. During an interview on 6/25/26 at 11:00 A.M., Housekeeper #4 said she works on the second floor. She said she cleans both on top of and under the fall mats that are in the residents' rooms. She said she had noticed rips and tears in the mats, but she does not report that to anyone and does her best to clean over them. During an interview on 6/25/26 at 11:23 A.M., Nurse #2 said maintenance stores the fall mats and brings them to the units when requested. She said if she notices a mat is in disrepair she would notify maintenance verbally or by using the log so they could be replaced. She said torn frayed mats are a potential tripping hazard, and any exposed foam is a hazard for potentially holding germs. She said the torn mats should be replaced and not left in the residents' rooms. During an interview with observations on 6/25/26 at 11:35 A.M., Unit Manager #1 said once nursing identifies a need for a fall safety mat, they can obtain it themselves or contact maintenance to drop it off and housekeeping is responsible for cleaning them. She said if any were in disrepair the staff would notify maintenance via the written log or verbally to replace them. She said torn mats are not homelike and can create a tripping hazard and exposed foam could potentially hold onto bacteria creating an infection control risk. She said she does rounds at least daily in each resident's room and hadn't noticed any issues with the fall safety mats. The Unit Manager did rounds with the surveyor and observed the safety mats in rooms 201, 223, 227 and 228 and said the mats were in poor condition and needed repairing or replacement. She said the mats posed a potential hazard and should not be in residents' rooms in disrepair. During an interview on 6/25/26 at 11:49 A.M., the Administrator observed the torn mats in the resident rooms with the surveyor. He said he would expect staff to remove and replace equipment that is in disrepair and the torn mats with exposed foam should not be in the residents' rooms. On 6/26/26 at 8:29 A.M., the surveyor observed the mats in use in resident rooms 201, 223, 227 and 228 to remain in disrepair. During an interview on 6/26/26 at 9:18 A.M., the Regional Director of operations viewed the torn frayed fall mats in the residents' rooms and said they should have been removed and replaced.

Based on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for one Resident (#40), out of a total sample of 19 residents. Specifically, the facility failed to ensure Resident #40's right pressure relieving heel boot was implemented per physician's orders.Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.Review of the facility's policy titled Physician Order, dated April 2017, revised April 2022, indicated but was not limited to:-The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders.-Treatment orders-when recording treatment orders, specify the treatment, frequency and duration of the treatment. Resident #40 was admitted to the facility in June 2026, with diagnoses including: Type 2 diabetes mellitus, acquired absence of right foot, and peripheral vascular disease (slow, progressive circulation disorder in blood vessels). Review of the Minimum Data Set (MDS) assessment, dated 6/11/26, indicated Resident #40 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated the Resident had a behavior of rejection to care 1 to 3 days in the assessment period. Review of the Physician's Orders indicated but was not limited to:-Pressure relief heel boots to right heel when in bed removed as needed for skin checks or patient tolerance, every shift for monitoring (6/5/26).On 6/24/26 at 9:15 A.M., the surveyor observed Resident #40 lying in bed. The Resident showed the surveyor his/her right foot and said he/she has had all the toes amputated on the right foot and now has a wound on his/her right heel. The surveyor observed Resident #40's right foot to have a dressing covering the right heel, dated 6/23/26. The Resident's right foot was directly on the mattress with no offloading device observed. On 6/25/26 at 7:20 A.M., the surveyor observed Resident #40 lying in bed with no offloading pressure relief heel boot to right heel at 7:20 A.M. During an interview on 6/29/26 at 11:43 A.M., the surveyor observed Resident #40 lying in bed with no offloading pressure relief heel boot to right heel. Resident #40 said, No one ever puts the boot on my right foot. Review of the June 2026 Treatment Administration Record (TAR) for Resident #40 indicated the licensed nursing staff were signing off the pressure relief heel boots to right heel every shift as completed and licensed nursing staff were signing off behavior monitoring as completed with no indication of behaviors observed. Review of Resident #40's progress notes failed to indicate Resident #40 refused the pressure relief boot to his/her right heel when in bed for the month of June 2026. Review of Resident #40's care plan indicated but was not limited to the following:-Actual alteration in skin integrity: Intervention- follow MD orders for skin care and treatment (6/5/26). During an interview on 6/29/26 at 3:16 P.M., Certified Nursing Assistant (CNA) #1 said Resident #40 is assigned to her and he/she should be wearing a boot on the right foot at all times. During an interview on 6/29/26 at 3:28 P.M., Unit Manager (UM) #2 said Resident #40 has an order to have a boot on his/her right foot every shift, and she would expect the boot to be on as ordered. UM #2 said the nurses are signing the TAR for the order as completed so they should have been checking every shift to be certain Resident #40 had the boot on. During an interview on 6/29/26 at 3:36 P.M., Nurse #1 said Resident #40 has a wound on his right heel and wears a boot to offload the foot. Nurse #1 said the boot was to be in place every day. Nurse #1 said nurses had signed the TAR each shift that the boot was in place. During an interview on 6/29/26 at 3:42 P.M., the Director of Nursing (DON) said the process for the offloading device for Resident #40 is that either the assigned nurse or CNA can place the boot on the Resident. The DON said Resident #40 is supposed to wear a boot to their right foot as an offloading device every shift. She said if the Resident refused the boot those refusals would be documented. She said she expects the boot to be in place each shift as ordered by the physician.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#9), out of a total sample of 19 residents. Specifically, the facility failed to ensure infection control practices were maintained while performing wound care. Findings include:Review of facility's policy titled Infection Control, dated as revised May 2024, indicated but was not limited to the following:-Employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions or perform hand hygiene using alcohol-based sanitizer:-Before and after direct contact with residents-When hands are visibly dirty or soiled with blood or other body fluids-After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin-After removing gloves-After handling items potentially contaminated with blood, body fluids, or secretions-In most situations, the preferred method of hand hygiene is an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations:-Before and after direct contact with residents-Before performing any non-surgical invasive procedure-Before handling clean or soiled dressing, gauze pads, etc.-After contact with resident's intact skin-After handling used dressings, contaminated equipment, etc.-After contact with objects (e.g. medical equipment) near the resident, and-After removing gloves.Resident #39 was admitted to the facility in January 2026 with diagnoses which included stage IV right gluteal pressure ulcer (large, deep, full thickness wound that destroyed skin, underlying tissues and directly exposes the bone, muscle, tendon or ligaments), severe protein-calorie malnutrition, type 2 diabetes mellitus, and neurocognitive disorder with Lewy body.Review of the medical record indicated but was not limited to the following Physician's Orders:-Right Buttock, clean with normal saline, pat dry, apply silver alginate to wound bed, cover with foam dressing change every other day and as needed for wound care (6/5/26)-Enhanced barrier precautions every shift (1/15/26)On 6/25/26 at 10:45 A.M., the surveyor observed Nurse #3 complete Resident #9's wound care with assistance from Nurse #4 as follows:Right buttock wound care:-Nurses #3 and #4 performed hand hygiene and donned (put on) personal protective equipment (PPE) including gloves and a gown.-Nurse #3 removed the previously applied/soiled dressing, doffed (took off) gloves and performed hand hygiene.-Nurse #3 donned gloves and touched Resident #9's peri-wound area (region of skin immediately surrounding a wound), with same donned gloves opened a block package of unsterile gauze 4x4's and a small bottle of normal saline solution. The nurse was not observed to perform hand hygiene between touching the Residents' peri-wound and opening the dressing supplies.-Nurse #3 cleaned the wound and doffed gloves.-Nurse #3 donned clean gloves and dried the wound area with 4x4 unsterile gauze, doffed gloves. Nurse #3 was not observed to perform hand hygiene between taking off her dirty gloves and putting on her clean gloves. -Nurse #3 went to Resident #9's restroom and performed hand hygiene with soap and water, turned to the treatment cart in the doorway of Resident's room and returned to the clean dressing field with a foam border dressing.-Nurse #3 performed hand hygiene and went back to the treatment cart and took out a pair of scissors and returned to the clean dressing field, placing the scissors on the dressing field. The nurse was not observed to clean the scissors prior to placing them on the clean field or remove them from a protective clean case.-Nurse #3 closed the bottle of normal saline solution, donned gloves, opened the foam border dressing signed and dated the dressing with a black marker. Nurse #3 opened the packaging of calcium alginate (a type of wound product, commonly used to absorb heavy wound drainage) with the scissors, with the same scissors Nurse #3 cut a section of calcium alginate for the wound bed and doffed gloves. Nurse #3 was not observed to clean the scissors in between opening the dressing outer packaging and cutting a piece of the new clean dressing.-Nurse #3 donned gloves and placed the calcium alginate on Resident #9's wound bed and doffed gloves. The nurse was not observed to perform hand hygiene prior to putting on the new pair of clean gloves after removing her gloves.-Nurse #3 donned gloves then applied a foam border dressing, then doffed gloves. The nurse was not observed to perform hand hygiene prior to putting on the new pair of clean gloves after removing her gloves.During an interview on 6/25/26 at 11:20 A.M., Nurse #3 said she should have performed hand hygiene prior to applying clean gloves and said she thought she cleaned the scissors with cleaning wipes on the treatment cart but realized she did not when the wipes were on the windowsill of Resident #9's room. Nurse #3 said she should have cleaned the scissors prior to using them to cut the calcium alginate. Nurse #3 said she should not have touched Resident #9's peri-wound area with gloves and then touch the clean bottle of normal saline solution or the block of unsterile gauze with the same dirty gloves donned.During an interview on 6/29/26 at 3:23 P.M., Unit Manager #2 said she expects the nurses to perform hand hygiene prior to donning gloves each time during treatments and would expect the nurse to clean the scissors prior to and after use.During an interview on 6/29/26 at 3:46 P.M., the Director of Nursing (DON) said she expects nurses to perform hand hygiene when donning/doffing gloves during wound care. The DON said the expectation is the nurse should clean the scissors before and after each use to be certain they are clean. The DON said the nurse should have performed hand hygiene prior to donning gloves and should have cleaned the scissors prior to use.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure he/she was free from abuse from a staff member, when on 03/30/25, Resident #1 became combative during care and in response to his/her behaviors, Certified Nurse Aide (CNA) #2, told Resident #1 if he/she hit her again, she would hit him/her back. CNA #2 hit Resident #1 on the top of his/her left hand twice. The incident was witnessed by another staff member who was assisting with Resident #1's care. A cognitively intact person would experience pain and mental anguish after being hit by a caregiver. Findings include: Review of the Facility's Policy titled Abuse Prohibition, dated as revised 3/2025, indicated the following: -each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property; every resident in the facility will always be treated with respect and dignity -it is the goal of this facility to foster an environment that recognizes the worth, specialties and uniqueness of all individuals --abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident -physical abuse includes, but not limited to, hitting, slapping, pinching, kicking and control of behavior through corporal punishment of a resident Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/30/25, indicated that Resident #1 was being combative during incontinence care. The Report indicated that during the provision of care to Resident #1, CNA #1 reported that [in response to Resident #1 hitting her] CNA #2 said to Resident #1 If you hit me again, I will hit, you back. The Report further indicated that CNA #1 witnessed CNA #2 forcibly grab Resident #1's left arm and slap the back of his/her left hand two times. Resident #1 was admitted to the Facility in May 2021, diagnoses included dementia, anxiety disorder, and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/17/25, indicated that he/she had severe cognitive impairment. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. During an interview on 05/22/25 at 12:29 P.M., (which included review of her written witness statement) CNA #1 said around 5:00 A.M., she and CNA #2 were providing care to Resident #1. CNA #1 said Resident #1 became combative, hit CNA #2 several times and he/she called her (CNA #2) a racial slur. CNA #1 said CNA #2 became frustrated and told Resident #1, If you hit me again, I will hit, you back. CNA #1 said CNA #2 then forcefully grabbed Resident #1 by his/her left wrist, slapped the top of his/her left hand twice and Resident #1 yelled out Ow. CNA #1 said it was not a tap it was a hard slap because she heard the slapping noise when CNA #2 hit Resident #1's left hand. During an interview on 05/28/25 at 9:46 A.M., (which included review of her written witness statement, sent to the facility via email) CNA #2 said around 5:00 A.M., she and another CNA (later identified as CNA #1) were providing care to Resident #1, and he/she became verbally and physically combative. CNA #2 said Resident #1 told her to Get out, get out, I do not want you, and that he/she called her (CNA #2) a racial slur. CNA #2 said Resident #1 hit her right arm and that she told him/her Not to do that! and that she said to him/her If you hit me again, I will hit, you back. CNA #2 said Resident #1 then hit her again, kicked her left breast and said that in response she (CNA #2) tapped the top of Resident #1's left hand. CNA #2 said Resident #1 did not make a sound and moved his/her hand. During an interview on 05/22/25 at 3:19 P.M., (which included review of her written witness statement) Nurse #1 said on 03/30/25 she worked from 3:00 A.M. to 3:00 P.M. and around 5:00 A.M. she heard Resident #1 yelling at staff while they were providing care. Nurse #1 said Resident #1 could be physically and verbally combative with care. Nurse #1 said she was starting her medication pass and said she did not go to Resident #1's room. During an interview on 05/21/25 at 2:44 P.M., the Director of Nursing (DON) said that on 03/30/25 around 9:19 A.M. Nurse #1 notified her that CNA #1 reported that she had witnessed CNA #2 slap Resident #1 on the hand. The DON said she started her investigation, told Nurse #1 to notify the Police, and she notified the scheduler to remove CNA #2 from the schedule pending investigation. The DON said CNA #1 told her Resident #1 was being combative during care, that she (CNA #1) heard CNA #2 tell Resident #1 If you hit me again, I will hit you back, that Resident #1 hit CNA #2 again, and that she (CNA #1) observed CNA #2 grab Resident #1's left arm and slap the back (top side) of his/her left hand twice. The DON said CNA #2 told her Resident #1 was combative, hitting her, and called her (CNA #2) a racial slur. The DON said CNA #2 said she only tapped the back (top side) of Resident #1's left hand, and that she (CNA #2) had told him/her If you are going to hit me, I am going to hit, you back. The DON said the facility substantiated the allegation of abuse and that CNA #2 was terminated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Identification and Reporting Policy, when on 03/30/25 during the night shift, Certified Nurse Aide (CNA) #1 witnessed CNA #2 slap Resident #1's hand while providing care to him/her. CNA #1 did not immediately report the allegation of physical abuse to the nurse on duty as required and did not do so, until four hours after witnessing the incident. Findings include: Review of the Facility's Policy titled Abuse Identification and Reporting, dated as revised 3/ 2022, indicated the following: -identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property -any suspected allegation of abuse shall be immediately reported to the administrator or his/her designee Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/30/25, indicated that on 03/30/25 Resident #1 was being combative during incontinence care. During the provision of care to Resident #1, CNA #1 reported that [in response to Resident #1 hitting her] CNA #2 stated to Resident #1 If you hit me again, I will hit, you back. The Report further indicated that CNA #1 witnessed CNA #2 forcibly grab Resident #1's left arm and slap the back of his/her left hand two times. Resident #1 was admitted to the Facility in May 2021, diagnoses included dementia, anxiety disorder, and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/17/25, indicated that he/she had severe cognitive impairment. During an interview on 05/22/25 at 3:19 P.M., (which included review of her written statement) Nurse #1 said on 03/30/25 she worked from 3:00 A.M. to 3:00 P.M. and around 5:00 A.M. she heard Resident #1 yelling at staff while they were providing care. Nurse #1 said she was not aware of any physical abuse by CNA #2 at that time. Nurse #1 said after CNA #1's shift ended (7:00 A.M.), she (CNA #1) came back to the Facility around 9:00 A.M. Nurse #1 said CNA #1 reported to her (Nurse #1) then that CNA #2 had hit the back of Resident #1's hand (could not recall which hand) during care. Nurse #1 said she immediately notified the Director of Nursing (DON). During an interview on 05/22/25 at 12:29 P.M., (which included review of her written statement) CNA #1 said around 5:00 A.M., her and CNA #2 were providing care to Resident #1. CNA #1 said Resident #1 became combative, hit CNA #2 several times and called her (CNA #2) a racial slur. CNA #1 said CNA #2 became frustrated and told Resident #1, If you hit me again, I will hit, you back. CNA #1 said CNA #2 then forcefully grabbed Resident by his/her left wrist, slapped the top of his/her left hand twice and Resident #1 yelled out Ow. CNA #1 said she became anxious about what she saw and that she did not report the incident to the Nurse on duty. CNA #1 said she went home after the end of her shift (7:00 A.M.) but knew that she was supposed to report what she had observed. CNA #1 said she went back to the Facility around 9:00 A.M. and told Nurse #1 that CNA #2 had slapped Resident #1's left hand while she (CNA #1) and CNA #2 were providing care to him/her. During an interview on 05/21/25 at 2:44 P.M., the Director of Nursing (DON) said that on 03/30/25 around 9:19 A.M. Nurse #1 notified her that CNA #1 reported that she had witnessed CNA #2 slap Resident #1's hand. The DON said she started her investigation, told Nurse #1 to notify the Police, and she notified the scheduler to remove CNA #2 from the schedule pending investigation. The DON said CNA #1 did not immediately report the incident to Nurse #1 per Facility Policy. The DON said her expectation is that all staff immediately report any concern for potential abuse, and that they should notify the Administrator or DON.

Based on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were competent in immunosuppressant drug therapy resulting in: a. failure to identify the adverse discontinuation of a necessary immunosuppressant medication (tacrolimus) for the prevention of organ rejection for one Resident (#40) in a sample of 18 residents; and b. failure to communicate with the practitioner about abnormally low tacrolimus level laboratory results for Resident #40, readmitted to the facility with a known history of heart transplant, resulting in emergent hospitalization in March 2025 for transplanted organ rejection surveillance and medication regimen adjustments. Findings include: Review of the Facility Assessment, updated 4/25/25 and reviewed by the QAPI Committee on 4/28/25, indicated: -Services and Care We Offer Based on our Residents' Needs Medications: Awareness of any limitations of administering medications Administration of medications that residents need Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure -Staff training/education and competencies Once the new staff member has completed the classroom orientation, they are partnered with a member to learn the specifics of their role. The mentor trains and completes a competency check list to assure the staff has received the proper training and can perform the necessary tasks related to their role and according to [Facility Name's] standards. Once competency is evaluated and successfully completed, they can assume their position autonomously. If any deficits are identified, additional training is provided. The staff is then provided with regular in-service opportunities and evaluations at least annually, to identify any additional dementia training, and a corporate compliance review. Review of the facility's policy titled Change in Condition in a Resident Status, effective 3/2017, indicated, but was not limited to, the following: -The Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: *A need to alter the resident's medical treatment significantly *Abnormal laboratory reports *A need to transfer the resident to a hospital/treatment center Review of the facility's policy titled Labs and Diagnostics, revised 4/2022, indicated, but was not limited to, the following: -Review by Nursing Staff 1. A nurse will review all results. -Deciding How Urgently to Contact the Physician 1. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 2. A nurse will try to determine whether the test was done a. As a routine screen or follow-up; b. To assess a condition change or recent onset of signs and symptoms; or c. To monitor a drug level. -Identifying Situations that Warrant Immediate Notification Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results. 1. The physician has requested to be notified as soon as a result is received. 2. The result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Determining the Reason for Testing 1. If the results do not meet the preceding criteria for immediate notification, then the nursing staff will review why the test was obtained, as well as the resident's current clinical status including the presence of any signs or symptoms. -Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. -Physician Responses 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab result requiring immediate notification . and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and organ transplant. a. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. Review of documentation received from Resident #40's consulting heart failure team indicated at time of discharge from the hospital back to the facility on [DATE], the Resident was prescribed tacrolimus 1 mg - Take 2 mg daily at 9 A.M. and take 3 mg daily at 9 P.M. Review of Resident #40's Medication Reconciliation, dated 2/27/25, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. -On 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated the order was subsequently discontinued on 2/27/25 at 6:05 P.M. Review of Resident #40's Physician's Orders indicated no tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Records (MAR) indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Nurse #1 and Nurse #2's staff education files during the extended survey on 5/8/25 failed to indicate there was previous education completed on immunosuppressant medication. Nurse #2 was working on Resident #40's unit and assigned to Resident #40's care during survey. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing (DON) at the facility from 12/24/24 until the new DON started at the facility on 3/14/25. Regional Nurse Consultant #1 said that when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said if there is a medication that they recognize a resident is no longer prescribed, they need to make note of it. During an interview on 5/7/25 at 3:22 P.M., Nurse #2, Nurse #3, and Nurse #4, working on the unit where Resident #40 resides, said they could not recall any education pertaining to Resident #40 or his/her immunosuppressant medication regimen. During an interview on 5/8/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the SDC and she said that records of all in-service training she conducted were in the binder. In-service training records in the education binder failed to include in-service training on immunosuppressant medication use/monitoring prior to 3/18/25. b. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of documentation received from Resident #40's consulting heart failure team indicated, but was not limited to, the following: -The Resident's tacrolimus level on 2/26/25 was 6.4 ng/ml (goal level was 4-6 ng/ml). A tacrolimus level drawn 2/27/25 remained pending at time of discharge and the facility was to send a tacrolimus level on 3/3/25 to the heart failure team for follow-up and dosing recommendations. Review of Resident #40's Physician's Orders failed to indicate that an order was obtained for a tacrolimus level on 3/3/25 related to abnormal tacrolimus level and tacrolimus dosing adjustments during hospitalization as indicated in the Resident's hospital After Visit Summary 2/27/25. Review of Resident #40's medical record indicated that on 3/6/25, the Resident had a tacrolimus level drawn (three days after the recommended draw date). The tacrolimus level resulted low at 1.2 ng/ml on 3/11/25 at 4:06 P.M. and were marked as reviewed by the Physician Assistant (PA) on 3/13/25 at 12:45 P.M. The medical record failed to indicate the lab values were received by or reviewed with the heart failure team for recommendations for ongoing dosing of tacrolimus prior to 3/18/25. Review of Resident #40's Progress Notes indicated: -On 3/19/25 at 3:05 P.M., the facility nurse documented that the Resident's cardiologist requested the Resident be transferred to the emergency room at the hospital affiliated with the consulting heart failure team due to the Resident not having immunosuppressant drugs for the last two weeks. The Progress Note indicated the Resident was stable at the time of transfer. Review of the facility's education binder on 5/8/25 failed to indicate there was in-service education conducted on provider notification of abnormal lab results or communication with consulting providers. Review of Nurse #1 and Nurse #2's staff education files during the extended survey on 5/8/25 failed to indicate there was previous education completed on laboratory reporting. Nurse #1 and Nurse #2 currently work on Resident #40's unit. On 5/7/25, the surveyor attempted a phone interview with former First Floor Unit Manager #1, the nurse that admitted Resident #40. She has since resigned from the facility and did not return the surveyor's call. During an interview on 5/7/25 at 3:22 P.M., Nurse #2, Nurse #3, and Nurse #4, working on the unit where Resident #40 resides, said they could not recall any education pertaining to Resident #40. During an interview on 5/8/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the SDC and she said that records of all in-service training she conducted were in the binder. In-service training records in the education binder failed to include in-service training on immunosuppressant medication use/monitoring or laboratory reporting prior to 3/18/25. Refer to F760

Based on record review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, an Admission Medication Regimen Review (AMRR) was completed by the Consultant Pharmacist upon readmission to the facility and an irregularity was identified. Specifically, the Consultant Pharmacist failed to identify the discontinuation of Resident #40's immunosuppressant medication and, as a result, Resident #40 (a heart transplant recipient) missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization . Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. -Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (Medication Administration Record) (if applicable), and the admitting orders (sources). -List the dose, route, and frequency for all medications. -Review the list carefully to determine if there are discrepancies/conflicts. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/30/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Resident #40's tacrolimus level laboratory result, obtained via a blood draw from the Resident on 2/26/25, was 6.4 nanograms per milliliter (ng/ml). The Resident's goal tacrolimus level was 4-6 ng/ml -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of Resident #40's Medication Reconciliation, dated 2/27/25 and completed by nursing, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. Review of Resident #40's Physician's Orders indicated that on 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated an order was entered to discontinue the medication on 2/27/25 at 6:05 P.M. Review of Resident #40's medical record failed to indicate that an AMRR had been completed by a Consultant Pharmacist after the Resident returned to the facility from the hospital on 2/27/25, and there was no indication of a pharmacy review of Resident #40's record from the date of his/her return to the facility until 3/8/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated: -On 2/27/25, an Order Note entered by nursing indicated an order for Tacrolimus 1 mg - Give 3 capsules by mouth at bedtime and 2 capsules by mouth one time a day was entered and was outside of the recommended dose or frequency (the usually dosing regimen per the note is 3 to 46.5386 capsules two times per day) -On 2/27/25 at 11:48 P.M., the nurse at the facility documented that the Resident had been treated at the hospital for altered mental status and his/her medications were confirmed by the PA. -The Progress Notes failed to indicate that the physician's order for tacrolimus was discontinued on 2/27/25 or why the medication was discontinued. -On 3/8/25, the Resident's medication regimen was reviewed by the pharmacy consultant and no irregularities were noted. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated that on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. A Performance Improvement Plan (PIP) attached to the Medication Incident and Discrepancy Form indicated medication was not administered for a resident on tacrolimus and the root cause was the medication was entered in the electronic health record incorrectly as it was entered as a one-time order. The Medication Incident and Discrepancy Report Form and PIP failed to indicate that the pharmacy's AMRR had not been completed after Resident #40's readmission to the facility on [DATE] or that the Consultant Pharmacist's monthly MRR did not identify the discontinuation of the Resident's immunosuppressant medication. During an interview on 5/7/25 at 7:58 A.M., Resident #40 said that he/she had been sent to the hospital at the end of March because he/she had missed doses of his/her anti-rejection medication and the transplant doctor wanted him/her to be monitored. Resident #40 said he/she underwent testing at the hospital and everything was okay and he/she returned to the facility. Resident #40 said he/she did not know how much medication was missed or why. During a telephonic interview on 5/7/25 at 11:35 A.M., the Consultant Pharmacist said that a different pharmacist is assigned to review admission/readmission MRRs. The Consultant Pharmacist said that he cannot recall being notified of medication errors at the facility. During an interview on 5/7/25 at 1:08 P.M., the Regional Pharmacy Manager said the AMRRs are not conducted by the Consultant Pharmacist who conducts the routine monthly Medication Regimen Reviews (MRRs) and that there is an additional Consultant Pharmacist who only completes the AMRRs for the facility. The Regional Pharmacy Manager said that he had conducted an audit and concluded that the AMRRs were not completed consistently in February and March 2025. The Regional Pharmacy Manager said that the AMRRs should be completed within 72 hours of a resident's admission/readmission to the facility. The Regional Pharmacy Manager said that Resident #40 had returned to the facility on [DATE], but no AMRR had been completed within 72 hours of his/her readmission. The Regional Pharmacy Manager said that when he reviewed Resident #40's record, a tacrolimus order was in place for only one day and there was a discrepancy between the hospital discharge orders and facility's admission orders for the Resident. The Regional Pharmacy Manager said that had an AMRR been completed, this discrepancy would have been identified at that time. The Regional Pharmacy Manager said that tacrolimus is a medication used to prevent organ rejection and blood levels of the medication are monitored routinely to ensure dosing of the medication is therapeutic. The Regional Pharmacy Manager said Resident #40 had missed 20 days of his/her twice daily tacrolimus doses and that this put the Resident at higher risk for organ rejection. During an interview on 5/7/25 at 4:52 P.M., Regional Nurse Consultant #1 said that she is copied on an email from the pharmacy containing a report of all Medication Regimen Reviews completed for the facility when they are completed. Regional Nurse Consultant #1 said that she was made aware of the inconsistent completion of AMRRs in February and March 2025 by the Regional Pharmacy Manager on 5/7/25. During a subsequent telephonic interview on 5/08/25 at 9:00 A.M., the Regional Pharmacy Manager said that there are consultant pharmacists who complete the monthly medication regimen reviews (MRRs) and other consultant pharmacists that only complete the AMRRs. The Regional Pharmacy Manager said that when he receives the AMRRs, he reviews a report called the Action Summary from the facility's electronic health record and reviews the residents' date of admission/readmission and the date the AMRR was completed to ensure AMRRs are completed within 72 hours of admission/readmission. The Regional Pharmacy Manager said that when he was doing the audit for the facility at the end of March, he noted that the AMRRs had not been completed as required in February and March 2025. The Regional Pharmacy Manager said that the facility's corporate nursing leadership (Regional Nurse #3) was notified of the issue at the beginning of April 2025. The surveyor attempted to contact Regional Nurse #3, but she was unable to be reached. Refer to F760

Based on record review, interview, and observation, the facility failed to ensure a physician and/or the physician assistant (PA) provided supervision and oversight for the care of one Resident (#40) with a known history of an organ transplant, out of a total sample of 18 residents, who required the daily use of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection). Specifically, the physician and PA failed to: 1. Identify that tacrolimus was discontinued after a recent hospitalization , resulting in a total of 40 missed doses; and 2. Address and intervene on abnormal tacrolimus level laboratory values, leading to the Resident's emergent hospitalization for organ transplant rejection surveillance and medication management. Findings include: Review of the facility's policy titled Labs and Diagnostics, revised 4/2022, indicated, but was not limited to, the following: -Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. -Physician Responses 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. When necessary to help explain clinical decisions, a physician or mid-level practitioner should document the basis for conclusions about how the results were addressed; for example, at the next scheduled or interim visit. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/30/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Resident #40's tacrolimus level laboratory result, obtained via a blood draw from the Resident on 2/26/25, was 6.4 nanograms per milliliter (ng/ml). The Resident's goal tacrolimus level was 4-6 ng/ml -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of Resident #40's current Physician's Orders indicated the following: - Fax tacrolimus level results to [fax number redacted] every month between the 7th and the 11th of every month for immunosuppressive therapy (order start date 7/10/24). Further review indicated the fax number was directed to Resident #40's cardiologist's office. -No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. -Review of the current Physician's Orders failed to indicate an order for a tacrolimus level on 3/3/25 as indicated in the Resident's hospital After Visit Summary 2/27/25. Review of Resident #40's laboratory results indicated, but was not limited to, the following: -On 3/6/25, the Resident had a tacrolimus level drawn (three days after the recommended draw date). The tacrolimus level resulted low at 1.2 ng/ml on 3/11/25 at 4:06 P.M. and were marked as reviewed by the PA on 3/13/25 at 12:45 P.M. There was no additional documentation or new orders from the PA entered in the Resident's record at that time. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated, but was not limited to, the following: -On 2/27/25, a progress note was entered by the PA. The note indicated that the Resident had a prolonged hospitalization for CHF exacerbation and urinary tract infection and that the Resident's history was significant for organ transplant. The medication list, included in the PA's progress note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The PA's note failed to identify the change in the Resident's tacrolimus regimen to include the additional dose of 3 mg each day at 9 P.M. Additionally, the PA's progress note failed to indicate the follow-up tacrolimus level monitoring to be drawn on 3/3/25, as recommended by the hospital. -On 2/28/25, a progress note was entered by the physician. The physician documented in her note that the Resident was transferred to the hospital on February 22 and returned to the facility on [DATE]. The physician indicated the Resident was hospitalized due to change in mental status, nausea, and tremors and was treated with antibiotics for a urinary tract infection. The physician indicated the Resident was on immunosuppression with prednisone and tacrolimus and was at high risk of complications and infections. The medication list, included in the physician's note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note failed to identify the change in the Resident's tacrolimus regimen to include the additional dose of 3 mg each day at 9 P.M. Additionally, the physician's progress note failed to indicate the follow-up tacrolimus level monitoring to be drawn on 3/3/25, as recommended by the hospital. -On 3/19/25, a progress note was entered by the physician. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, and hospital discharge summary were reviewed. The physician documented that the Resident had received an organ transplant in 2021 and that she was contacted by the Cardiology RN in regard to Resident #40's low tacrolimus level of 1.2 ng/ml. The note indicated the Cardiology RN had discussed the Resident's medication regimen with staff at the facility and it appeared that the Resident had missed his/her tacrolimus since he/she was readmitted to the facility on [DATE] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff that the Resident had not received the tacrolimus and was later informed that the Cardiology RN had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Despite the documentation written in the physician's progress note, the medication list included in the progress note again indicated the Resident was taking tacrolimus 1 mg two capsules in the morning and provided no indication of the 9 P.M. tacrolimus dose the Resident should have received but did not. Review of documentation received from Resident #40's consulting cardiology team indicated that on 3/19/25, the Cardiology RN spoke with the Resident's physician at the facility and the physician was unaware of the critical tacrolimus lab value and discontinuation of tacrolimus. During a telephonic interview on 5/7/25 at 1:01 P.M., the physician said the Resident's tacrolimus didn't make it onto his/her medication list at the facility. The physician said the medication was to be used to prevent organ rejection as the Resident had received an organ transplant. The physician said she was made aware of the omission on 3/19/25 when she was informed by the Cardiology RN at the hospital. The physician could not recall being contacted about Resident #40's tacrolimus lab results on 3/11/25, despite being reviewed by the PA. During a telephonic interview on 5/7/25 at 1:39 P.M., the PA said he was aware of the medication error and had seen Resident #40 in between his/her readmission to the facility on [DATE] and transfer back to the hospital on 3/19/25. The PA said he could not recall when he was made aware of the medication error but if he had been aware of it before the Resident was transferred back to the hospital, he would have restarted the medication at that time. The PA said that he was aware the Resident's tacrolimus level had resulted low on 3/11/25, and said the results should be faxed to cardiologist for review. The PA said he was unaware if the results had been sent to the cardiologist because that is something the nursing staff would do and he did not follow up with nursing to ensure the results were communicated to the Resident's cardiologist. The PA further said he was unaware the Resident had not received the medication at the time the lab value was obtained. During a subsequent interview with record review on 5/8/25 at 1:48 P.M., the PA said he did not recall the date that he became aware of Resident #40's abnormal tacrolimus level in March 2025, but thought it was around the same time the Resident went out to the hospital and the nurses called him for the order to transfer the Resident. The PA said he reviewed the lab but would not make changes to the Resident's tacrolimus regimen despite abnormal tacrolimus levels because the Resident's tacrolimus labs and dosing are managed by the cardiology office. The PA said the results of the Resident's labs drawn at the facility are forwarded to the cardiology office by the facility staff and the cardiologist will review and make any new dosing recommendations, which he or the Resident's attending physician would then review. Further review of Resident #40's medical record failed to indicate that the PA or physician adequately reviewed the hospital discharge/cardiology recommendations or followed up with nursing to ensure the resident's medical care was supervised by the facility's physician services. Refer to F760

Based on document review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, to ensure he/she was free from a significant medication error when the Resident's immunosuppressant medication was discontinued in error. As a result, Resident #40 missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization . Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. -Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (Medication Administration Record) (if applicable), and the admitting orders (sources). -List the dose, route, and frequency for all medications. -Review the list carefully to determine if there are discrepancies/conflicts. Review of the facility's policy titled Aftercare of Heart Transplant, effective 4/17, indicated, but was not limited to, the following: -After a heart transplant, a comprehensive aftercare plan is crucial for long-term success and involves ongoing monitoring for rejection, infection, and medication side effects, as well as adherence to lifestyle modifications and regular follow-up appointments. This includes taking immunosuppressant medications, adhering to a prescribed exercise program, and maintaining a healthy diet. -This policy applies to all adult patients who have undergone a heart transplant and are currently more than three years post-transplant. -All heart transplant recipients post-transplant must receive individualized, evidence-based follow-up care focusing on immunosuppressive management, cardiovascular health, infection surveillance, malignancy screening, and psychosocial well-being. -Immunosuppressive Management *Maintain lowest effective dose of maintenance immunosuppression (e.g. tacrolimus, mycophenolate, prednisone) *Monitor for long-term side effects: nephrotoxicity (deterioration in kidney function due to toxic substances), hypertension (high blood pressure), diabetes, dyslipidemia (abnormal levels of fats in the blood) *Evaluate for medication adherence at every visit -Documentation and Communication *All assessments and interventions must be documented in the patient's electronic health record (EHR). *Coordinate care with primary care providers and other specialists. -Quality Assurance *Annual review of resident outcomes (graft survival, complications, hospitalization s) *Compliance audits on follow-up scheduling and lab monitoring Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/3/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. Review of Resident #40's Medication Reconciliation, dated 2/27/25, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. Review of Resident #40's Physician's Orders indicated on 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated the order was subsequently discontinued on 2/27/25 at 6:05 P.M. No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated but was not limited to: -On 2/27/25, an Order Note entered by nursing indicated an order for Tacrolimus 1 mg - Give 3 capsules by mouth at bedtime and 2 capsules by mouth one time a day was entered and was outside of the recommended dose or frequency (the usually dosing regimen per the note is 3 to 46.5386 capsules two times per day) -On 2/27/25, a progress note was entered by the physician assist (PA). The medication list, included in the PA's progress note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The PA's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M. -On 2/27/25 at 11:48 P.M., the nurse at the facility documented that the Resident had been treated at the hospital for altered mental status and his/her medications were confirmed by the PA. -On 2/27/25 at 11:56 P.M., the nurse at the facility indicated the Resident's medication list was faxed to the hospital and receipt was confirmed. -On 2/28/25, a progress note was entered by the physician. The physician documented in her note that the Resident was transferred to the hospital on February 22 and returned to the facility on [DATE]. The physician indicated the Resident was hospitalized due to change in mental status, nausea, and tremors and was treated with antibiotics for a urinary tract infection. The physician indicated the Resident was on immunosuppression with prednisone and tacrolimus and was at high risk of complications and infections. The medication list, included in the physician's note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M. -On 3/8/25, the Resident's medication regimen was reviewed by the pharmacy consultant and no irregularities were noted. -On 3/19/25, a progress note was entered by the physician. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, and hospital discharge summary were reviewed. The physician documented that the Resident had received an organ transplant in 2021 and that she was contacted by the hospital's Transplant Coordinator in regard to his/her low tacrolimus level of 1.2 ng/ml. The note indicated the Transplant Coordinator had discussed the Resident's medication regimen with staff at the facility and it appeared that the Resident had missed his/her tacrolimus since he/she was readmitted to the facility on [DATE] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff that the Resident had not received the tacrolimus and was later informed that the Transplant Coordinator had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Despite the documentation written in the physician's progress note, the medication list again indicated the Resident was only taking tacrolimus 1 mg two capsules in the morning. -On 3/19/25 at 3:05 P.M., the facility nurse documented that the Resident's cardiologist requested the Resident be transferred to the emergency room at the hospital affiliated with the consulting heart failure team due to the Resident not having immunosuppressant drugs for the last two weeks. The Progress Note indicated the Resident was stable at the time of transfer. Further review of Resident #40's Progress Notes failed to indicate that the physician's order for tacrolimus was discontinued on 2/27/25 or why the medication was discontinued. Review of documentation received from Resident #40's consulting heart failure team indicated, but was not limited to, the following: -At time of discharge from the hospital back to the facility on [DATE], the Resident was prescribed tacrolimus 1 mg - Take 2 mg daily at 9 A.M. and take 3 mg daily at 9 P.M. The Resident's tacrolimus level on 2/26/25 was 6.4 ng/ml (goal level was 4-6 ng/ml). A tacrolimus level drawn 2/27/25 remained pending at time of discharge and the facility was to send a tacrolimus level on 3/3/25 to the heart failure team follow-up and dosing recommendations. -On 2/27/25, 3/4/25, 3/5/25, and 3/18/25 the Cardiology Registered Nurse (RN) documented that she called the facility to request the Resident's medication list and lab results be faxed to the cardiology office. The Cardiology RN indicated that she had difficulty reaching a nurse or provider at the facility -On 3/19/25, the Cardiology RN documented that the Resident's labs and medication list were faxed on 3/18/25. The Cardiology RN noted that the labs were drawn on 3/6/25 and the tacrolimus level was 1.2 ng/ml after the dose had been decreased to 2 mg in the A.M. and 3 mg in the P.M. The Cardiology RN reviewed the medication list and no tacrolimus was noted. -On 3/19/25, the Cardiology RN documented that she contacted the Resident's physician at the facility and the physician was unaware of the critical value and discontinuation of tacrolimus and would call back with confirmation. -On 3/19/25 the consulting cardiologist requested to coordinate a hospital admission for the Resident for further testing (transthoracic echocardiogram - a non-invasive test that uses ultrasound to create images of the heart, and possible biopsy - a procedure that involves taking a sample of tissue to examine it more closely). Review of Resident #40's hospital Discharge Summary, dated 3/26/25, indicated, but was not limited to, the following: -The Resident presented to the hospital from the facility with recent history of missed immunosuppression doses and was admitted for rejection surveillance. -The Resident was found to have tacrolimus trough (the lowest level of the drug in the body) of 1.5 ng/ml. TTE and blood work for rejection was reassuring and the heart failure team deferred inpatient heart biopsy. -The Resident was discharged with his/her tacrolimus dosing increased to achieve tacrolimus trough to goal level of 4-6 ng/ml, recommendations for weekly labs including tacrolimus level every Friday for two weeks, prednisone taper for empiric transplant rejection therapy, and changes to his/her insulin regimen due to high blood sugar levels while on prednisone. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated that on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. The Form indicated that the Resident's transplant clinic had noted the medication was missing from the Resident's medication list. In the section of the Form titled Outcome of Investigation, it is noted that the medication was not administered and was entered as a one-time administration. During an interview on 5/7/25 at 7:58 A.M., Resident #40 said that he/she had been sent to the hospital at the end of March because he/she had missed doses of his/her anti-rejection medication and the transplant doctor wanted him/her to be monitored. Resident #40 said he/she underwent testing at the hospital and everything was okay and he/she returned to the facility. Resident #40 said he/she did not know how much medication was missed or why. During an interview on 5/7/25 at 12:24 P.M., the Staff Development Coordinator (SDC) said that on 3/19/25, former First Floor Unit Manager #2 approached her and informed her that the hospital had called asking about the Resident's tacrolimus regimen and that he/she was supposed to be on tacrolimus two times daily because he/she had received an organ transplant. The SDC said she was not familiar with the Resident's medication regimen at the time but reviewed his/her record and confirmed that the order for tacrolimus was initially entered but then was discontinued. The SDC said the hospital instructed the facility to monitor the Resident's tacrolimus level and ensure the Resident received his/her medications. The SDC said she did not have further involvement in the situation and that former First Floor Unit Manager #2 handled all further communication with the hospital and the Resident's providers. The SDC said former First Floor Unit Manager #2 was new to the position at the time and no longer worked at the facility. During a telephonic interview on 5/7/25 at 1:01 P.M., the Physician said the Resident's tacrolimus didn't make it onto his/her medication list at the facility. The Physician said the medication was to be used to prevent organ rejection as the Resident had received an organ transplant. The Physician said she was made aware of the omission on 3/19/25 when she was informed by the Cardiology RN at the hospital. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said that when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and reviews the medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said the pharmacy also completes a medication review when a resident is admitted /readmitted to the facility. Regional Nurse Consultant #1 said that when a medication error is identified, an incident report is completed and a root cause analysis is done. Regional Nurse Consultant #1 said that in regard to this specific medication error, former First Floor Unit Manager #2 was notified of the error first and then she notified Regional Nurse Consultant #1. Regional Nurse Consultant #1 said she spoke with the Cardiology RN who reported that a medication list had been sent to her and that tacrolimus was not on the Resident's medication list. Regional Nurse Consultant #1 said the Cardiology RN requested to know when the Resident had last received the medication and that his/her tacrolimus level was below goal range. Regional Nurse Consultant #1 said she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch, and he/she had not received the medication since then. Regional Nurse Consultant #1 said that staff at the facility had not identified the medication error prior to being notified by the Cardiology RN on 3/19/25. Regional Nurse Consultant #1 said that the Cardiology RN notified the facility that the Resident should be transferred to the hospital for admission for rejection surveillance. Regional Nurse Consultant #1 said as a result of the medication error, staff at the facility were reeducated on the process for medication reconciliation and that if there is a medication that they recognize a resident is no longer prescribed, they need to make note of it. During a telephonic interview on 5/7/25 at 1:39 P.M., the Physician Assistant (PA) said he was aware of the medication error and had seen Resident #40 in between his/her readmission to the facility on [DATE] and transfer back to the hospital on 3/19/25. The PA said he could not recall when he was made aware of the medication error but if he had been aware of it before the Resident was transferred back to the hospital, he would have restarted the medication at that time. The PA said he did not recall giving an order to discontinue the Resident's tacrolimus on 2/27/25. The PA said he was unaware if the results had been sent to the cardiologist because that is something the nursing staff would do and he did not follow up with nursing to ensure the results were communicated to the Resident's cardiologist. The PA further said he was unaware the Resident had not received the medication at the time the lab value was obtained. The PA said that he was aware the Resident's tacrolimus level had resulted low on 3/11/25, but was not aware the Resident had not received the medication. During an interview on 5/7/25 at 1:59 P.M., the Regional Director of Operations said that when a medication error is discovered, the Director of Nursing at the facility would oversee the investigation, education, follow-up, and any disciplinary action that may occur as a result. The Regional Director of Operations said that when there is no Director of Nursing at the facility, a Regional Nurse Consultant would be assigned to the position until a new Director of Nursing is hired. The Regional Director of Operations said that he was not aware of the medication error before being informed by the survey team on 5/7/25. During a telephonic interview on 5/7/25 at 2:03 P.M., the Cardiology RN said that Resident #40 has been followed by the cardiology team at the hospital since receiving an organ transplant years prior. She said that Resident #40 is seen every three to six months for routine clinic visits and the cardiology team communicates with the facility to obtain an updated medication list periodically, such as when the Resident returns to the facility after a hospitalization . The Cardiology RN said that after Resident #40 was discharged from the hospital on 2/27/25, she reached out to the facility that day to request an updated medication list and labs. The Cardiology RN said she ran into extensive hurdles when trying to contact a nurse or provider at the facility and attempted calls on 3/4/25, 3/5/25, and 3/18/25. The Cardiology RN said she had reviewed the medication list and tacrolimus level on 3/19/25 and noted that the Resident's tacrolimus level was virtually undetectable at 1.2 ng/ml and that the lab had been drawn on 3/6/25 and resulted on 3/11/25, but she had not been notified of the abnormal result prior. The Cardiology RN said she placed a call to the facility on [DATE] and spoke with a nurse who reported the medication had been discontinued on 2/27/25. The Cardiology RN said the Resident had gone a significant amount of time without the anti-rejection medication before she was able to speak with someone at the facility. The Cardiology RN said there was no follow-through by the facility staff and she encountered many barriers when trying to get an updated medication list from the facility. The Cardiology RN said the reason a medication list is requested is so the cardiology team can ensure the Resident is taking the anti-rejection medication and that the medication error would have been caught sooner and avoided a hospital admission if the information had been sent to her sooner. The Cardiology RN said that the medication error could have caused organ transplant rejection, which can be irreversible and could have resulted in a severe outcome. The Cardiology RN said that as a result of the medication error, the Resident required a weeklong hospital admission, testing, and intravenous steroid infusions. The surveyor attempted to contact former First Floor Unit Manager #2, but she was unable to be reached and was no longer employed at the facility.

Based on a resident group meeting, interviews, and record reviews, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group. Findings include: Review of the facility's policy titled Grievance, revised 3/22, indicated but was not limited to the following: The Resident Council is an additional forum within the facility for voicing complaints/grievances. Complaints/grievances received from this council will be acted upon by this procedure. Review of Resident Council minutes, dated 11/21/24 through 4/30/25, indicated residents voiced concerns with long call bell wait times at five out of six Resident Council meetings held. Review of the Resident Council resolution plan, dated 11/21/24, indicated audits were ongoing with no additional follow-up noted. The facility was unable to provide Resident Council resolution or follow-up for call light concerns identified in the January minutes and February minutes. During an interview on 5/5/25 at 11:14 A.M., the Resident Council President said he/she does not feel the resident group meetings are productive. He/She has said they have served as the president of the council for over a year and the most discussed concern continues to be long call bell wait times. He/She said they were not aware of any follow-up from the concerns raised at the Resident Council meetings. On 5/5/25 at 1:00 P.M., the surveyor held a group meeting with six residents in attendance. The residents shared the following information: -The concern regarding call bell wait times was brought up every month with no resolution, improvement, or follow-up from the staff on what the facility was doing to reduce call bell wait times. During an interview on 5/5/25 at 1:55 P.M., the Activities Director said if follow up was required after the meetings, she would complete a Resident Council Follow-up form and give it to the department responsible for completing. She said she would expect that the department would follow up with the Residents regarding the response. She said she could not answer any questions about Resident Council group meetings prior to 4/30/25 as she was not working at the facility. During an interview on 5/7/25 at 12:20 P.M., the Director of Operations said he expected the grievance policy to be followed completely and expected staff to follow-up on concerns brought forth at the Resident Council meetings.

Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight specific to clinical management when a Resident (#40) did not receive his/her tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) after readmission from the hospital in February 2025, resulting in abnormally low laboratory results and the Resident required emergent hospitalization and medication adjustments during and after hospitalization . Specifically, the facility administration failed to: 1. Ensure the use of laboratory services and pharmacy services, which provide ongoing support and oversight to the facility was addressed in the Facility Assessment; 2. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, safe, and effective resident care related to medication reconciliation, laboratory result reporting and communication with consulting providers; 3. Ensure an Admission Medication Regimen Review (AMRR) was completed for Resident #40 upon return to the facility after a hospitalization , resulting in Resident #40 missing a total of 40 doses of tacrolimus; and 4. Ensure a medication error was fully investigated and brought all components of the error, including missed laboratory values and AMRR, to the Quality Assurance Performance Improvement Committee. Findings include: 1. Review of the Facility Assessment, most recently updated on 4/25/25 and reviewed with the QAPI committee on 2/28/25 and 4/28/25, indicated the following: -[The facility] has established a clinical grid that outlines what our clinical capabilities are. Our admission and field liaisons staff use this grid to determine if we can meet a resident's continuing needs. The clinical team along with the corporate office are responsible for validating a competency before a new clinical competency is added to the Grid. -[The facility] accepts and cares for patients that its staff is competent to care for. The facility must be able to meet the medical, nursing, therapy and equipment needs to meet the requirements of the patients admitted . The DNS updates the Clinical Service Level of Care grid quarterly and as clinical capabilities are added under the direction of the clinical team and of the corporate office. Reviews are done throughout the year regarding whether a clinical capability needs to be added to ensure the staff is prepared. -The staff is provided with regular in-servicing opportunities and evaluations -The Staff Development Coordinator tracks required in-service to monitor compliance with requirements. Further review of the Facility Assessment indicated the facility offers services and care related to medications including awareness of any limitations of administering medications and the administration of medications that residents need. The Facility Assessment failed to indicate the use of Laboratory Services or Pharmacy Services, including how discrepancies and concerns are brought to the Administration. 2. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Further review of the medical record for Resident #40 indicated the following: -Resident #40's Medication Reconciliation, dated 2/27/25, indicated potential clinically significant medication issues were identified. The document failed to indicate what the issues were or the provider's resolutions for the issues. -Review of Resident #40's February 2025 and March 2025 MAR indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. -Resident #40's laboratory results indicated that on 3/6/25 (3 days after the recommended lab draw date), the Resident had a tacrolimus level drawn. The tacrolimus level resulted low at 1.2 ng/ml (nanograms per milliliter) on 3/11/25 at 4:06 P.M. The results were reviewed by the cardiology office on 3/19/25, 8 days after the results were reported to the facility. -Review of Resident #40's medical record failed to indicate an AMRR had been completed by a Consultant Pharmacist after the Resident returned to the facility from the hospital on 2/27/25. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said nursing staff are supposed to call and report labs to the Attending Physician or their designee and that specifically for Resident #40, the labs are also reported to the cardiology office. Review of the facility's education binder on 5/8/25 failed to indicate there was in-service education conducted on medication reconciliation, provider notification of abnormal lab results or communication with consulting providers before 3/18/25. During an interview on 5/08/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the Staff Development Coordinator (SDC). The SDC said that medication reconciliation in-servicing was conducted on 3/20/25 after discovery of a medication error but failed to provide evidence of medication reconciliation training conducted prior. 3. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. During a telephonic interview on 5/08/25 at 9:00 A.M., the Regional Pharmacy Manager said when he was doing an audit for the facility at the end of March, he noted that the AMRRs had not been completed as required in February and March 2025. The Regional Pharmacy Manager said the facility's Corporate nursing leadership (Regional Nurse #3) was notified of the issue at the beginning of April 2025 by his supervisor. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she was unaware of any MRR or AMRR discrepancies or concerns back in March or April, despite her being in the acting role of Director of Nurses. During an interview on 5/7/25 at 11:35 A.M., the Consultant Pharmacist said communication with the facility had been challenging lately because there has been a lot of turnover in management. The Consultant Pharmacist said he usually includes Regional Nurse Consultant #1 on the email that includes his report and recommendations because he is not sure who is covering. The Consultant Pharmacist said the facility's responsiveness to recommendations fluctuates from month to month. The Consultant Pharmacist said that readmissions are reviewed by another pharmacist who completes the AMRR. The Consultant Pharmacist said he could not say that he had been notified of medication errors at the facility. The surveyor attempted to contact the Regional Nurse #3, but she was unable to be reached. 4. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. A Performance Improvement Plan (PIP) was attached to the Medication Incident and Discrepancy Form and indicated medication was not administered for a resident on tacrolimus and the root cause was the medication was entered in the electronic health record incorrectly as it was entered as a one-time order. Recommendation/Action Steps on the PIP indicated all other residents on medication were reviewed to ensure that no medications were entered incorrectly, the physician and patient were aware, the transplant clinic was aware, education was provided to nursing staff, an interdisciplinary team (IDT) meeting was held to review new admission medications vs. discharge summary or new orders to ensure medications were not missed, the Resident was sent to the emergency room for evaluation, and medication errors would be tracked. The PIP failed to identify that an Admission Medication Regimen Review had not been completed by the pharmacy after the Resident returned from the hospital on 2/27/25 or that the facility staff failed to ensure the Resident's cardiology office was aware of the abnormal tacrolimus level results prior to the Cardiology RN's request for information on 3/18/25. During an interview on 5/7/25 at 1:08 P.M., the Regional Pharmacy Manager said he had conducted an audit and concluded that the AMRRs were not being completed consistently in February and March 2025. The Regional Pharmacy Manager said that the AMRRs should be completed within 72 hours of a resident's admission/readmission to the facility. The Regional Pharmacy Manager said Resident #40 had returned to the facility on [DATE], but no AMRR had been completed within 72 hours of his/her readmission. The Regional Pharmacy Manager said that had an AMRR been completed, this discrepancy would have been identified at that time. The Regional Pharmacy Manager said Resident #40 had missed 20 days of his/her twice daily tacrolimus doses and that this put the Resident at higher risk for organ rejection. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said after the medication error had been identified, she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch. Regional Nurse Consultant #1 further said the pharmacy should complete a medication review when a resident is admitted /readmitted to the facility. Regional Nurse Consultant #1 said staff at the facility had not identified the medication error prior to being notified by the Cardiology RN on 3/19/25. Regional Nurse Consultant #1 said nursing staff are supposed to call and report labs to the Attending Physician or their designee, and that specifically for Resident #40, the labs are also reported to his/her cardiology office. During an interview on 5/7/25 at 1:59 P.M., the Regional Director of Operations said when a medication error is discovered, the Director of Nursing at the facility would oversee the investigation, education, follow-up, and any disciplinary action that may occur as a result. The Regional Director of Operations said when there is no Director of Nursing at the facility, a Regional Nurse Consultant would be assigned to the position until a new Director of Nursing is hired. The Regional Director of Operations said he was not aware of the medication error before being informed by the survey team on 5/7/25. During a subsequent interview on 5/8/25 at 1:29 P.M., Regional Nurse Consultant #1 said that she did not report Resident #40's medication error to the governing body because she had handled the situation as a part of the governing body. Refer to F867 50740

Based on interview, observation, and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Investigate and address voiced grievances; and 2. Ensure residents had access to grievance/concern forms to submit grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievance, last revised 3/2022, indicated but was not limited to: -The resident and/or resident representative will be made aware of the right to voice grievances orally, in writing, and anonymously. -If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievances/Complaint Report form. -Grievances and complaints may be submitted orally or in writing. The resident, and/or health care representative, or the person filing the grievance or complaint on behalf of the resident, should be encouraged to sign written complaints or grievances. If the person filing the grievance is anonymous or wishes to remain anonymous, confidentiality will be maintained, to the extent possible. During a tour of the facility on 5/5/25 at 8:00 A.M., the surveyor was unable to find any information regarding the grievance process posted in resident care areas. The surveyor observed information regarding how to file grievance in the main lobby which was not accessible to all residents. Review of the facility grievance binder on 5/4/25 at 2:30 P.M., indicated the last grievance was resolved on 3/31/25. On 4/7/25 at 1:00 P.M., the surveyor held a resident group meeting with six residents, representing each of the facility's two units, in attendance. The residents said they had not seen any postings about the grievance process and did not know how to file a grievance. The residents said the only way they knew how to submit a grievance was to report the problem to a staff member. One resident said he/she thought they saw grievance forms by the elevator but was not sure and did not know who the grievance officer was. During an interview on 5/5/25 at 4:37 P.M., the Administrator said he had been in the Administrator role for about one month and was unsure about the grievance process prior to his tenure. The Administrator said he expected any staff member responsible for resolving a grievance to follow up with residents about that grievance and to discuss the outcome. The Administrator said the facility's grievance officer and the person responsible for keeping track of the grievance process was the social worker. During an interview on 5/6/25 at 11:09 A.M., the Ombudsman said she reported concerns and grievances to administration, however, she was unsure if reported concerns were being addressed or handled as a grievance. The Ombudsman said the facility had not provided her with any updates or resolutions for the concerns she reported. The Ombudsman said, similarly, the residents she had been communicating with were also not updated on their reported concerns and grievances. During an interview on 5/6/25 at 11:59 A.M., the Social Worker said the Administrator was the grievance officer for the building. The Social Worker said she gave resident concerns and grievance forms to the Administrator. During an interview on 5/5/25 at 1:55 P.M., the Activities Director said she was unsure who the facility grievance officer was, and she was unsure who was responsible for providing residents with grievance updates and resolutions.

Based on interview and record review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASARR) for one Resident (#35), out of a total sample of 18 residents, resulting in Resident #35 being admitted to the facility without the determination of whether he/she screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation. Findings include: Resident #35 was admitted to the facility in February 2025 with diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. Review of Resident #35's Minimum Data Set (MDS) assessments indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the assessments listed multiple other mental health diagnoses upon admission to the facility. Review of Resident #35's Level I PASARR indicated: -The Level I PASARR was submitted for review after admitting into the facility. -The Resident subsequently required a Level II PASARR evaluation to be completed. Review of the Resident's record indicated that a Level II PASARR evaluation was completed on 3/4/25 and the Resident met the criteria for SMI and specialized services and/or behavioral health services were required to meet the needs of the Resident while in the nursing facility. During an interview on 5/6/25 at 11:59 A.M., Social Worker #1 said the Level I PASARR should be completed prior to a resident's admission to ensure that the facility is able to meet the needs of the residents. Social Worker #1 said she was not here at the time Resident #35 was admitted and was unable to find documentation the Level I PASARR was submitted prior to Resident #35's admission to the facility. During an interview on 5/6/25 at 3:54 P.M., the Director of Operations said there was no additional information or evidence to provide to indicate the Level I PASARR was completed prior to admission. He said it is the expectation for staff to complete Level I PASARRs for residents before they are admitted into the facility.

Based on document review and interview, the facility failed to ensure residents were provided Physician/Nurse Practitioner (NP)/Physician's Assistant (PA) visits every 30 days within the first 90 days of admission and then every 60 days thereafter for two Residents (#65 and #30), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #65, to ensure the Resident was seen by a Physician within 30 days of his/her admission to the facility; and 2. For Resident #30, to ensure required visits alternated between the Physician and NP. Findings include: Review of the facility's policy titled Physician Services and Discipline Recommendations, dated as revised March 2022, indicated but was not limited to the following: Policy Statement: The medical care of each resident is under the supervision of a Licensed Physician; Policy Interpretation and Implementation: -The physician will perform pertinent, timely medical assessments; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage; -Physician visits, frequency of visits, emergency care of residents, etcetera, are provided in accordance with current Omnibus Budget Reconciliation Act (OBRA, a series of laws passed by Congress which set minimum standards of care for nursing homes) regulations and facility policy. 1. Resident #65 was admitted to the facility in June 2024 with diagnoses which included spinal cord injury and paraplegia. Review of Resident #65's physician progress notes and assessments indicated he/she had not been seen by a physician until 11/8/24, five months after his/her admission. On 5/6/25 at 4:49 P.M., the Regional Director of Operations provided the surveyor with Resident #65's provider notes. Review of the provider notes failed to include a physician visit prior to 11/8/24. During an interview on 5/7/25 at 9:05 A.M., the Regional Director of Operations (RDO) said there was no evidence Resident #65 had been seen by a physician prior to 11/8/24 and the facility had no additional documentation to provide. The RDO said new admissions should be seen by a physician within 30 days. 49428 2. Resident #30 was admitted to the facility in November 2020 with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, dysarthria following cerebral infarct, hemiplegia and hemiparesis, pain, and major depressive disorder. Review of Physician progress notes and assessments indicated Resident #30 had not been seen by a Physician during the timeframe of 6/4/24 through 12/19/24, for a total of 199 days. During an interview on 5/7/25 at 9:00 A.M., the RDO reviewed Resident #30's Physician's notes and said the Physician must see residents every 60 days; visits can alternate between the Physician and NP/PA. The RDO said during the 199-day period from June to December 2024, Resident #30 was not visited by the Physician every 60 days and visits during that time did not alternate between the Physician and the NP/PA. The RDO said the Resident should have been seen more frequently by the Physician.

Based on observation, interview, and record review, the facility failed to implement the person-centered plan of care for two Residents (#20 and #69), out of 18 sampled residents. Specifically, the facility failed to: 1. Implement the care plan for Resident #20 which indicated that the Resident required two staff for all care; and 2. Follow the plan of care for Resident #69 to wear eyeglasses. Findings include: 1. Resident #20 was admitted to the facility in June 2023 with diagnoses including but not limited to cerebral infarction. Review of Resident #20's care plan indicated but was not limited to: Focus: Behavior problems, sexually inappropriate and accusatory, revised 8/1/23; Goal: Resident will have fewer episodes of accusations and sexually inappropriate statements, revised 5/24/24; Interventions: 2 people always, date initiated 8/1/23. On 5/5/25 at 9:23 A.M., the surveyor observed Resident #20 in their wheelchair being brought out of his/her room by Certified Nursing Assistant (CNA) #3. During an interview with observation on 5/5/25 at 9:23 A.M., CNA #3 said she completed the Resident's care by herself, and that the Resident hadn't had any recent behaviors that she was aware of. She said she had recently provided care to him/her by herself before with no issues. During an interview on 5/6/25 at 8:33 A.M., Unit Manager #1 said Resident #20 still required two people for all care because he/she had a history of accusatory behaviors and could be sexually inappropriate. She said, as an example, the Resident would say staff did something that they didn't do, therefore two people for all care was to protect the Resident and the staff providing care from unfounded accusations. During an interview with on 5/6/25 at 8:38 A.M., CNA #4 said she took care of the Resident last week by herself on the 7 A.M. to 3 P.M. shift and most recently she had cared for the Resident on the 3 P.M. to 11 P.M. shift by herself. She said the Resident was very nice and she had no issues providing care to the Resident by herself with no other staff present. During an interview on 5/6/25 at 12:10 P.M., the Director of Nurses (DON) said CNAs should have access to the information in the electronic health record regarding residents who require two staff members and staff should be following a resident's care plan at all times. The DON said she expected staff to implement Resident #20's care plan requiring two staff members present at all times during Resident care. 36542 2. Resident #69 was admitted to the facility in February 2024. Review of the Minimum Data Set (MDS) assessment, dated 2/21/25, indicated Resident #69 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had a moderate cognitive impairment. Review of the MDS indicated Resident #69 had impaired vision and wore corrective lenses. During an interview on 5/4/25 at 10:15 A.M., Resident #69 said he/she could not see the surveyor because they did not have their glasses and was not sure where they were. Review of a care plan for Resident #69, initiated on 2/17/24, indicated Resident #69 had impaired visual function, with a goal of using appropriate visual devices (glasses) to promote participation in activities of daily living and other activities with a target date of 5/22/25. The care plan indicated the following interventions: ensuring glasses are available to support participation in activities, ensure Resident is wearing glasses which are clean, free from scratches and in good repair and to report any damage to the nurse and family. On 5/5/25 at 11:30 A.M., the surveyor observed Resident #69 in the unit day room, not wearing eyeglasses. During an interview on 5/5/25 at 12:05 P.M., CNA #1 said she was the assigned CNA for the Resident on this day. She said the staff switch assignments every month and had just switched in May and could not recall if Resident #69 wore glasses. During an interview on 5/5/25 at 12:06 P.M., CNA #2 said she was familiar with Resident #69 and could not recall if the Resident wore glasses. During an interview on 5/5/25 at 1:15 P.M., Unit Manager #1 said she had been the Unit Manager on this unit for about a year and a half. Unit Manager #1 said Resident #69 did not wear glasses. When the surveyor inquired about the care plan and the MDS indicating Resident #69 wore glasses, the Unit Manager said the Resident has glasses but does not wear them and the glasses must be in the Resident's room. During an interview on 5/5/25 at 1:40 P.M., Unit Manager #1 said she looked in the Resident's room and was unable to locate the Resident's glasses and would need to call the Resident's son to follow up. She said the staff do not keep eyeglasses in the medication cart and she was not sure where else they could be. The surveyor inquired about plastic drawers on the desk at the nurses' station, one with a drawer labeled glasses. She said those were glasses that were unlabeled so they were not sure who they belonged to. The surveyor opened the drawer labeled scrap paper and found four pairs of glasses, one labeled with a current resident's name. The surveyor opened the drawer labeled glasses and found 7 pairs of glasses, one labeled with a current resident's name. During an interview on 5/5/25 at 5:00 P.M., the Unit Manager said she spoke with the Resident's son who said the Resident's glasses had been missing and he would like assistance in getting the Resident a new pair. The Unit Manager said at care plan meetings the team reviews family concerns or any issues that have occurred throughout the quarter but they do not review each individual care plan. She said she, as the unit manager, will add a new target date to the care plans, but must have missed that Resident #69 had glasses. During an interview on 5/5/25 at 6:55 P.M., the son/Health Care Proxy of Resident #69 said the Resident had been at the facility for a little over a year. He said the Resident was wearing eyeglasses until about 2 months ago when the eyeglasses went missing; he could not be sure of the exact timeframe. He said he had come in one day and the glasses were gone; he had left a note for Unit Manager #1, had asked the staff, had checked with laundry and was unable to locate the glasses. He said he felt the facility was working on finding the glasses or replacing them, but he was not sure what the plan was.

Based on document review and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP), including a corrective action plan with effective monitoring for delayed laboratory result reporting, readmission medication reconciliation, and pharmacy Admission Medication Regimen Review (AMRR) after admission/readmission. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, revised 4/2022, indicated, but was not limited to, the following: -The facility has a Quality Assurance/Performance Improvement (QAPI) Program which systematically monitors, analyzes, and improves its performance to improve resident outcomes. -The QAPI committee will consist of the Administrator, Director of Nursing Services, a physician designated by the center and at least three other members of the facility staff. These additional members may include representation from nursing, dietary, housekeeping, laundry, maintenance, health information management, activities, and staff education. -Our QAPI plan addresses: *Clinical Care monitor existing QI/Q (Quality Improvement/Quality) results, intention monitors for falls, medication errors, pressure ulcers, incident reports, infection reports. Center Leadership, including, but not limited to Administrator and Director of Nursing meets at least quarterly with Medical Director and others to address care concerns. -Review of State/National and past facility measures will be used to benchmark for improvement in all areas. These benchmarks will be reviewed at least quarterly, and reported to the QAPI Committee on a quarterly basis. -The Administrator is responsible and accountable for developing, leading, and closely monitoring a QAPI program. *Input is obtained from facility staff on a quarterly basis through members of the QAPI Committee through ongoing dialogue with employees. Department heads are responsible for talking to their employees before reporting into QAPI. Residents and families have input through resident and family committee or queries. *The input given is acted upon and brings QAPI to life in the facility. Concerns are brought up when a certain department or task is not hitting benchmark. The concern is discussed and an action plan is developed. -The information gathered is analyzed and compared to benchmarks and/or targets established by the facility. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and organ transplant. Review of Resident #40's Physician's Orders indicated, but was not limited to, the following: -Fax Tacrolimus, CBC w/ diff (Complete Blood Count, a blood test that measures various components of your blood, helping to diagnose and monitor numerous health conditions), and CMP (Comprehensive Metabolic Panel, a blood test that measures 14 different substances in your blood, providing important information about your body's metabolism and the functioning of various organs, particularly the liver and kidneys), results to [fax number redacted] every shift starting on the 7th and ending on the 11th of every month for immunosuppressive therapy (order start date 7/10/24) -On 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated a phone order was obtained from the Physician Assistant (PA) to discontinue the medication on 2/27/25 at 6:05 P.M. -No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. -The Physician's Orders failed to indicate an order was obtained for a tacrolimus level on 3/3/25 related to abnormal tacrolimus level and tacrolimus dosing adjustments during hospitalization as indicated in the Resident's hospital After Visit Summary 2/27/25. Further review of Resident #40's medical record indicated that on 3/6/25, the Resident had a tacrolimus level drawn (3 days after the recommended draw date). The tacrolimus level resulted low at 1.2 ng/ml on 3/11/25 at 4:06 P.M. and were marked as reviewed by the Physician Assistant (PA) on 3/13/25 at 12:45 P.M. The medical record failed to indicate the lab values were faxed to the heart failure team for recommendations for ongoing dosing of tacrolimus. Review of Resident #40's Progress Notes indicated that on 3/19/25, a Progress Note was entered by the physician. The medication list in the physician's note indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, and hospital discharge summary were reviewed. The physician documented that the Resident had received an organ transplant in 2021 and she was contacted by the hospital's Transplant Coordinator in regards to his/her low tacrolimus level of 1.2 ng/ml. The note indicated the Transplant Coordinator had discussed the Resident's medication regimen with staff at the facility and it appeared the Resident had missed his/her tacrolimus since he/she was readmitted to the facility on [DATE] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff the Resident had not received tacrolimus and was later informed that the Transplant Coordinator had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Review of Resident #40's medical record failed to indicate that an Admission Medication Regimen Review (AMRR) had been completed by a Consultant Pharmacist after the Resident returned to the facility from the hospital on 2/27/25. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. The Form indicated that the Resident's transplant clinic had noted the medication was missing from the Resident's medication list. In the section of the Form titled Outcome of Investigation, it is noted the medication was not administered and was entered as a one-time administration. A Performance Improvement Plan (PIP) attached to the Medication Incident and Discrepancy Form indicated medication was not administered for a resident on tacrolimus and the root cause was the medication was entered in the electronic health record incorrectly as it was entered as a one-time order. Recommendation/Action Steps on the PIP indicated all other residents on medication were reviewed to ensure that no medications were entered incorrectly, the physician and patient were aware, the transplant clinic was aware, education was provided to nursing staff, an interdisciplinary team (IDT) meeting was held to review new admission medications vs. discharge summary or new orders to ensure medications were not missed, the Resident was sent to the emergency room for evaluation, and medication errors would be tracked. An Education Sheet included with the Medication Incident and Discrepancy Form indicated education was provided on going through medications with patient and family member/HCP (health care proxy) on 3/20/25. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said after the medication error had been identified, she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch. Regional Nurse Consultant #1 said as a result of the medication error, staff at the facility were reeducated on the process for medication reconciliation and if there is a medication they recognize a resident is no longer prescribed, they need to make note of it. During a telephonic interview on 5/7/25 at 2:03 P.M., the Cardiology RN said that Resident #40 has been followed by the cardiology team at the hospital since receiving an organ transplant years prior. She said that Resident #40 is seen every three to six months for routine clinic visits and the cardiology team communicates with the facility to obtain labs and an updated medication list periodically, such as when the Resident returns to the facility after a hospitalization . The Cardiology RN said that after Resident #40 was discharged from the hospital on 2/27/25, she reached out to the facility that day to request an updated medication list and labs. The Cardiology RN said she ran into extensive hurdles when trying to make contact with a nurse or provider at the facility. The Cardiology RN said she had received the medication list and tacrolimus level on 3/19/25 and noted that the Resident's tacrolimus level was virtually undetectable at 1.2 ng/ml and that the lab had been drawn on 3/6/25 and resulted on 3/11/25, but she had not been notified of the abnormal result prior. The Cardiology RN said the Resident had gone a significant amount of time without the anti-rejection medication before she was able to speak with someone at the facility. The Cardiology RN said there was no follow-through by the facility staff and she encountered many barriers when trying to get an updated medication list and lab results from the facility. The Cardiology RN said that the medication error could have caused organ transplant rejection, which can be irreversible and could have resulted in a severe outcome. The Cardiology RN said that as a result of the medication error, the Resident required a weeklong hospital admission, testing, and intravenous steroid infusions. On 5/7/25 at 3:22 P.M., the surveyor reviewed the 3/20/25 Education Sheet included with the Medication Incident and Discrepancy Form with nurses on the First Floor unit. Nurse #4 reviewed the Education Sheet confirmed her signature was on it. Nurse #4 said she thought the education was related to explaining the medication regimen to a resident at time of discharge from the facility and it was a general education, not specific to a certain resident. Nurse #4 said if the education was specific to a resident, the resident's initials would be on the Education Sheet and there were no initials on the 3/20/25 Education Sheet. Nurse #2 said he did not recall any education or in-servicing specifically related to Resident #40 and his/her medications. On 5/7/25 at 3:30 P.M., the surveyor reviewed the 3/20/25 Education Sheet with Unit Manager #1. Unit Manager #1 reviewed the Education Sheet and confirmed her signature was on it. Unit Manager #1 said she thought the education was related to when a Resident or their family member wanted the staff to review the Resident's medications with them. Unit Manager #1 said if the education was specific to a resident, the resident's initials would be on the Education Sheet and there were no initials on the 3/20/25 Education Sheet. Unit Manager #1 said she did not recall any education being done on admission/readmission medication reconciliation procedures. During an interview on 5/8/25 at 10:52 A.M., the Regional Director of Operations said the PIP implemented as a result of the identified medication error was reviewed at the last monthly QAPI meeting. The Medication Incident and Discrepancy Report Form and PIP failed to indicate the facility had failed to obtain the Resident's tacrolimus level on 3/3/25 as recommended in the hospital After Visit Summary, failed to ensure the abnormal tacrolimus level results reported to the facility on [DATE] and reviewed by the PA on 3/13/25 were addressed, failed to indicate a breakdown in communication between facility staff and the Resident's consulting cardiology clinic, and failed to indicate the pharmacy AMRR had not been completed after the Resident returned to the facility on [DATE]. The PIP also failed to include any identified benchmarks or targets established by the facility for monitoring of performance improvement activities.

Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Quarterly MDS assessment within the required timeframe for five Residents (#49, #63, #1, #4, and #27), out of five residents reviewed for overdue assessments. Findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. A Quarterly MDS assessment is considered timely if the Assessment Reference Date (ARD) of the Quarterly MDS is completed within 92 days of the most recent OBRA Assessment reference date (Admission, Annual, Quarterly, or a Significant Change in Status Assessment), and the completion date must be no later than 14 days after the ARD. 1. Resident #49 was admitted to the facility in April 2021. Review of Resident #49's quarterly MDS assessment, dated 3/19/25, indicated it was not completed until 5/1/25, a total of 30 days late. 2. Resident #63 was admitted to the facility in September 2023. Review of Resident #63's quarterly MDS assessment, dated 3/19/25, indicated it was not completed until 5/1/25, a total of 30 days late. 3. Resident #1 was admitted to the facility in January 2023. Review of Resident #1's quarterly MDS assessment, dated 3/26/25, indicated it was not completed until 5/4/25, a total of 26 days late. 4. Resident #4 was admitted to the facility in July 2022. On 5/5/25, the surveyor reviewed Resident #4's quarterly MDS assessment, dated 4/2/25, which indicated the assessment had not been completed. 5. Resident #27 was admitted to the facility in October 2023. On 5/5/25, the surveyor reviewed Resident #27's quarterly MDS assessment, dated 3/26/25, which indicated the assessment had not been completed. During an interview on 5/5/25 at 1:00 P.M., the Regional Nurse reviewed the MDS assessments and said the assessments for Residents #49, #63, #1, #4, and #27 had not been completed within 14 days of the ARD. The Regional MDS Nurse said quarterly MDS assessments should be completed within 14 days of the ARD.

Based on observation and interview, the facility failed to ensure nurse staffing information which included the current date and actual hours worked per shift for licensed and unlicensed staff including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA) was posted daily as required. Findings include: On 5/4/25 at 7:46 A.M. and 10:23 A.M., the surveyor observed a nurse staffing document posted in the main lobby on top of the receptionist's desk. Review of the Nurse staffing document indicated it was dated 5/2/25. During an interview on 5/7/25 at 3:25 P.M., the Receptionist said the Scheduler leaves the completed nurse staff documents at the desk for the receptionist to change out each morning. The Receptionist said the Nurse staffing document should be updated every morning. During an interview on 5/7/25 at 3:39 P.M., the Scheduler said she was responsible for preparing the nurse staffing document and leaves the completed documents at the receptionist desk. The Scheduler said on Friday evenings she prepares the weekend sheets and leaves them for whoever is working Saturday and Sunday mornings. The Scheduler said the documents should be changed out first thing in the morning.

Based on documentation review and interview, the facility failed to provide training and education to all their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, revised 4/2022, indicated, but was not limited to, the following: -Small group education sessions on QAPI are provided to all caregivers working in the building. QAPI is also part of orientation for new staff members joining the team. -Administrator is responsible to ensure ongoing orientation, education and training on QAPI. In addition, as part of annual evaluations, staff members are expected to answer questions regarding performance improvement and how QAPI is used in operations of the facility. Review of five education records (including the electronic training system) for direct care staff, which included two nurses, a unit manager, a social worker, and the staff development coordinator, failed to indicate QAPI training had been completed for five out of the five education records reviewed. During an interview on 5/8/25 at 11:18 A.M., Nurse #1 said she was not familiar with the facility's QAPI program. She said she was not sure what the goals of the program were or what her role in it was. She said she had not received any training on the QAPI program. During an interview on 5/8/25 at 11:20 A.M., Unit Manager #2 said she attended the QAPI meetings but could not recall any in-servicing or education she completed in relation to the process. During an interview on 5/8/25 at 11:28 A.M., the Social Worker said she completed all her training online and there was not any information related to the QAPI program during orientation or after she was hired. During an interview on 5/8/25/ at 1:59 P.M., Nurse #2 said he had not received any training or orientation to the QAPI program. During an interview on 5/8/25 at 11:59 A.M., the Staff Development Coordinator said she recently attended orientation upon hire in February 2025 and did not recall completing any training on the facility's QAPI program. She said that she believed there was a slide in the orientation PowerPoint presentation that informed staff of the program but could not recall any details. The Staff Development Coordinator said she did not review QAPI with staff during orientation.

Based on records reviewed and interviews for two of three sampled residents' (Resident #1 and #2) who were both assessed as requiring psychiatric interventions and evaluations, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when recommendations made by psychiatric services for both residents, were not followed up on timely by nursing. Findings include: Review of the Facility Policy titled Physician Services and Discipline Recommendations, dated as revised 3/2022, indicated that the medical care of each resident is under the supervision of a licensed physician. The Policy indicated that the attending physician will determine the relevance of any recommended interventions form any discipline, however in not obligated to accept these recommendations if he/she has clinically valid reason for not doing so. 1) Resident #1 was admitted to the Facility in June 2024, diagnoses include Parkinson's Disease, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Urinary Tract Infection (UTI), and hypokalemia (low levels of potassium in the blood). Review of Resident #1's Physician's Order, dated 09/08/24, indicated to administer Hydroxyzine HCl (antihistamine, can be used to control anxiety and tension caused by nervous and emotional conditions) tablet 50 milligrams (mg), give 50 mg by mouth two times a day. Review of Resident #1's Initial Psychiatric Consult, dated 09/23/24, indicated he/she had been referred for a psychiatric evaluation related to a generalized anxiety disorder and the use of Melatonin and Hydroxyzine. The Consult (written by the Psychiatric Nurse Practitioner) also indicated the following medication recommendation: -Start Sertraline (Zoloft, an antidepressant) 25 mg daily for anxiety. Review of Resident #1's Medical Records, dated 09/23/24 through 10/31/24, indicated that there was no documentation to support that his/her physician had been notified of the psychiatric consult recommendation. 2) Resident #2 was admitted to the Facility in May 2019, diagnoses include dementia, malnutrition, anxiety, depression, and psychotic mood disturbance. Review of Resident #2's Physician Order, dated 07/19/24, indicated that his/her Health Care Proxy had been activated. Review of Resident #2's Initial Psychiatric Consult, dated 09/23/24, indicated to he/she had been referred for a psychiatric evaluation related to insomnia, psychotic disturbances, and adjustment disorder and the use of Trazadone (antidepressant) for sundowning. The Consult (written by the Psychiatric Nurse Practitioner) also indicated the following medication recommendation: -Add Citalopram (Celexa, antidepressant) 10 mg daily for depression. Review of Resident #2's Medical Record, dated from 09/23/24 through 10/08/24, indicated that there was no documentation to support that his/her physician had been notified of the psychiatric consult recommendation prior to 10/09/24, when his/her Physician conducted a visit. Review of Resident #2's Physician Progress Note, dated 10/09/24 (16 days after the recommendation had been made), indicated that he/she had been seen by a psychiatric provider (09/23/24) who had recommended adding Celexa to his/her medication regimen and the Physician agreed with the recommendation to add Celexa. During an interview on 10/31/24 at 1:51 P.M., Nurse #2 said that recommendations made by any provider, including psychiatric services, get e-mailed to the management team, management prints out the recommendations and gives them to the Unit Manager to follow through with. During an interview on 10/31/24 at 2:14 P.M., the Unit Manager said that she did not know that there were recommendations that had not been followed up on for Resident #1. The Unit Manager said that all recommendations get e-mailed to the Director of Nurses (DON) or the Unit Manager and then the Unit Manager or a Nurse will follow through with contact the Provider and address any recommendations. During an interview on 10/31/24 at 1:35 P.M., the Director of Nurses (DON) said that she did not know that the psychiatric recommendations for Resident #1 had not been addressed. The DON said that it is the Facility's expectation that all recommendations from any provider, including psychiatry, are sent to me by e-mail and then are given to the Unit Manager to follow up with the resident's provider in a timely manner.

Based on record review and interviews for one of three sampled residents (Resident #1) the Facility failed to ensure that Resident #1 was safely transferred with the approved standard mechanical lift pad, and on 10/13/11 at approximately 6:30 PM, staff used an incontinence lift pad that staff were unfamiliar with, Resident #1 fell through the lift pad onto the floor, and Resident #1 sustained a laceration to the back of the head. Certified Nurse Aide (CNA) #1 and CNA #2 said the incontinence lift pad was smaller than the standard pad and had an opening in the middle and CNA #1 and CNA #2 were not inserviced on how to use the mechanical lift pad. The Hospital records, dated 10/13/11, indicated that Resident #1 required one suture to close the one centimeter (cm) laceration. Findings include: Resident #1 was admitted to the Facility August of 2000, and [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 8/10/11, indicated that Resident #1: required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene; required total care for locomotion on the unit, dressing, eating, and bathing, and had no previous falls. The care plan, dated 8/24/11, indicated that Resident #1 was at risk to fall and care plan interventions included transfer with two staff and mechanical lift. The nurse's note, dated 10/13/11, indicated that Resident #1 fell , was assessed by the Physician who was at the Facility and was transferred to the Hospital for evaluation. CNA #1 and CNA #2 were interviewed on 10/27/11, CNA #1 at 2:30 PM and CNA #2 at 2:50 PM. CNA #1 and CNA #2 said on 10/13/11 at approximately 6:30 PM, CNA #1 and CNA #2 assisted Resident #1, who was sitting in the wheelchair, back to bed by using the mechanical lift. CNA #1 and CNA #2 said the mechanical lift pad was not in the wheelchair so they had to put the pad under Resident #1, who was sitting up in the wheelchair. CNA #2 said the mechanical lift pad that was in the room was not the usual pad that they used with the mechanical lift, the pad was flimsy and appeared unsafe, so CNA #2 asked Nurse #1 about the pad. CNA #2 said that nurse #1 said that was the pad Resident #1's family member wanted the staff to use for Resident #1. CNA #1 and CNA #2 said they adjusted the pad in the wheelchair, crossed the bottom of the pad and attached the pad to the mechanical lift. CNA #1 and CNA #2 said as they raised Resident #1 up in the mechanical lift, the lift pad went over Resident #1's head, Resident #1's legs went up in the air, Resident #1's buttocks went through the opening in the lift pad, and Resident #1 fell on to the floor. Nurse #1 was interviewed on 10/27/11 at 3:20 PM. Nurse #1 said on 10/13/11 at approximately 6:30 PM, Resident #1 fell through the opening of the mechanical lift pad. Nurse #1 said that Nurse #1 assessed Resident #1 for injuries which included a head laceration, the Physician was in the Facility and assessed Resident #1, who was sent to the Hospital for evaluation. Nurse #1 said the mechanical lift pad was a new pad that staff were unfamiliar with, and Nurse #1 was not sure who recommended the new mechanical lift pad. CNA #3 was interviewed on 10/27/11 at 10:15 AM. CNA #3 said that CNA #3 also used the mechanical lift pad, that was used for incontinence care, for Resident #1 once and was never inserviced on how to use the pad. The Hospital records dated 10/13/11, indicated that Resident #1 had x-rays of the head and cervical spine that were negative for injury and required one suture to close a one centimeter (cm) laceration. The DON was interviewed on 10/27/11 at 8:20 AM. The DON said the DON had no idea where the (incontinence) mechanical lift pad came from, who ordered the pad, and who recommended using the mechanical lift pad.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received the anticoagulant medication, [MEDICATION NAME] (blood thinner) every 12 hours as ordered by the physician. Nurse #1 incorrectly transcribed the administration times of [MEDICATION NAME] as every six hours, instead of every 12 hours. The Director of Nurses and Unit Manager #1 said, due to the transcription error, Resident #1 received three extra doses of [MEDICATION NAME] 60 mg from 9/30/11 at 6:00 PM to 10/2/11 at 6:00 AM. The nurse's note, dated 10/2/11, indicated that Resident #1 experienced oral bleeding, had loose tarry stools, dry pink blood was noted on Resident #1's underwear, and Resident #1 was admitted to the Hospital due to bleeding, [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Findings include: The Face Sheet indicated that Resident #1 was admitted to the Facility September 2011, with [DIAGNOSES REDACTED]. The Hospital Discharge Summary, dated 9/30/11, indicated that Resident #1 received the anticoagulant medication, [MEDICATION NAME] five milligrams (mg) by mouth daily and [MEDICATION NAME] 60 mg. subcutaneously (SC) every twelve hours to achieve an international normalized ratio (INR: a laboratory test to determine clotting tendency of blood) of 2.5 (therapeutic range 2.3-3.0). The Hospital Discharge Summary also indicated once Resident #1's INR reached 2.5 or above, [MEDICATION NAME] was to be discontinued. The physician's orders [REDACTED]. The nurse's note written on admission, dated 9/30/11 at 5:00 P.M., indicated that Resident #1 had no bruises and no bleeding noted when admitted to the Facility. The nurse's note indicated that Resident #1's health condition was stable. The Admission Assessment, dated 9/30/11, indicated that the physician's orders [REDACTED]. The order was correctly transcribed to the Medication Administration Record (MAR) as "[MEDICATION NAME] 60 mg every twelve hours subcutaneously ." However, Nurse #1 incorrectly transcribed the administration times as every six hours instead of every 12 hours. Further review of the MAR indicated that Resident #1 received [MEDICATION NAME] as followes: 9/30/11, [MEDICATION NAME] 60 mg was administered to Resident #1, SC at 6:00 P.M. 10/1/11, [MEDICATION NAME] 60 mg was administered to Resident #1, SC at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M 10/2/11, [MEDICATION NAME] 60 mg was administered to Resident #1, SC at 12:00 A.M. and 6:00 . A.M. Nurse #1 was interviewed at 1:05 P.M. on 10/20/11. Nurse #1 said Nurse #1 admitted Resident #1 to the Facility. Nurse #1 said Nurse #1 made an error when transcribing the physician's orders [REDACTED].M., 12:00 P.M., 6:00 P.M. and 12:00 A.M. Nurse #1 said Nurse #2 was assigned to Resident #1 for the evening on 9/30/11. Nurse #1 said Nurse #2 administered the first dose of [MEDICATION NAME] at 6:00 P.M. on 9/30/11 to Resident #1. Nurse #2 was interviewed at 11:25 A.M. on 10/20/11. Nurse #2 said Nurse #2 did not read the transcription of the order on the MAR. Nurse #2 said Nurse #2 looked at the administration times written and administered the [MEDICATION NAME] dose to Resident #1 at 6:00 P.M on 9/30/11. Nurse #3 was interviewed at 9:10 A.M. on 10/20/11. Nurse #3 said at 12:00 A.M. Nurse #2 told Nurse #3 that Resident #1 was due for a dose of [MEDICATION NAME]. Nurse #3 said Nurse #3 looked at the MAR and read the administration times written down as 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. while the order was transcribed as [MEDICATION NAME] sixty milligrams every twelve hours. Nurse #3 said Nurse #3 did not refer to the physician's orders [REDACTED]. Nurse #3 said Nurse #3 altered the transcribed order from the MAR to read "every six hours." Nurse #3 said Nurse #3 administered the [MEDICATION NAME] to Resident #1 at 12:00 A.M. on 10/1/11 and at 6:00 A.M. on 10/1/11, subsequently, Nurse #4, administered [MEDICATION NAME] 60 mg subcutaneously to Resident #1 at 12:00 P.M. on 10/1/11, Nurse #5 administered [MEDICATION NAME] 60 mg subcutaneously to Resident #1 at 6:00 P.M. on 10/1/11, and Nurse #6 administered [MEDICATION NAME] 60 mg subcutaneously to Resident #1 at 12:00 A.M. and 6:00 A.M. on 10/2/11. A nurse's note, dated 10/2/11 for the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #1 was observed with bleeding gums after brushing teeth. The nurse's note indicated that Resident #1's gum bleeding was stopped after rinsing Resident #1's mouth with cool water. The nurse's note indicated that the physician was notified and an order was obtained for an immediate complete blood count (CBC) and an INR. The nurse's note indicated that Resident #1's oral bleeding reoccurred at approximately 10:30 A.M., and Resident # 1 had loose tarry stools (a sign of hemorrhage in the stomach or small intestine) and dry pink blood was noted on Resident #1's underwear. The nurse's note indicated that the physician was notified and a new order was obtained to send Resident #1 to the Hospital to be evaluated. The Nurse's note indicated that Resident #1 was admitted to the Hospital due to bleeding, [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. The 5-day Minimum Data Set assessment, dated 10/07/11, indicated that Resident #1 had short-term memory impairment. The MDS indicated that Resident #1 had internal bleeding. The Director of Nurses (DON) was interviewed at 11:00 A.M. on 10/20/11. The DON said the DON interviewed nursing staff about the three extra doses of [MEDICATION NAME] administered to Resident #1. The DON said nursing staff told the DON that nursing staff did not check the physician's orders [REDACTED]. The DON said Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #6 confirmed administering [MEDICATION NAME] to Resident #1 without verifying the physician's orders [REDACTED]. Unit Manager #1 was interviewed on 10/20/11 at 10:10 AM., Nurse #1 was interviewed on 10/20/11 at 1:05 P.M., Nurse #2 was interviewed on 10/20/11 at 11:25 A.M., Nurse #3 was interviewed on 10/20/11 at 9:10 A.M., Nurse #4 was interviewed on 10/24/11 at 2:01 P.M., Nurse #5 was interviewed on 10/20/11 at 1:35 P.M., and Nurse #6 was interviewed on 10/20/11 at 2:15 P.M. Unit Manager #1, The DON, Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5 and Nurse #6 said that the order for [MEDICATION NAME] every 12 hours was correctly written, however, the administration times were incorrectly transcribed as every six hours instead of every twelve hours.

Based on record review, observation and staff and resident interview, the facility failed to insure that services being provided met professional nursing standards for three residents (#1, #4 and #6) in a total sample of 18. For Resident's #1, #4 and #6 the facility failed to rotate daily subcutaneous injection sites consistent with nursing standards of practice. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." Please refer to the "Nursing 2011 Drug Handbook" for accepted standards in regards to proper medication administration along with nursing considerations of drug administration issues. Findings are as follows: 1. For Resident #4 the facility failed to rotate daily anticoagulant subcutaneous injection sites on the abdomen consistent with standards of practice and facility policy.. The resident had been receiving daily injections of anticoaguilant medication since admission for approximately a 6 month duration. Resident #4 was admitted to the facility in April 2011 and had [DIAGNOSES REDACTED]. Review of the facility's policy for anticoagulant subcutaneous injections indicated that the injection site was to be rotated in a "U" shape pattern. The policy stated, "DO NOT (emphasis as written) inject in the same place each time. Alternate the site from the left and right sides." The policy also required documentation of "the site where the injection was given." Review of the Medication Administration Records for April, May, June, July, August and September 2011 revealed no documentation of, or limited documentation of the injection sites for each administration of the medication. The resident developed two painful, protruded areas which the physician attributed to the daily anticoagulant injections. (Please refer to F 309 #1.) 2. The facility failed to follow their own policy by neglecting to rotate subcutaneous injection sites when administering an anticoagulant to Resident #6. The resident had been receiving the anticoagulant [MEDICATION NAME] injections every 12 hours for approximately a 6 month duration. Review of the facility's policy for anticoagulant subcutaneous injections indicated that the injection site was to be rotated in a "U" shaped pattern. The policy stated, "DO NOT (emphasis as written) inject in the same place each time. Alternate the site from the left and right sides." The policy also required documentation of "the site where the injection was given." Resident #6 was admitted to the facility following a hospitalization for treatment of [REDACTED]. The resident had a [DIAGNOSES REDACTED]. On admission to the facility the resident had a physician order [REDACTED]. Review of the Medication Administration Records for August 2011 and September 2011 revealed no documentation of the injection site for each administration of [MEDICATION NAME]. On 9/8/11 at 8:40 am, during medication pass observation, Nurse #1 administered a [MEDICATION NAME] injection. There was no way for Nurse #1 to know the site of the previous injection. Nurse #1 did not question the resident prior to administering the medication. 3. For Resident #1, the facility failed to document the injection sites when administering insulin twice daily, consistent with standards of practice. Resident #1 was a long term care resident with multiple [DIAGNOSES REDACTED]. The medical record was reviewed 9/7/11. A review of the physician orders [REDACTED]. The resident also was on a Humalog (short acting) insulin sliding scale. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per reference to the "Nursing 2011 Drug Handbook" for accepted standards in regards to proper medication administration along with nursing considerations of drug administration issues. The nursing considerations for insulin administration included, "As with any insulin therapy, [DIAGNOSES REDACTED] may occur at the injection site and delay the absorption. Reduce this risk by rotating the injection site with each injection. Interview with Unit Manager #2, 9/8/11 at 10:10 AM, confirmed the nurses had not documented the injection sites.

Based on observation, record review and staff and resident interview, the facility failed to provide necessary care and treatment for two sampled residents (#3 and #4) in a total sample of 18. For Resident #4, the facility failed to prevent injury resulting from subcutaneous injections. For Resident #3, the facility failed to monitor and provide care for a necrotic finger. Findings included: 1. For Resident #4 the facility failed to rotate daily anticoagulant subcutaneous injection sites on the abdomen consistent with facility policy and standards of practice for administering daily injections. The resident had been receiving daily injections of anticoagulant medication for approximately a 6 month duration. Resident #4 was admitted to the facility in April 2011 and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 7/14/11, revealed the resident's was alert and oriented, and able to verbalize needs. The resident required assistance of staff for all aspects of daily care. Review of the facility's policy for anticoagulant subcutaneous injections indicated that the injection site was to be rotated in a "U" shaped pattern. The policy stated, "DO NOT (emphasis as written) inject in the same place each time. Alternate the site from the left and right sides." The policy also required documentation of "the site where the injection was given." Failure to rotate daily injection sites can cause scarring and hardening of fatty tissue which can be painful and interfere with the absorption of medication. Resident #4 was admitted to the facility following a hospitalization for surgical repair of a fractured right hip. The hospital discharge record recommended the anticoagulant dalteparin sodium subcutaneously (sc) 5000 mg daily to prevent [MEDICAL CONDITIONS] post-operatively. Following a cardiology recommendation to rule out [MEDICAL CONDITION] emboli and/or [MEDICAL CONDITION], the physician changed the anticoagulant from dalteparin sodium sc to Lovenex sc daily on 5/17/11. Review of the Medication Administration Records for April, May, June, July, August and September 2011 revealed no documentation of, or limited reference to, documenting the injection sites for each administration of the medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"U" shape pattern consistent with facility policy. The May 2011 MAR indicated [REDACTED]. On 6/29/1, the nurse documented the resident complained of not feeling well and complained of right upper quadrant pain. The nurse noted the area was bruised and firm. The physician ordered the resident to be transferred to the emergency room . The emergency room discharge record, dated 6/29/11, documented the resident had a bruised and painful lump over the right upper quadrant of the abdomen. The clinical impression was an abdominal wall hematoma and it was determined that the lump would resolve. However, following the resident's return from the emergency room , there was no documentation in the clinical record regarding the hematoma. There was no evidence the area was reassessed, monitored or resolved. On 9/8/11 at 1:09 am, during observation of a wound treatment, the resident complained of right sided abdominal pain and discomfort. The area was observed and appeared ecchymotic (bruised). The skin over the area was taut with a knob-like protrusion. Nurse #1 stated he/she would have the physician assess the area. On 9/9/11 at 8 AM, the Director of Nurses provided a copy of the physician's note dated 9/8/11. The physician documented that the resident had two painful, protruded areas on the abdomen caused by the daily anticoagulant injections. The physician ordered the nursing staff to avoid injections into these areas and to rotate the injection site. 2. For Resident #3, the facility failed to identify, assess or monitor the index finger on the resident's left hand, which had been noted by the physician as being necrotic. Resident #3 was a long term resident with multiple [DIAGNOSES REDACTED]. The resident had a left arm fistula and received [MEDICAL TREATMENT] three times weekly. The medical record was reviewed 9/8/11. The current monthly physician orders [REDACTED]. The resident was hospitalized [DATE] - 2/8/11 and had a revision of the arteriovenous fistula (AV fistula), an access site used for [MEDICAL TREATMENT], on the left arm. When readmitted to the facility 2/8/11, the nursing admission assessment did not document any condition or abnormality of the left hand or fingers. Per review of the treatment records for 2/2011 that included weekly skin checks by the licensed nurses, the records had no information specific to the left hand. A review of the most recent annual Minimum Data Set (MDS) assessment, dated 3/18/11, indicated the resident had short term memory problems and modified independence for decision making. The resident ambulated independently and required limited assistance from staff for hygiene and dressing. The assessment indicated the resident had no skin conditions. In a progress note dated 4/27/11, the physician questioned necrosis of the index finger on the left hand and ordered a vascular consult for the resident. The resident was seen by a vascular surgeon 5/2/11, and the consultation report noted the resident had dry, gangrenous tissue on the tips of the first and fourth fingers on the left hand. The report noted that no surgical intervention was recommended and advised the caretakers to keep the fingers clean and continue to observe. There were no nurses' notes from 1/2011 - 7/2011 that indicated the resident had any skin issues on the left hand or that staff were cleaning or monitoring the resident's fingers. The medical record had no treatment records or nurses' notes for the month of March 2011 to review. A review of the 4/2011, 5/2011, 6/2011 and 7/2011 treatment records had no documentation of any observations of the fingers on the resident's left hand. On 8/1/11, a nurse wrote that the resident's left hand index finger was necrotic at the tip of the finger down to the knuckle. On 8/3/11 a nurse's note documented the same information as on 8/1/11. On 8/4/11, a nurse noted the necrotic finger and wrote that part of the digit was now red and warm. The note indicated the Physician Assistant (PA) was called, but there had been no return call from the PA. There was no notation of any other action taken by the nurse. On 8/5/11, a nurse wrote that when the resident returned from [MEDICAL TREATMENT], the [MEDICAL TREATMENT] center had recommended the vascular surgeon evaluate the resident's finger which was swollen. The resident had been given two immediate doses of an antibiotic while at [MEDICAL TREATMENT], and the [MEDICAL TREATMENT] center had notified the resident's physician. The note read that an appointment had been made for 8/11/11 with the vascular surgeon. The 8/11/11 nurse's note indicated the resident had seen the surgeon and was to be scheduled for surgery for [REDACTED]. The resident underwent [REDACTED]. The most recent quarterly MDS assessment, dated 8/19/11, indicated the resident required more assistance for personal hygiene and dressing. The assessment noted the resident had a left hand deformity due to [MEDICAL CONDITION], but did not note any skin conditions. Interview 9/9/11 at 2:10 p.m. with the Assistant Director of Nurses, who is also the facility's wound care specialist, confirmed there was no documentation of the on-going status of the resident's finger. During interview 9/9/11 at 2:30 p.m., the Director of Nurses (DON) had no explanation why the nurses had not initially identified early signs of problems with the resident's finger and failed to identify or monitor the necrotic finger. The DON reviewed the medical record and at 4:00 p.m. returned with the record and confirmed there was no documentation regarding the condition of the resident's finger. On 9/13/11, the DON presented the surveyor with a note written by the vascular surgeon on 9/12/11. The note indicated the resident had peripheral ischemia due to Steal syndrome (vascular insufficiency resulting from an AV fistula), but there was no information relevant to the nursing staff's responsibility to monitor the condition of the resident's finger. The facility failed to identify any change in condition of the left hand index finger. The nursing staff had done glucose blood glucose testing in the finger tips three times daily and weekly skin checks and had not documented any observations of the resident's finger changes that ultimately resulted in the surgical amputation of the resident's finger.