Every finding on record at South Orange Health and Rehabilitation Center

Based on observation, interview, and record review the facility failed to administer intravenous (IV) antibiotic and maintain an intravenous access site according to professional standards for 1 of 1 resident sampled for IVs, of a total sample of 40 residents, (#91). Findings: Review of resident #91's medical record revealed he was admitted to the facility on [DATE] with diagnoses of chronic osteomyelitis left ankle and foot, other specified noninfective gastroenteritis and colitis, generalized abdominal pain, pressure ulcer of left heel, unspecified stage. Review of resident #91's medical record revealed a physician's order dated 1/15/2025 for the antibiotic, Linezolid by intravenous 600 milligrams (mg) per 300 milliters (ml) over 120 minutes at a rate of 150 milliliters per hour (ml/hr) every 12 hours for chronic osteomyelitis for 34 days. On 2/10/2025 at 9:49 AM, resident #91 was seated in his wheelchair with his left upper arm intravenous catheter connected via tubing to a intravenous bag labeled, Linezolid 600 mg/300 ml. There was no flow device used to regulate the rate of the intravenous antibiotic being infused. On 2/10/2025 at 9:55 AM, resident #91's assigned nurse Licensed Practical Nurse, (LPN) B verified there was no device in use to regulate the flow of resident #91's intravenous infusion of Linezolid. She stated she was not sure how to calculate the infusion rate of the medication she was administering. She verified the physician ordered rate was 150 ml/hr. She confirmed resident #91 had a peripherally inserted central catheter (PICC) line in his left arm. She said resident #91 had expressed a desire to attend physical therapy so she increased the infusion rate to what she considered a faster rate to accommodate his wish to go to therapy. She acknowledged it was not appropriate to not know the rate of infusion nor change the rate of infusion based on resident preference rather than a physician's order. Review of the facility's Intravenous Therapy policy dated 8/2/22 revealed in the compliance guidelines section that when an infusion pump is not used, a mechanical flow device will be used. Review of resident #91's medical record revealed physician's orders dated 1/10/25 to measure arm circumference 3 inches above PICC insertion site with dressing change and as needed and measure the external central line catheter length with each dressing change and as needed. Both tasks were timed to be completed on the day shift every Friday. A physician's order dated 1/17/2025 noted to change PICC line dressing every week with transparent dressing and change the needless access device on the day shift every Friday. On 2/10/25 at 10:08 AM, LPN B verified the transparent dressing that covered resident #91 PICC line was dated 1/20/25. She said the evening nursing shift was responsible for changing the PICC line dressing. On 2/10/25 at 3:07 PM, LPN B acknowledged it was her signature initials on resident #91's medication administration record on 2/7/25 that indicated she had changed the PICC line transparent dressing and the needless access device. She verified the order to change the PICC line site dressing every week with transparent dressing and change the needleless access device were scheduled to be done on the day shift, when she had worked. She said she documented in error and she had not changed the PICC line dressing nor changed the needless access device on 2/7/25. She said she was afraid to do the PICC line dressing change. She said she had changed resident #91's PICC line's needleless access device since resident #91's admission but had not documented every time she did it nor did she do it with each dressing change. She confirmed she had never measured resident #91's arm circumference above his PICC line nor measured the external part of PICC line. She explained she had never done those tasks. She reviewed the medication administration records for January 2025 and February 2025 and confirmed that on 1/17/2025, 1/24/2025, 1/31/2025, and 2/7/2025 she was assigned to do those tasks. She noted there were blanks on the medication administration record that indicated the PICC line dressing changes were not done. She verbalized the tasks of measuring resident #91's arm circumference above the PICC line and measuring the external portion of the PICC line were important to verify and ensure resident #91 was not having any complications from the line such as inflammation of the vein, a blood clot, or an inappropriate change in placement.

Based on interview and record review, the facility failed to provide a written copy/summary of the initial care plan to the resident/representative for 2 of 4 residents reviewed for care plans, of a total sample of 40 residents, (#2, #97). Findings 1. Resident #2, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included chronic respiratory failure, pleural effusion, diabetes type II, difficulty walking, malignant neoplasm of nasal cavity, and repeated falls. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 of 15. On 2/10/25 at 10:18 AM, and on 2/12/25 at 9:37 AM, resident #2 stated he had not been to a care plan meeting and was not sure if his son or granddaughter received any invitation to a care plan meeting. The resident said he did not get a copy or summary of his initial care plan. Review of the resident's clinical records revealed no document pertaining to the resident's care plan meeting, or any documentation to indicate a summary/copy of the resident's initial care plan was provided to the resident/representative. On 2/12/25 at 1:33 PM, and at 2:23 PM, the Registered Nurse (RN) MDS Coordinator stated invitations for care plan meetings were done either via mail, or hand delivered to residents and/or their representative, and a copy of the invitation would be included in the residents' Electronic Medical Record (EMR). She stated resident #2 was admitted to the facility in November 2024, and since November 7, 2024, the facility had not had care plan meetings for residents due to lack of staff. She explained care plan meetings were held on Admission, then quarterly. The RN/MDS Coordinator said at the admission care plan meeting, a copy of the resident's initial care plan, and medication list would be given to the resident/representative. The RN/MDS Coordinator said a summary/copy of the initial care plan could also be mailed or reviewed/discussed over the phone if the resident's representative was unable to attend the care plan meeting. She explained that when the resident was readmitted to the facility on [DATE], he should have had a care plan meeting, but the meeting was not held, and the last scheduled care plan meeting held by the facility, was on 11/07/24. The RN/MDS Coordinator said she spoke with the Medical Records personnel, reviewed documents in the file cabinet, the MDS file cabinet, and the resident's EMR, and could not identify any documentation to indicate a summary /copy of the resident's initial care plan was provided to the resident and/or his representative. 2. Resident #97, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included encephalopathy, diabetes type II, trigeminal neuralgia, bradycardia, anxiety disorder, and heart failure. Review of the resident's Medicare-5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired with a BIMS score of 11 of 15. On 2/10/25 at 11:50 AM, the resident's son stated he was not invited to the resident's care plan meeting, and he did not receive a written summary/copy of the resident's initial care plan. On 2/12/25 at 1:51 PM, the RN/MDS Coordinator stated the last care plan meeting completed by the facility was on 11/07/24, so the resident would not have had a care plan meeting. Review of the resident's clinical records revealed no document pertaining to any care plan meeting, or documentation to indicate a copy/summary of the resident's initial care plan was provided to the resident/representative. On 2/12/25 at 2:23 PM, the RN/MDS Coordinator stated documentation to indicate a summary of the resident's initial care plan was provided to the resident/representative could not be identified. On 2/12/25 at 4:30 PM, the Administrator stated that on 11/08/24 the facility went down in personnel to one person in the MDS office. She stated that at that time, the facility's focus was on completing and submitting the MDS assessments timely. She verbalized that due to this focus, and lack of MDS personnel some care plan meetings were not completed. The Administrator said the new RN/MDS Coordinator completed her onboarding, and since the facility now had adequate staffing in MDS, a Performance Improvement Project (PIP) was initiated on 2/05/25 to get current on the care plan meetings, and to ensure all current residents received a care plan meeting at least every quarter and prn (as needed). She explained the team reviewed and identified the facility did not have a policy regarding care plan meetings, so the Governing Board developed a policy, which was completed and dated 2/07/25. The Administrator said the facility resumed care plan meetings on 2/11/25. However, the PIP did not address the provision of a copy/summary of the resident's initial care plan to be provided to the resident/representative. The facility's policy titled, Baseline Care Plan implemented on 11/03/2020, and reviewed/revised on 9/18/2023, read, A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand.

Based on observation, interview and record review, the facility failed to ensure enteral feeding was infused according to physician's orders for 3 of 8 residents reviewed for tube feedings from a total sample of 40 residents, (#42, #73, #84) Findings: 1. Review of resident #84's medical record revealed an admitted [DATE]. Her diagnoses included gastrostomy malfunction, unspecified protein-calorie malfunction, and unspecified dementia. Her quarterly Minimum Data Set assessment dated [DATE] indicated her cognitive skills for daily decision making were severely impaired and she rarely/never made decisions. Review of resident #84's medical record contained a physician's order dated 10/18/24 to receive Jevity 1.5 (nutrition) at a rate of 65 milliliters per hour (ml/hr) for 20 hours until 1300 ml infused and to receive free water at the rate of 20 ml/hr for 20 hours until 400 ml infused via tube feed. On 2/11/25 at 4:52 PM, resident #84's assigned nurse Licensed Practical Nurse (LPN) D verified that resident #84 should receive 20 hours of nutrition provided through her feeding tube in a 24 hour period. She verified the Jevity 1.5 bottles contained approximately 1000 ml of nutrition. She said the time off being provided nutrition was 10:00 AM to 2:00 PM each day. She verified the feeding pump was not on nor was the feeding tubing connected to resident #84, nor had it been providing nutrition nor free water since her shift began at approximately 3:00 PM and it was unknown if it had been off since 10:00 AM. She could not provide any explanation nor documentation in the resident's medical record of how the nursing staff ensured the physician ordered daily nutrition and water had been provided. On 2/11/25 at 5:00 PM, the North Unit Manager verified Jevity 1.5 bottles contained approximately 1000 ml of nutrition. LPN D requested support from the North Unit Manager to understand how much nutrition and free water had been infused over the past 20 to 24 hours for resident #84. The North Unit Manager then requested the Regional Nurse's support to understand how much nutrition and water had been provided over the past 20 or 24 hours. Both verified they were not sure how much nutrition and water had been infused for resident #84 over the past 20 to 24 hours. They could not provide any explanation nor documentation in the resident's medical record of how the nursing staff ensured the physician ordered daily nutrition and water had been provided. They both verified resident #84 was overdue in being provided nutrition through her feeding tube since the 4 hour off time was 10:00 AM to 2:00 PM. Review of resident #84's medication administration record (MAR) from 1/1/25 to 2/11/25 revealed the facility time code at 9:00 AM Jevity 1.5 at a rate of 65 ml/hr for 20 hours until 1300 ml was infused and free water at the rate of 20 ml/hr for 20 hours until 400 ml infused was signed by a nurse. There was no MAR entry when another bottle of Jevity 1.5 began its administration to complete the physician's order of administering 300 ml of nutrition within a 20 hour time period. Review of resident #84's medical record revealed a physician's order dated 2/11/25 at 5:19 PM for Jevity 1.5 to be provided via the resident's feeding tube at 5:00 PM at the rate of 65 ml/hr for 20 hours until a total volume of 1300 ml had been infused and free water 20 ml/hr for 20 hours until a total volume of 400 ml had been infused. On 2/12/25 at 9:13 AM, the North Unit Manager assigned as resident #84's nurse verified that resident #84's feeding pump was running and connected to resident #84's feeding tube and the flush rate was set at 20 ml every 0 hours. She said that someone on the night shift had not set the pump correctly and according to the physician's orders it should have been providing free water at a rate of 20 ml per hour. 2. Review of resident #73's record revealed an admitted [DATE]. His diagnoses included cerebral palsy, unspecified, unspecified severe protein-calorie malnutrition, muscle weakness generalized, quadriplegia unspecified, and unspecified convulsions. His quarterly Minimum Data Set assessment dated [DATE] indicated his cognitive skills for daily decision making were severely impaired and that he rarely/never made decisions. Review of resident #73's medical record contained a physician's order dated 2/4/2024 to administer Jevity 1.5 (nutrition) at a rate of 85 ml/hr for 14 hours until 1200 ml was infused and to receive free water at the rate of 20 ml/hr for 14 hours by feeding tube. On 2/11/25 at 5:20 PM, LPN C said she did not know how to tell how much nutrition and free water had been provided to resident #73 through his feeding tube in the past 24 hours. She could not provide any explanation or documentation in the resident's medical record of how the nursing staff ensured the physician ordered daily nutrition and water had been provided. On 2/11/2025 at 5:28 PM, Registered Nurse (RN) A supervisor could not provide any explanation or documentation in the resident #73's medical record of how the nursing staff ensured the physician ordered daily nutrition and water had been provided through his feeding tube. Review of resident #73's MAR for 2/5/25 to 2/11/25 revealed time code at 5:00 PM Jevity 1.5 at a rate of 85 ml/hr for 14 hours until 1200 ml was infused and free water at the rate of 20 ml/hr for 14 hours infused was signed by a nurse. There was no MAR entry when another bottle of Jevity 1.5 began its administration to complete the physician's order of administering another 200 ml of nutrition within a 14 hour time period. 39943 3. Review of resident #42's medical record revealed resident #42 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke), dementia, and anxiety. The quarterly MDS assessment dated [DATE] revealed resident #42 had severe cognitive impairment, was dependent on all activities of daily living care and had a feeding tube. The Care Plan dated 8/02/23 read, resident #42 required enteral feeding tube to meet nutrition and hydration needs. Interventions included, provide tube feeding as ordered. The Order Summary Report revealed the following physician orders: Osmolite 1.5 at 95 ml/hr for 20 hours dated 1/16/25, Osmolite 1.5 at 110 ml/hr. for 15 hours until 2/11/25, Osmolite 1.5 at 95 ml/hr. for 20 hours dated 2/11/24. On 2/10/25 at 11:00 AM, resident #42 was observed lying in bed with his eyes closed. Next to his bed was a feeding pump with Osmolite 1.5 feeding attached to the pump. The feeding was not attached to the resident and the feeding pump was off. On 2/10/25 at 4:22 PM, resident #42 was observed in bed with his tube feeding infusing at 56 ml/hr. Record review revealed the feeding should be 95 cc/hr. An interview with his nurse, LPN D confirmed the pump for the tube feeding infused at 56 ml/hr. She reviewed the order in the electronic record and acknowledged the tube feeding should have been set to infuse at 95 ml/hr. She replied she did not start the tube feeding, and added, it was started by the day shift nurse. The LPN explained that when she started her shift, she saw each of her residents to ensure they were okay. She then began her medication administration and verified the settings on the pumps. Review of the resident's MAR revealed the order for Osmolite 1.5 at 95 ml/hr. x 20 hours was signed off as given by LPN B. Review of the facility policy, Care and Treatment of Feeding Tubes read Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders. On 2/13/25 at 3:29 PM, the Director of Nursing stated her expectation was for the nurse to check the order for tube feedings and verify the rate. She noted there were times the nutritionist changed the rate.

Based on observation, interview and record review, the facility failed to accurately document medications for 1 of 7 resident reviewed, out of a total sample of 40 residents, (#222). Findings: Resident #222 was admitted to the facility on [DATE] with diagnoses of nondisplaced fracture of the 7th cervical vertebra, hypertension, hypokalemia, atrial fibrillation, syncope, type 2 diabetes, and bradycardia. Review of the resident hospital records from 2/2/25 revealed the resident was admitted after sustaining a fall. The record showed the resident had Cervical 7 compression fracture. Surgical intervention was not recommended, and a cervical collar was ordered. On 2/13/24 at 12:27 PM, licensed practical nurse (LPN) A prepared resident #222's scheduled medications. She removed 1 tablet of Potassium Chloride extended release (ER) 20 milliequivalents (mEq), 1 table of Hydralazine 100 milligrams (mg), and 1 tablet of Methocarbamol 500 mg. When LPN A finished preparing the resident's medication, she proceeded to administer the medications to the resident who was in her room. Review of Resident #222's Medication Administration Record (MAR) for February 2025 revealed physician orders for the following medications, Potassium Chloride ER 20 mEq three times a day every Thu, Fri for hypokalemia for 2 Days with a start date of 2/12/25, Hydralazine 100 mg three times a day for high blood pressure with a start date of 2/7/25, Methocarbamol 500 mg four times a day for muscle spasms start date 2/7/25 Review of resident #222's MAR showed on 2/13/25 at 1:00 PM, Potassium Chloride ER 20 mEq was noted to be administered by the Unit Manager of North Wing. On 2/13/25 at 1:00 PM, Hydralazine HCl 100 mg was noted to be administered by the Unit Manager of North Wing. On 2/13/25 at 1:00 PM, Methocarbamol 500 mg was noted to be administered by the Unit Manager of North Wing. On 2/13/25 at 12:50 PM, the Unit Manager of North Wing revealed she was aware that LPN A had documented her medication administration under her name. The UM stated that LPN A was new and did not have her own login information yet. Interview on 2/13/25 at 3:14 PM with the Director of Nursing (DON) revealed that LPN A was still on orientation and that UM of North Wing was her preceptor. She stated that in the morning, the North Wing UM was more hands on with LPN A and that as the day went on the UM allowed LPN A to work on the medication cart alone. The DON stated there were no guidelines or policies for preceptors and that allowing an orientee to work alone was preceptor judgement. She stated that 2/13/25 was LPN A's third day of orientation and the first day out of the classroom. On the third day of orientation, management provided orientees with their logins for the computers. She explained they 'got busy' today and had not had time to obtain LPN A's login access. The DON stated that because the Unit Manager was precepting, it was okay for LPN A to document under the UM's name. The facility had no policy on precepting, orientation or accuracy of documentation.

Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for 8 of 8 residents reviewed for medication administration, of a total sample of 13 residents, (#6, #7, #8, #9, #10, #11, #12, and #13). Findings: On 12/10/24 at 10:01 AM, Registered Nurse (RN) A was at her medication cart preparing medications. The RN stated she still had morning medications to give and had just started giving medications on the short hallway. On 12/10/24 at 10:23 AM, RN A was observed still at her medication cart preparing medications. On 12/10/24 at 10:49 AM, RN A stated she was now giving her last resident their scheduled 9:00 AM medications. The RN said she was the Unit Manager and was working on a medication cart because they had a call out. She acknowledged that she was behind with the medications. On 12/11/24 at 10:28 AM, Licensed Practical Nurse (LPN) B was at her medication cart preparing medications, and stated she had to give 9:00 AM medications to five more residents. LPN B verbalized that she had one hour before and one hour after the scheduled time to give medications. On 12/11/24 at 11:03 AM, the Director of Nursing (DON) stated the protocol for medication administration, was that staff had a window of one hour before, and one hour after a medication's scheduled time in which to administer the medication. The DON stated if the medication was to be given at 9:00 AM, after 10:00 AM would be considered late. She said if nurses needed assistance, assistance would be provided. She verbalized that the facility had staggered medication times, so all medications were not scheduled for 9:00 AM. On 12/11/24 at 11:46 AM, LPN B stated staff had a medication administration window of one hour before and one hour after the scheduled time to give medications. The LPN stated that during medication administration time she often had to stop for various interruptions. She explained that if medications were going to be administered late, the nurse should notify the provider. LPN B said she prioritized the residents with high blood pressure, and the residents who received blood glucose monitoring, and gave those medications first, then concentrated on the other residents. She verbalized that she had completed administration of her 9:00 AM scheduled medications at approximately 10:50 AM. Review of the Medication Administration Audit Reports for the day shift on 12/10/24, and on 12/11/24 revealed the following: Resident #6 received his scheduled 9:00 AM medications late on 12/11/24 at 10:53 AM including Baclofen 5 milligram (mg) every (Q) morning and night (HS) for muscle spasms, and Lamictal 200 mg Q AM, and HS for seizures. Resident #7 received his scheduled 9:00 AM medications late on 12/10/24 at 10:50 AM, and on 12/11/24 at 11:00 AM including, Oxcarbazepine 150 mg twice per day (BID) for mood disorder, Glimepiride 4 mg daily (QD) for diabetes, Lisinopril 20 mg QD for high blood pressure, and Lisinopril-Hydrochlorothiazide 20-25 mg in the AM for high blood pressure. Resident #8 received her scheduled 9:00 AM medications late on 12/10/24 between 12:51 PM and 12:53 PM including, Trazadone 100 mg three times daily (TID) for depression/mood disorder, Lithium carbonate 150 mg in the morning for bipolar disorder, Anastrozole 1 mg QD for breast cancer, Tamsulosin 0.4 mg for urinary tract infection, Losartan Potassium 50 mg QD, and Amlodipine 5 mg QD for high blood pressure, and Divalproex sodium 500 mg QAM and HS for seizure. The resident's scheduled 1:00 PM Trazadone was administered at 12:52 PM, the same time as her scheduled 9:00 AM dosage. Resident #9 received her scheduled 9:00 AM medications late on 12/10/24 at 12:54 PM, including, Carvedilol 12.5 mg BID, and Losartan Potassium 25 mg- 2 tabs Q AM and HS for high blood pressure, Clopidogrel 75 mg QD for blood clot prevention, Gabapentin 100 mg TID for nerve pain, Escitalopram 15 mg QD for mood disorder, Isosorbide Mononitrate 5 mg BID for angina, and Furosemide 40 mg, give 0.5 tablet QD for fluid overload. Her scheduled 1:00 PM Gabapentin 100 mg was administered at 12:54 PM, the same time as her scheduled 9:00 AM dosage. On 12/11/24 at 1:08 PM, resident #9 stated that her 9:00 AM medications were not given on time. She said when the nurses got to her it was approximately 10:00 AM-10:30 AM. The resident stated she was on blood pressure medications, medication for her heart and stated she thought she was on a blood thinner, and that medications were late most of the time. Resident #9 said it would be nice to have her medications on time. Resident #10 received her scheduled 9:00 AM medications late on 12/10/24 at 11:08 AM, and on 12/11/24 at 10:14 AM including, Baclofen 10 mg BID for torticolis (twisted neck), Losartan Potassium 50 mg Q AM for high blood pressure, and Eliquis 5 mg BID for atrial fibrillation. Resident #11 received his scheduled 9:00 AM medications late on 12/10/24 at 11:04 AM, and on 12/11/24 at 10:30 AM including, Gabapentin 100 mg BID for neuropathy, Hydralazine 50 mg BID for high blood pressure, Trazadone ointment 50 mg TID for mood disorder, Sertraline 25 mg QD for depression, and Quetiapine Fumarate 25 mg- give 12.5 mg in the AM for psychosis. His scheduled 1:00 PM Trazadone dose was administered at 1:25 PM, 2 hours and 21 minutes after his 9:00 AM dosage. Resident #12 received her scheduled 9:00 AM medications late on 12/10/24 at 11:02 AM including, Pregabalin 50 mg QAM and Q HS for nerve pain, Lidocaine pain relief 4% patch Q 12 hours on at 9:00 AM off at 9:00 PM for shoulder pain, Levetiracetam 1000 mg Q AM and HS for seizure, and Sertraline 25 mg QD for mood disorder. Resident #13 received his scheduled 9:00 AM medications late on 12/10/24 at 11:01 AM including, Amlodipine 10 mg QD for high blood pressure, Eliquis 5 mg BID for blood clot prevention, and Methocarbamol 500 mg BID for muscle spasms. On 12/11/24 at 1:15 PM, resident #13 said he was not sure what time he actually received his scheduled 9:00 AM medications. On 12/11/24 at 3:30 PM, the DON stated the residents' providers should be notified if medications were administered late. She stated the Advanced Practice Registered Nurse (APRN) was in the facility at the time and had been made aware. However, no documentation of the communication was identified. This was acknowledged by the DON. The Medication Administration Audit Reports for the identified residents were reviewed with the DON. She acknowledged that medications were administered outside of the parameters of one hour before, and/or one hour after the medications' scheduled time. She verbalized that some nurses did not document in real time, and that would also be a violation, and not within professional guidelines. The policy Medication Administration implemented 11/2020, and reviewed/revised 10/2023 read, Medications are administered by licensed nurses, . as ordered by the physician and in accordance with professional standards of practice .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.

Based on interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 5 residents reviewed, of a total sample of 13 residents, (#5). Findings: Resident #5, a [AGE] year-old male was admitted to the facility on [DATE]. Review of the census showed the resident was discharged on [DATE]. Clinical record review revealed no progress note, change in condition documentation, no physician's order, or transfer documentation to indicate the resident's condition, reason for the discharge, or any care and services provided for the resident. An Orders Administration Note dated 11/06/24 at 7:04 PM, read hospitalized but did not give any further explanation. On 12/11/24 at 3:00 PM, the Director of Nursing (DON) stated if a resident was transferred to the hospital or discharged from the facility, the protocol was that staff should obtain a physician's order for transfer/discharge, document a change in condition, a transfer out note, and nurses were supposed to document a progress note. The resident's clinical records were reviewed with the DON, she acknowledged that documentation to indicate if the resident had a change in condition, reason for transfer, or a physician order for transfer could not be identified. She stated she could not recall why the resident was hospitalized . On 12/11/24 at 3:16 PM, Licensed Practical Nurse (LPN) C, stated she recalled resident #5, but did not recall sending him out to the hospital. The LPN stated she did not recall if she received report from the off going nurse regarding why the resident was sent out. She stated she did not see the resident on 11/06/24 but had to document a reason for not giving his medications, and entered the code on the Medication Administration Record, that triggered the Orders Administration Note dated 11/06/24 indicating the resident was hospitalized . LPN C stated that if she had to send a resident out to the hospital, she would document a note regarding the reason for the transfer, and add documentation addressing the resident's change in condition with the resident's Provider. She stated that usually a physician's order was needed for the resident to be sent out of the facility. On 12/11/24 at 3:52 PM, the DON stated she spoke with the Advanced Practice Registered Nurse (APRN), and was told the resident was sent to the hospital from a physician's office. The DON acknowledged that a note to indicate that the resident was out of the facility for an appointment, and that he was transferred to the hospital from the physician's office should have been documented. The facility's policy Documentation in Medical Record implemented 11/2020, and revised 11/2021 read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed failed to ensure a resident was assessed to self-administer medication safely for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 14 residents, (#4). Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, and contractures of his left and right knees. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 8/30/24 revealed resident #4 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. Review of resident #4's Admit/Readmit Screener evaluation dated 6/02/24 revealed he was his own responsible party. Review of the care plan revealed a focus for, At risk for decrease ability to perform ADLS (Activities of Daily Living) . revised on 9/25/24. One of the interventions instructed nurses to, monitor medications, especially new/changed/discontinued, for side effects and resident's response contributing to cognitive loss/dementia, including all medications, drug interactions, adverse drug reactions drug toxicity, or errors. On 11/07/24 at 10:34 AM, a pill was seen on resident #4's bedside table next to him. He stated it was vitamin C he, neglected to take it this morning and explained he had his, own vitamins. He pointed to 4 bottles of vitamins in a basket on the nightstand table next to his bed. He stated he had Vitamin C, Kelp, Ginkgo Biloba, and something else he could not recall. He stated his nurse was aware he had vitamins with him. On 11/07/24 at 10:44 AM, Licensed Practical Nurse (LPN) G stated resident #4 was alert and oriented, not confused, and was able to express his needs. LPN G indicated the resident was not able to self-administer his own medications. She explained when she passed his medications, she waited for him to take them before leaving his room. She explained upon admission, residents signed a form accepting that the facility nurses would provide all their medications. She indicated if she saw any medications at the bedside, she would remove them from the resident's room. She stated she gave resident #4's medications except a Lidocaine patch this morning because he was going to take a shower. At 11:01 AM, LPN G and the surveyor entered resident #4's room and she validated there was a pill on the bedside table and 4 bottles of vitamins in a basket on the nightstand next to his bed. LPN G explained to resident #4 she needed to remove the bottles and discard the pill on the bedside table since she did not know what it was. She told him she would discuss the vitamins with the physician and if ordered, she would administer those with his other prescribed medications. She told him she was taking the bottles of Gingko Biloba, Calcium, Vitamin C, and Kelp, along with the pill found at the bedside table. Resident #4 stated he was frustrated, and did not want to be treated like a baby. Upon exiting resident #4's room, LPN G stated she was not aware he had the bottles with him. She read the labels on the bottles: Vitamin C 1000 milligrams (mg); Calcium 600 mg + Vitamin D3; Ginkgo Biloba- no strength, 2 capsules equivalent to 500 mg; [NAME] 1000 mg. She discarded the unidentified pill. She indicated vitamins could interact with prescribed medications and must be ordered by the physician. She said, It is dangerous, not a good thing for the resident to take vitamins/minerals without the physician's knowledge. She validated he had not been assessed to self-administer the supplements by himself and they were not included in his active medications. On 11/07/24 at 11:26 AM, the Director of Nursing (DON) stated self-administration of medication was done according to the cognition of the resident. She stated residents could self- administer medications, but it was not encouraged. She validated the Interdisciplinary team would assess a resident to determine if they could self-administer medications and they would need a physician's order. The DON could not explain why there were 4 bottles of Vitamins/Minerals and a pill lying on resident #4's bedside table without the facility's knowledge. On 11/07/24 at 4:07 PM, Certified Nursing Assistant (CNA) H indicated he saw the bottles of vitamin in resident #4's room before today and assumed he had permission to have them. He recalled resident #4 was transferred to this assignment about 3 weeks ago and he came with those bottles. He stated he did not ask the resident or the nurse about the vitamins he saw. He mentioned he should not have assumed and should have told the nurse. On 11/09/24 at 12:08 PM, the North Wing Unit Manager (UM) stated she never noticed the vitamins/minerals in resident #4's room. She explained he ordered a lot of stuff online and the Activities staff assisted him to open the packages because he had contractures on his left arm. She indicated they did their best to check what he ordered. The UM explained they were supposed to discuss resident #4's preference with the provider and ensure the vitamins/minerals were ordered. She explained the medication self-administration process included residents signing a document included in the admission packet and the care plan would reflect this after the provider approved it. On 11/08/24 at 2:22 PM, the Administrator stated resident #4 was not supposed to have bottles of vitamins/minerals in his room. She indicated the physician, and/or the nurse did not know he had them. She explained the staff was aware residents should not have medications including vitamins/minerals in their possession and should tell the nurse if they saw any at bedside. Review of the Resident Self-Administration of Medications policy and procedure dated 11/2020 indicated a resident would only self-administer medications after the facility's Interdisciplinary team had determined which medications could be self-administered safely. The policy continued that, The results of the Interdisciplinary team assessment are recorded on the Self-administration of Medication Evaluation, which was located in the resident's medical record. The policy described that all nurses and aides were required to report to the charge nurse on duty any medication(s) found at the bedside not authorized for bedside storage and the care plan must reflect the resident self-administered medications and have safe storage arrangements.

Based on interview, and record review, the facility neglected to provide the appropriate care and services after a fall with injury for 1 of 2 residents reviewed for neglect, of a total sample of 14 residents, (#12). Findings: Resident #12, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included wedge compression fracture of the lumbar vertebra, repeated falls, generalized weakness, functional quadriplegia, and dementia. Review of the resident's clinical records revealed a physician's order dated 10/17/24 for the resident to be sent out to the hospital for further evaluation and treatment on 9/03/24 after a fall. Review of the resident's MDS assessment dated [DATE] revealed resident #12 was rarely/never understood and had short- and long-term memory problem. The assessment noted the resident was dependent on the assistance of staff for toileting hygiene, to roll left and right, transfer from sitting to lying, and for chair/bed-to chair transfer. A progress note documented by Licensed Practical Nurse (LPN) B dated 9/03/24 read, Was notified by CNA (Certified Nursing Assistant) that resident was on the floor, upon entering the room observed resident has redness to the right side of her eye and chin area. Upon assessment vital signs were taken. Assisted resident back to bed, notified [Advance Practice Registered Nurse (APRN)] order to send resident out for further evaluation. On 11/06/24 at 9:50 AM, the South Wing Unit Manager (UM) stated she was out of the facility on the date of the incident with resident #12. She recalled she received a phone call regarding the incident but could not recall the details. The UM stated the resident had a minor injury, an investigation was initiated by the Administrator, and the resident's assigned CNA was suspended. On 11/08/24 at 11:47 AM, the Administrator stated the incident with resident #12 was on 9/03/24, and she was notified by the Director of Nursing (DON) on 9/04/24, after a clinical review revealed a resident went out to the hospital after a fall. She stated that investigation, `identified that resident #12 had a fall out of bed on 9/03/24 at 8:30 PM as per interview with the resident's assigned CNA but was not reported to the resident's assigned nurse until 10:15 PM. The Administrator verbalized that resident#12's assigned CNA reported that he heard noise coming from resident #12's room, and the resident's roommate was asking for help. She explained that the resident's assigned CNA, CNA D verbalized that he physically picked resident #12 up off the floor and placed her in bed. The fall code, Code Star was not initiated, and the CNA did not inform the resident's assigned nurse and left the resident's room. Approximately one hour and forty-five minutes later CNA D asked CNA E to accompany him into the room to check on the resident, who had sustained a laceration over her right eyebrow. CNA E asked what happened to the resident and was told by CNA D that he picked the resident up off the floor and placed her in bed. The Administrator said CNA E reported her observation to the resident's assigned nurse LPN B, who evaluated the resident, contacted the provider, and resident #12 was sent to the hospital for further evaluation. The Administrator stated that based on the investigation, the facility classified the incident as neglect, and on 9/04/24, CNA D was placed on administrative suspension and was terminated on 9/12/24. However, as of 11/08/24, the facility had not reported the CNA to the Board of Health. On 11/09/24 at 7:59 AM, in a telephone interview LPN B stated she worked on the 3:00 PM to 11:00 PM shift, and recalled she was resident #12's primary nurse on 9/03/24. LPN B recalled the resident fell from her bed, the assigned CNA did not report the fall to her but picked the resident up off the floor and returned her to her bed. She stated another CNA informed her, she could not recall if it was at the change of shift, when the oncoming CNA was doing her walk around report, that she noticed the bruise to the resident's face, and reported the findings to her. LPN B stated she went into the resident's room, observed the resident, and noted a bruise to the right of the resident's face. She documented the findings, notified the physician, and received an order to send the resident out to the Emergency Department( ED) for further evaluation. LPN B recalled she spoke to CNA D, who said the resident rolled out of bed. She recalled she asked CNA D why he did not report the resident's fall to her, and the CNA said he was afraid to tell her, he did not want her to get mad. The statement documented by LPN B dated 9/03/24 read, was notified by CNA that resident had fallen . observation noticed resident right side her face was red. Complete assessment was done notified APRN and proper management. Sent resident to hospital for evaluation. On 11/09/24 at 8:12 AM, in a telephone interview, CNA E, stated she recalled that on 9/03/24, she worked a double shift, from 3:00 PM to 7:00 AM. She recalled she was doing rounds at approximately 7:00 PM-8:00 PM, when resident #12's assigned CNA asked her for help to reposition the resident. CNA E stated she noticed a bruise on the resident's face, and she asked CNA D what happened, and he said he did not know. The CNA said she went to get the nurse and asked her if she was aware of the bruise on the resident's face, the nurse said no, she had given the resident medication earlier, and there was no bruise. CNA E said she asked LPN B to come and observe the resident, and the nurse asked CNA D what happened. CNA E recalled she left the resident's room, and when LPN B came out of the resident's room she heard her saying why didn't you report it. CNA E stated resident #12 would be included in her assignment on the 11:00 PM-7:00 AM shift, and she wanted to be sure that the nurse was aware of her observation. CNA E's statement dated 9/03/24 revealed that while doing rounds after 8:00 PM assigned CNA asked for assistance to pull up the resident in bed. noticed bruises on one side of her face, asked assigned CNA what happened was told he don't know. So, I reported to the nurse. A telephone interview was conducted with CNA D on 11/09/24 at 11:17 AM, with translation provided by Spanish speaking Surveyor. The CNA stated he worked at the facility for approximately nine months and was resident #12's assigned CNA on 9/03/24. He recalled that at approximately 8:30 PM, he had completed a shower for another resident, and when he went to place the dirty linen in the soiled utility room, he heard the resident's roommate calling for help because she wanted to be changed. He recalled resident #12 was on the floor, and he saw redness around the left side of the resident's face. CNA D, said he did not recall if a mechanical lift was required for transfer of the resident, but he was able to transfer her, and he lifted her up off the floor back into bed. He said he did not follow the Code Star procedure, and after about twenty-five to thirty minutes, he asked another CNA if the marks the resident had were old. He recalled CNA E told the nurse, and the nurse and CNA E checked the resident. He said the nurse asked him what happened, and he told her the resident had fallen, and he had picked her up. The nurse told him he needed to report that fall immediately, and he was supposed to let the nurse know before picking the resident up. He was suspended and later terminated. CNA D's statement dated 9/03/24 read, when I walked in because the next bed calling. I found (resident #12) on the floor on the right side of the bed . was left face down . face sideways, with a blow to the mouth. The statement did not document any actions taken by CNA D after resident #12 was found on the floor. Review of the ED Provider Note dated 9/03/24 revealed the resident was in the ED for 3 hours, and read, Patient sustained an unwitnessed ground level fall at her nursing home tonight .trauma to her right orbital. A care plan for Activities of Daily Living self-care performance deficit created on 8/23/24 with revision on 9/05/24, had interventions which included that the resident required total assistance by two staff with bed mobility, and with transfers using a mechanical lift. The facility's Fall Program instructions on what to do when a fall occurs included, that the Nurse on duty should call a Code Falling Star, assess/evaluate the resident for pain, signs of injury, bleeding, changes in level of cognition, and if no injury was suspected, the resident should be assisted, back to bed or wheelchair via minimum of a 2 person assist or [mechanical] lift.

Based on interview, and record review, the facility failed to conduct a thorough investigation pertaining to a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2). Findings: Resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage, altered mental status, cognitive communication deficit, schizophrenia, history of falling, and difficulty walking. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status score of 06 out of 15. The assessment noted the resident required substantial/maximal assistance of staff for personal hygiene, and chair/bed-to chair transfer. Physician orders dated 9/20/24 was for stat (immediate) x-ray 2 Views of the left hip and left leg. Physician order on 9/24/24 was for stat anterior-posterior lateral 4 views x-ray of the resident's bilateral hips, and 2 views x-ray of the lumbar spine, due to history of fall. Another order on 9/24/24 was to send the resident out to the hospital for CT (Computed tomography) scan due to conflicting X-ray results A progress note documented by Registered Nurse (RN) A dated 9/20/24 at 11:48 PM, read, Nurse call to room by staff @ 1600 hr (4:00 PM). Observed resident sitting on floor. Head to toe assessment completed, no visible injury noted at this time . Resident complaint of L (left) hip, L leg, and L wrist pain, Tylenol administered . Resident assisted to wheelchair. Resident stated, 'I was walking from my Table (bed) to my wheelchair when I fell .' [Advanced Practice Registered Nurse [(APRN)] notified, Labs ordered: X ray 2 views L femur, . lt wrist . Neuro check started. Review of the results of the X-ray on 9/20/24 of the Left femur/tibula /fibula, and left wrist showed no fracture, and no acute bone abnormality. Progress note documented by the South Wing Unit Manager dated 9/24/24 at 11:55 AM, read, Reported by staff that resident was complaining of pain during therapy. Resident states, it's pain all down here from my thigh to leg . Resident assisted back to bed and given Tylenol for relief. APRN made aware and agrees with STAT hip and thoracic spine x-ray for further evaluation. Review of the X- ray results on 9/24/24 of the resident's bilateral hips showed a fracture of the femoral neck without significant displacement or angulation, and read, this demonstrates interval change since prior exam. There is osteoporosis and degenerative joint disease . studies compared 9/20/2024. On 11/08/24 at 10:17 AM, the incident was reviewed with the Administrator and the Director of Nursing. The Administrator acknowledged that she was the facility's Risk Manager, and said on 9/20/24, resident #2's family visited and left the resident in her room, and at 4:31 PM, the resident was found on the floor in her room, and on assessment, she complained of pain to her left hip and left wrist. She stated the physician was notified, and staff received physician order for left hip and left wrist x-ray, and neuro checks. The Administrator verbalized that the x-ray results on 9/20/24 showed no acute bone abnormality, and no fracture, and follow up was recommended if the resident's pain persisted. She stated a second set of x-rays were done of the resident's bilateral hip, and left spine on 9/24/24 after the resident complained of pain in therapy. The result showed osteoporosis, mild degenerative disease of the left hip, and a fracture of the femoral neck without significant displacement or angulation, and resident #2 was sent out to the hospital for further imaging. The Administrator stated the resident's family called back a day or so later and said the resident had a fracture. The Administrator stated an investigation of the resident's fall was done, the resident's assigned nurse RN A, and the assigned Certified Nursing Assistant (CNA) were interviewed. She stated resident #2 was not interviewed due to her cognition, and telephone call with the resident's family confirmed that he left her in her room then left the facility after his visit. She stated the facility determined that the root cause of the fall, was that the fall was caused by her family leaving the resident in her room. The Administrator stated she did not recall if the facility's camera footage for 9/20/24 was reviewed to identify the time the resident was placed in her room, and the time the family left the facility. She acknowledged that an immediate or five-day State Agency Nursing Home Federal Report was not completed or submitted regarding the fall with fracture, Elder Affairs and/or Law Enforcement were not notified, because their Root Cause Analysis was that the family took the resident into her room without staff knowledge. On 11/08/24 at 3:25 PM, RN A acknowledged that on 9/20/24, she was resident #2's primary nurse. The RN recalled that on the day of the incident she came in to work at 3:00 PM, and it was reported to her that the resident was outside in the courtyard with her family. She stated that while standing at her medication cart in the hallway, she observed the resident's family member pushing the resident in her wheelchair into her room. The RN stated the family member left, and approximately forty-five minutes later a CNA told her the resident was on the floor. RN A could not recall which CNA reported the incident to her, and when she went into the resident's room, she saw resident #2 sitting on the floor between the bed and the closet. The RN recalled she assessed the resident, and she did not complain of pain at that time, but thirty minutes later, she started to complain of pain, the physician was notified, and imaging was done of the left hip and wrist. The results indicated there was no fracture. She recalled she asked all the staff present who transferred the resident to her bed, and they all denied putting her to bed. The RN said she was not aware the resident had a fracture. On 11/09/24 at 10:19 AM, the Administrator stated she called the resident's family on 9/23/24, and the family member confirmed he placed resident #2 in bed. However, she did not recall asking the family member what time he placed the resident in bed. The Administrator stated she believed that there was always room for improvement, in regards to the facility's investigation. She acknowledged that although the facility investigation concluded the root cause of resident #2's fall with fracture was the family took the resident to her room without staff knowledge, it was ultimately staff responsibility to be aware of where the resident was. She said staff should know where a resident was at all times to ensure they were safe. The Administrator stated, an investigation was done, and staff did not know the resident was in her room. The Administrator said staff on duty reported they did not place the resident in bed, and staff should have been aware of where the resident was at all times. On 11/09/24 at 11:52 AM, the Administrator provided the facility's Visitor Log, which revealed the resident's family member signed in on 9/20/24 at 2:10 PM, and signed out at 4:00 PM. The facility's policy Fall Prevention Program implemented 11/01/20, and reviewed/revised 10/18/22 read, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility's policy Abuse, Neglect and Exploitation, implemented 11/03/20 and reviewed/revised 7/2023 instructed that in investigating different types of alleged violations, the facility should be, Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation.

Based on interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2). Findings: Resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage, altered mental status, cognitive communication deficit, schizophrenia, history of falling, and difficulty walking. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status score of 06 out of 15. The assessment noted the resident required substantial/maximal assistance of staff for personal hygiene, and chair/bed-to chair transfers. Section J of the assessment revealed resident #2 had a fall in the last two to six months prior to admission and a fall without injury and a fall with non major injury since admission. Review of the Morse Fall Scale assessments conducted for the resident revealed the resident was assessed as being at moderate risk for falling on 8/06/24 with a score of 40, and was at high risk for falling on 8/11/24, and on 9/20/24 with a score of 75. The Morse Fall Scoring revealed that a score of 45 and higher indicated the resident was at high risk for falling, and a score of 25-45 indicated the resident was at moderate risk for falling. Review of the facility's incident log for the period July 2024 to current revealed the resident had an unwitnessed fall on 8/02/24 at 2:55 PM, the resident was observed in a sitting position near the foot of her bed. The resident said she was trying to walk. Intervention implemented, was to place bed in low position. On 8/11/24 at 9:30 AM, the resident was observed on the floor between the beds in a seated position. The resident stated she was trying to go brush her teeth. Intervention implemented was for frequent checks, and an intervention for bilateral bolsters to the bed was added on 8/12/24. A progress note documented by Registered Nurse (RN) A dated 9/20/24 at 11:48 PM read, Nurse call to room by staff @ 1600 hr (4:00 PM). Observed resident sitting on floor. Head to toe assessment completed, no visible injury noted at this time . Resident complaint of L (left) hip, L leg, and L wrist pain, Tylenol administered . Resident assisted to wheelchair. Resident stated, 'I was walking from my Table (bed) to my wheelchair when I fell .' [Advanced Practice Registered Nurse (APRN)] notified, Labs ordered: X-ray 2 views L femur, . lt wrist . Neuro check started. Review of the results of the X-ray on 9/20/24 of the left femur/tibula /fibula, and left wrist showed no fracture, and no acute bone abnormality. A progress note documented by the South Wing Unit Manager dated 9/24/24 at 11:55 AM, read, Reported by staff that resident was complaining of pain during therapy. Resident states 'it's pain all down here from my thigh to leg' . Resident assisted back to bed and given Tylenol for relief. ARNP made aware and agrees with STAT hip and thoracic spine x-ray for further evaluation. Review of the X- ray results on 9/24/24 of the resident's bilateral hips showed a fracture of the femoral neck without significant displacement or angulation, and read, this demonstrates interval change since prior exam. There is osteoporosis and degenerative joint disease .studies compared 9/20/2024. On 11/08/24 at 9:13 AM, the South Wing Unit Manager (UM) recalled resident #2 was fairly new to the unit, was admitted from the hospital to the facility for a fall at a previous facility and was assessed as being at risk for falls. She recalled that during the resident's stay in the facility, she had some falls, and with the last fall, the resident was sent back to the hospital. She shared that the resident's family member was attempting to transfer her from bed to restroom, and she spoke with the family regarding transferring the resident without asking staff for assistance. On 11/08/24 at 10:30 AM, the falls were discussed with the Administrator and Director of Nursing (DON). The Administrator stated family was told by staff not to leave the resident in her room by herself since she was impulsive, and believed she could walk without assistance. She stated that when the resident was admitted to the facility, she was bedfast, but with therapy she was again able to walk, but needed assistance. When asked how often frequent checks were done, the Administrator stated that frequent checks were typically every two hours. On 11/08/24 at 3:25 PM, RN A acknowledged that on 9/20/24, she was resident #2's primary nurse. The RN recalled that on the day of the incident she came in to work at 3:00 PM, and it was reported to her that the resident was outside in the courtyard with her family. She stated that while standing at her medication cart in the hallway, she observed the resident's family member pushing the resident in her wheelchair into her room. The RN stated the family member left, and approximately forty-five minutes later a CNA told her that the resident was on the floor. RN A could not recall which CNA reported the incident to her, and explained when she went into the resident's room, resident #2 was sitting on the floor between the bed and the closet. The RN recalled she assessed the resident, and although she did not complain of pain at that time, thirty minutes later she started to complain of pain, the physician was notified, imaging done of the left hip and wrist, but there was no fracture. She recalled she asked all the staff present, who transferred the resident to her bed, and all denied putting her into bed. She verbalized that the resident had a history of attempting to get up out of bed and had to be told to stay in bed. RN A stated that if she had a resident who was at risk for falls frequent checks would need to bed done on the resident. On 11/09/24 at 10:02 AM, Licensed Practical Nurse (LPN) B recalled previously caring for the resident #2, who was confused, required total assistance from staff for transfers, and was at risk for falls. LPN B stated the resident's family would transfer the resident themselves, and had been told several times that the facility utilized mechanical lifts for transfers of the residents. The LPN stated resident #2 was a resident that staff needed to know where the she was at all times, as the resident was confused and would try to get out of bed, thinking she had to go to work, or clean her closet. The LPN said staff had to frequently repeat instructions to the resident, she said the resident did not need one-on-one supervision, but needed, lots of redirection and reassurance. On 11/09/24 at 1:50 PM, in a telephone interview, CNA F stated she worked on the 3:00 PM to 11:00 PM shift. She recalled that on 9/20/24 she came to work at 3:00 PM, and during report from the off going CNA, resident #2 was in the dining room, roaming around in her chair. The CNA stated she went on her break between 6:30 PM to 7:00 PM, and when she came back from her break, she heard that the resident had fallen. However, records showed the resident was found on the floor at 4:31 PM, and CNA F stated she had not transferred resident #2 to her bed and could not say who placed the resident back in her bed. The CNA could not say if the resident was observed by staff between the time the resident was taken to her room by the family member, and the time when the resident was found on the floor. She stated she heard the nurses saying that the resident's family member placed her in bed. CNA F verbalized that when family visited the resident, when they were leaving they would always put the resident in her bed, without telling staff, and without staff assistance. The resident's care plan for at risk for falls and fall related injury related to history of falls, impaired mobility, medication usage, and weakness was initiated on 7/31/24, with revision on 9/23/24. Interventions included, Educate/remind resident to request assistance prior to ambulation, an added intervention on 9/23/24 was, Educate family to leave patient in the common area after visiting, call staff to assist resident for safe transfer. The facility's policy Fall Prevention Program implemented 11/01/20 and reviewed/revised 10/18/22 directed that for High-Risk Protocols, the facility should Provide additional interventions as directed by the resident's assessment, including but not limited to .Increased frequency of rounds Family/caregiver or resident education.

Based on observation, interview, and record review the facility failed to implement a system to monitor and reconcile Pharmacy Recommendations to ensure all residents were being reviewed monthly for 3 of 5 residents (#37, #46, #22) and failed to implement a pharmacy recommendation for 1 of 5 residents reviewed (#16) reviewed for Unnecessary Medication Regimen Review, of a total sample of 37 residents. Findings: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, hyperlipidemia, unspecified dementia and depression. Review of resident #37's electronic medical record revealed he received Temazepam 7.5 milligrams (mg) daily for insomnia, Novolog insulin 100 unit/milliliter injected per sliding scale before meals and at bedtime for diabetes, Levemir insulin 20 units injected subcutaneously two times a day for Diabetes, Duloxetine 30 mg two times a day for depression and Atorvastatin 40 mg at bedtime for hyperlipidemia. Review of the pharmacy recommendations for the months of January 2023 through June 2023 revealed no documentation of pharmacy review conducted in January 2023, February 2023 and March 2023. 39943 2. Resident #46 was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury and bipolar disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 5/25/23 revealed resident #22 received the following medications daily for the seven day look back period, antipsychotics, antianxiety, hypnotic, and opioids. Review of the pharmacy recommendations for the months of April, May and June reflected no information for the month of May. 3. Resident #22 was readmitted to the facility on [DATE] with diagnoses to include anxiety disorder and depression. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 2/24/23 revealed resident #46 received the following medications daily for the seven day look back period, antidepressant, antianxiety, and opioids. Review of the pharmacy recommendations for the months of January 2023-June 2023 reflected no information for the months of January, February, and March. 32962 4. Review of resident #16's medical record noted she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD). Review of resident #16's physician orders revealed Symbicort Inhalation Aerosol 160-4.5 micrograms/actuation 2 puffs inhale orally two times a day for COPD. Review of the 05/22/23 Consultant Pharmacist Medication Regimen Review recommended to To rinse mouth and expectorate after use. Rinsing after corticosteroids inhalers reduces oral candidiasis as per manufacturer's guidelines. Review of resident #16 Medication Administration Record (MAR) for May 2023 and June 2023 revealed the instructions to rinse mouth after the use of corticosteroids inhalers to prevent oral candidiasis was not included. On 6/29/23 at 3:30 PM, The Director of Nursing stated she was not able to get the information for the residents who were reviewed from the pharmacy and acknowledged the recommendation for resident #16 was not implemented. She said, I am very upset but this is a learning experience for me. Review of the Facility's Consultant Pharmacist Reports Policy, dated May 2022, read, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review MMR) includes evaluation the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy . The MMR also involves reporting of findings with recommendations for improvement. All findings are reported to the Director of Nursing and the attending physician, the medical director and the administrator. Procedures . G. Recommendations are acted upon and documented by the facility staff and/or the prescriber . 3). The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure.

Based on interview, and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 2 residents reviewed for abuse of a total sample of 37 residents, (#77). Findings: Resident #77 was admitted to the facility on [DATE] with admitting diagnoses of hereditary and idiopathic neuropathy, insomnia, major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 12/27/22 revealed resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. A care plan for behavioral symptoms related to hollering out at others, easily agitated, involved himself in others' care, easily frustrated and did not follow facility guidelines was initiated 4/08/22. Interventions included to observe behaviors and document and report to physician of changes in behavior and/or if interventions were ineffective. Review of resident #77's progress notes for the month of June revealed no documentation regarding behaviors or incidents with staff or other residents. On 6/26/23 at 2:39 PM, resident #77's roommate stated about 2 weeks ago, one of the Certified Nursing Assistants (CNAs) assisting with a transfer was verbally abusive to resident #77. He recalled she said something derogatory about his mother. He stated he reported the incident to the 200 South Unit Manager (UM) and she stated she would take care of it. Review of the Grievance Log, Abuse Report Log and progress notes for resident #77 and his roommate did not show any documentation regarding the incident. On 6/28/23 at 11:32 AM, the 200 South UM stated she was aware of an issue involving a lift pad but could not recall the exact details. Upon entering the resident's room, resident #77 recalled the event. He stated there were several CNAs assisting his roommate with a transfer. Resident #77 said his roommate was asking them to use another lift pad and resident #77 was trying to tell them where it was in the room. He stated that was when CNA K told him to shut up and mind his own business and made a derogatory remark about his mother. The 200 South UM stated she did not know anything about the CNA telling resident #77 to shut up and the comment about his mother. Resident #77 and his roommate informed the 200 South UM the event was reported to Licensed Practical Nurse (LPN) N and the Admissions Director. On 6/28/23 at 12:15 PM, LPN N recalled an incident with a lift pad involving resident #77's roommate. She stated she spoke with the roommate that day and he told her the staff member was rude. She was unable to recall exactly what was said. LPN N stated she reported the incident and allegation to the 200 South UM and the Social Services Director (SSD). LPN N recalled she accompanied the SSD to the resident's room who spoke to him about the incident. LPN N clarified the SSD, 200 South UM and Admissions Director were in the room at the time. On 6/28/23 at 12:20 PM, the SSD recalled the roommate told her a staff member was rude to resident #77. She reviewed the grievance log and verified there was no grievance regarding this incident. On 6/28/23 at 4:06 PM, the Administrator reported resident #77 had a care plan in the old electronic medical record (EMR) system that noted resident #77 had a behavior of embellishing stories. The Administrator did not say if that negated an investigation into an allegation of verbal abuse. The Administrator explained the roommate stated CNA K said something about resident #77's mother. She acknowledged CNA K told resident #77 to mind his own business. The Administrator stated it was an appropriate remark for CNA K to make as resident #77 was not listening to what the staff were trying to tell him. On 6/29/23 at 10:29 AM, the SSD reported she interviewed resident #77 on 6/18/23 and he reported CNA K told him to go (curse word) your mama. She explained their investigation also noted the CNA told the resident to mind his own business. The SSD said there was no justification for a staff member to make a remark like that to a resident. On 6/29/23 at 3:28 PM, in a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC), the Administrator reported an investigation into the allegation was initiated 6/28/23. She stated they were able to determine resident #77 and his roommate were assigned to CNA L on the date of the incident. CNA L needed help getting the roommate up for an appointment and asked 3 other CNAs to assist which included CNA K. The staff were having trouble with the transfer and resident #77 started yelling at them to use the blue pad in the resident's drawer. The Administrator stated that according to their investigation, resident #77 continued to yell and cursed at the staff. The investigation showed that CNA K did tell resident #77 to mind his own business and said, your mama but denied using a curse word. The Administrator stated CNA K's remarks were not the level of communication she would expect a staff member to have with a resident and acknowledged it was inappropriate. The Administrator stated her expectation for any employee who heard a resident make an allegation was to report it immediately. She acknowledged the staff member did not report the incident and confirmed she was not aware of the incident until brought to her attention by state surveyors.

Based on interview and record review the facility failed to ensure a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed within 14 days and submitted to the Centers for Medicare and Medicaid Services (CMS) after a resident was discharged from the facility for 1 of 1 resident identified for Resident Assessment review of a total sample of 37 residents, (#54). Findings: Review of resident #54's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Cellulitis of left orbit with sudden visual loss, Chronic Kidney Disease, Heart Failure, and Diabetes Mellitus. Review of the resident's medical record revealed an Entry MDS assessment dated [DATE] and an Admission MDS assessment dated [DATE]. The record contained no other MDS assessments. Review of a Nursing Progress Note dated 03/06/23 at 9:49 AM showed the resident was discharged to home via ambulance on 03/06/23. On 06/28/23 at 12:50 PM, an interview was conducted with MDS Coordinator A and MDS Coordinator B. They both confirmed that resident #54 had been discharged to home and required a Discharge Return Not Anticipated MDS. MDS A said, Resident #54's Discharge Return Not Anticipated MDS had not been completed within the required timeframe. Review of the Facility's CMS Resident Assessment Instrument (RAI) Manual, dated October 2019, read, . 09. Discharge Assessment - Return Not Anticipated . Must be completed when a resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed . within 14 days after the discharge date .

Based on observations, record review and interview, the facility Administration failed to maintain an effective maintenance program to address roof leaks and failed to address identified concerns with water intrusion to maintain resident safety. On 7/11/2022, the facility failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. Several saturated ceiling tiles had fallen in resident rooms, with one that fell and cracked the light fixture above a resident's bed. Water intrusion was identified in the facility's dining room, activity room, medical storage room, resident rooms, kitchen, hallways, and offices. An onsite visit from a roofing contractor noted the roof was wet and soggy and indicated the entire roof needed to be replaced. These failures resulted in Immediate Jeopardy due to impending Atlantic Hurricane [NAME], a Category 4 intensity storm on the Saffir-[NAME] scale, and the amount of rainfall that was predicted for the City of [NAME], where the facility was located. The facility had a flat roof which allowed water to pool and water intrusion could result in electrical shortages and ceiling collapse. This placed the facility's 107 residents at risk for serious harm, injury, or death. Finding: Cross reference F837 and F921 On 9/26/22 at 12:23 PM, the Administrator explained he became aware of the roof leaks about two to three weeks ago. He said he was not aware of the basins that were placed between the roof and the drop ceiling and believed the water leaks were from condensation from the air conditioning system. He stated they began making calls to roofing companies and a roofing contractor was currently assessing the roof. On 9/26/22 at 10:30 AM, the Maintenance Assistant stated since he was hired on July 11, 2022, we had several leaks throughout the facility. He said there were approximately 40 basins placed in the interstitial space between the facility's drop ceiling to catch water from the leaking roof and he had added 6 more basins. He explained the Administrator was aware of the roof leaks and had directed maintenance staff to develop a plan to check and empty the basins. He indicated that he and the former Maintenance Director developed and implemented a schedule to check and empty the basins each Monday, Wednesday and Friday. He noted the Administrator had agreed with the schedule to empty the basins. The Maintenance Assistant provided a map diagram of the locations of the basins throughout the facility and said the map identified where the basins were located so they would not need to search for them. He stated the roof issues and building repairs were discussed several times at the daily meetings with all department heads present including the Administrator. He identified that on 9/14/22, pieces of ceiling tile fell in the dining room, when residents were eating dinner, but added that none of the residents were hit by debris. Review of the map diagram provided by the Maintenance Assistant showed a color-coded map used to identify water leak collection basins and fallen ceiling tiles. There were 27 pink colored dots that identified roof leaks which he explained were not associated with air conditioner condensation and 24 blue dots related to water leaks from the air conditioning system. An x noted ceiling tiles that had collapsed, of which there were eight. There was no indication when this diagram was created or if had been updated to ensure all information was current. Review of resident #1's medical record revealed he was moved from his room which had 2 basins above the drop ceiling to another room in the facility. During a telephone interview on 9/26/22 at 1:22 PM, resident #1's son said his father had told him the ceiling had fallen in his room, and hit him on the head. The son said he was not informed by the facility of the fallen ceiling tile in his father's room and believed some water had dripped on his father's head and that his father had mistaken the water for a ceiling tile. On 9/26/22 at 6:42 PM, during a telephone interview, Licensed Practical Nurse, (LPN) C recalled she was informed of the leaking water and when she went to resident #1's room, water was leaking from the ceiling and a ceiling tile was about to fall. LPN C stated they moved the resident to another room and noted that water had dripped onto the resident's bed but the ceiling tile had not fallen on the resident. On 9/26/22 at 11:50 AM, a roofing contractor was at the facility and stated he patched a few areas on the roof. He explained he could not guarantee his work as the roof was saturated with water and pointed out areas where water had pooled. He noted the roofing material membrane did not adhere to the underlying substrate and reported there were soft, mushy spots on the roof and the entire roof needed to be replaced. On 9/26/22 at 1:29 PM, a telephone meeting was conducted with the facility Administrator and the [NAME] Field Office Management via telephone. The roofing repairs that had been completed earlier that day and impending Hurricane [NAME] were discussed. The Administrator stated his plan was to monitor any leaks in resident rooms during the hurricane and move residents to other rooms if there were leaks in their rooms. He explained the facility had eight empty rooms where he could relocate residents if needed. The Administrator indicated he did not think the residents in the facility needed to be evacuated at this time. During a telephone interview on 9/26/22 at 4:24 PM, the facility's former Maintenance Director, stated he was hired on 9/12/22 and was fired on 9/22/22. He recalled on his first day of work, the Maintenance Assistant informed him the first thing they needed to do was to empty the basins that were located in the interstitial space between the roof and the drop ceiling. He remembered that some of the 40 wash basins located throughout the facility had to be modified or cut down to size so they fit in various sections below the facility's roof. He reported one morning, a Certified Nursing Assistant, (CNA) had notified him that a ceiling tile had fallen in one of the rooms and they moved the resident to another room. He said ceiling tiles had also fallen in the dining room and activity room. The previous Maintenance Director acknowledged he spoke to the Administrator the first day he worked regarding the water intrusion. He stated he tried to express his concerns about the roof leaks to the Administrator, but the Administrator dismissed the leaks as condensation from the facility's Heating, Ventilation, and Air Conditioning (HVAC) system. He told the Administrator there were leaks in areas that did not have any HVAC pipes/ducts. He noted the Administrator did not want to address the roof leaks due to the cost of the repairs and said the Administrator told him the issue will resolve in the Winter when the rainy season ended. On 9/27/22 at 1:07 PM, a tour of the facility was completed with City of [NAME] Code Enforcement Officers. The dining room had an area 5 feet by 12 feet roped off where ceiling tiles had previously fallen. The medication storage room had water dripping from the ceiling and there was a trash can on the left side of the wall and a bucket on the right side of the wall to collect water. On the floor, was a sheet that was saturated with water. One of the ceiling panels was separating from the ceiling and the Code Enforcement officers said it was from water damage. In the 200 hall across from room [ROOM NUMBER], there was a wet, discolored ceiling tile with a sprinkler head protruding from the tile. Code Enforcement staff stated that mold was starting to develop. Code Enforcement staff looked above the ceiling tiles in several areas and confirmed there were basins between the ceiling and roof. The Enforcement Staff were informed by the Maintenance Assistant there were more than 40 basins throughout the facility. The Code Enforcement Team recommended the facility evacuate all residents as the roof could collapse due to the impending hurricane [NAME]. On 9/27/22 at 11:45 AM, the facility's Maintenance Consultant stated the roofing company was at the facility and the plan was to place a felt cover on the roof and overlap tarps to keep the water out. He said the tarps will have sandbags and be nailed to keep them on the roof during the storm. On 9/27/22 at 1:50 PM, the City of [NAME] Chief Building Inspector arrived and City of [NAME] Code Enforcement staff shared their findings with him. He stated he saw the roofing activity outside with the tarps which would not keep the facility watertight. He said he researched the facility's history and the facility's roof was last replaced [AGE] years ago, in 2010. At 2:00 PM, a telephone discussion was held with the Administrator, Director of Nursing, Director of Operations, Code Enforcement, Chief Building Inspector, and the Survey Team including the [NAME] Field Office Managers. The Chief Building Inspector conveyed his concerns about the facility's roof and stated the residents would not be safe to remain in the building with the amount of water predicated in this area from the impending hurricane. He noted that water from the hurricane will settle on the building's flat roof and the roof may collapse. He explained the tarp will not hold during predicted hurricane winds. He spoke about the deteriorated roof system with evidential leaking and stated the entire building's roof was wet. He added, my best recommendation, I don't want anyone in this building (with the impending hurricane). He reiterated, I'm pointing out, there shouldn't be anyone in this building. There's a problem with this roof. At this time, the Administrator gave no indication the residents in the facility would be evacuated. Review of the facility's job description for Administrator dated November 2018 noted,.to direct the day to day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to our residents at all times.

Based on observations, interview and record review, the facility's Governing Body failed to implement policies regarding the management and operation of the facility to ensure the building's roof was maintained to prevent water intrusion and possible roof collapse and failed to maintain a safe environment for residents, staff, and visitors. On 7/11/2022, the facility administration failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. Several saturated ceiling tiles had fallen in resident rooms, with one that fell and cracked the light fixture above a resident's bed. Water intrusion was identified in the facility's dining room, activity room, medical storage room, resident rooms, kitchen, hallways, and offices. An onsite visit from a roofing contractor noted the roof was wet and spongy and needed to be totally replaced. These failures resulted in Immediate Jeopardy due to impending Hurricane [NAME] and the amount of rainfall that was predicted for the City of [NAME], where the facility was located. The facility had a flat roof which allowed water to pool and water intrusion could result in electrical shortages and ceiling collapse. This placed the facility's 107 residents at risk for serious harm, injury, or death. Findings: Cross Reference F835 and F921 On 9/26/22 at 10:30 AM, the Maintenance Assistant stated we have several leaks throughout the facility, since the first day he was hired on July 11, 2022. He said there were approximately 40 basins placed in the interstitial spaces between the facility's drop ceiling to catch water from the leaking roof. He explained the Administrator was aware of the roof leaks and had directed maintenance staff to develop a plan to check and empty the basins. He indicated that he and the former Maintenance Director developed and implemented a schedule to check and empty the basins each Monday, Wednesday and Friday. He noted the Administrator had agreed with the schedule to empty the basins and remembered he had added 6 more basins to the ceiling, since he was hired. The Maintenance Assistant provided a map diagram of the locations of the basins throughout the facility and said the map identified where the basins were located so they would not need to search for them. He stated the roof issues and building repairs were discussed several times at daily meetings with all department heads present including the Administrator. He identified that on 9/14/22, pieces of ceiling tile fell in the dining room, when residents were eating dinner, but added that none of the residents were hit by debris. During a telephone interview on 9/26/22 at 4:24 PM, the facility's former Maintenance Director, stated he was hired on 9/12/22. He recalled on his first day of work, the Maintenance Assistant informed him the first thing they needed to do was empty the basins that were located in the interstitial space between the roof and the drop ceiling. He remembered that some of the 40 wash basins located throughout the facility had to be modified or cut down to size so they fit in various sections below the facility's roof. He reported one morning a Certified Nursing Assistant, (CNA) had notified him that a ceiling tile had fallen in one of the rooms and they moved the resident to another room. He stated he tried to express his concerns about the roof leaks to the Administrator on 9/12/22 but the Administrator dismissed the leaks as condensation from the facility's Heating, Ventilation, and Air Conditioning (HVAC) system. He stated he told the Administrator there were leaks in areas that did not have any HVAC pipes/ducts. The former Maintenance Director noted the Administrator did not want to address the roof leaks due to the cost of the repairs and the Administrator told him the issue will resolve in the Winter when the rainy season ended. He stated he was very concerned about the roof leaks and sent an email to the Director of Operations but did not remember the date. The Director of Operations was a member of the facility's Governing Body. The previous Maintenance Director said he asked the Regional Operations Director if she could do something sooner and explained that a ceiling tile fell and hit a resident's bed rail. He also stated basins fell through the ceiling tiles in the dining room and three ceiling tiles fell in the activity room where basins came crashing down with the tiles. He stated the medical supply room leaked and some of the supplies got wet. He explained to the Regional Operations Director that sometimes the basins filled up faster than they could be emptied. He said the Director of Operations responded in an email which he provided. In the email snapshot, the Director of Operations response read, .As for the roof, I was made aware of it but not to the extent that you have now shared. Let me follow up with you and [Administrator's name] when he returns so we can plan as it is serious. The former Maintenance Director stated he was fired from the facility on 9/22/22. On 9/26/22 at 5:10 PM, the Administrator responded to questions about the facility's Governing Body and the reporting process. At first, he stated the Governing Body included himself, the Director of Nursing, (DON), and the facility's key personnel. When the difference between Governing Body and Quality Assurance Performance Improvement, (QAPI) committee were clarified, the Administrator stated he was not sure who the Governing Body comprised of and would have to check with corporate staff. The Administrator did not explain how he reported facility concerns to the Governing Body. On 9/27/22 at 12:45 PM, the Administrator and DON were again asked about the facility's Governing Body and any policy or procedures related to the Governing Body. The Administrator stated he and the DON were part of the Governing Body and the Governing Body's members were either corporate staff or people he reported to. He indicated he did not know much about the Governing Body and the DON noted she spoke to corporate office and they were getting information about Governing Body and a list of members. On 9/27/22 at 2:16 PM, a meeting was conducted with the Administrator, DON, and the Director of Operations. They provided the names of the Governing Body committee members and Governing Body policies and procedures. The Director of Operations stated the facility Administrator and DON did not participate in the Governing Body's quarterly meetings. She explained the Governing Body's responsibilities included appointing a facility Administrator, development of the QAPI program, and facility's Policy and Procedures. She added the Administrator and DON were responsible for the day-to-day running of the facility. The facility's water intrusion issues were discussed and the roofing contractor's recommendation for an entire roof replacement. The Director of Operations stated the Administrator needed approval from the Governing Body for any expenditures of $500 dollars or more. The Administrator indicated he was not aware of the basins in the ceiling but was told by a previous Maintenance Director about the condensation coming from the HVAC coils in September 2021. He said he informed the Director of Operations about the leaks from the HVAC but could not provide a date. The Director of Operations stated she received an email from another former Maintenance Director about the roof, but she was not aware of the extent of the problem. When asked about the Governing Body's role in the oversight of facility maintenance such as routine roof inspections, the Director of Operations stated there were no regulations/requirements for routine roof inspections. She stated the Maintenance Director was responsible for the physical structure of the facility and reported to the Administrator. In turn the Governing Body received information about the facility from the Administrator. Neither the Administrator nor the Director of Operations provided information on the process of how information was reported by the Administrator to the Governing Body. When asked about Governing Body meeting minutes/notes to demonstrate how the Governing Body was actively engaged with the facility, the Director of Operations stated there no actual minutes/notes. On 9/27/22 at 11:45 AM, the Maintenance Consultant stated the roofing company was at the facility and the plan was to place a felt cover on the roof and overlap tarps to keep the water out. He said the tarps will have sandbags and be nailed to keep them on the roof during the storm. On 9/27/22 at 1:07 PM, a tour of the facility was completed with City of [NAME] Code Enforcement Officers. The dining room had an area 5 feet by 12 feet that was roped off where the ceiling tiles had previously fallen. The medication storage room had water dripping from the ceiling and there was a trash can on the left side of the wall and a bucket on the right side of the wall to collect water. On the floor of the medication storage room, was a sheet saturated with water. One of the ceiling panels was separating from the ceiling and Code Enforcement said it was from water damage. In the 200 hall across from room [ROOM NUMBER], there was a wet, discolored ceiling tile with a sprinkler head protruding from the tile. The Code Enforcement officers stated that mold had started to develop on that ceiling tile. The Code Enforcement officers looked above the ceiling tiles in several areas of the facility and confirmed there were basins between the ceiling and roof to collect water that was leaking. The Code Enforcement Team recommended that all residents in the facility be evacuated due to the impending hurricane. On 9/27/22 at 1:50 PM, the City of [NAME] Chief Building Inspector arrived at the facility. He stated he would not feel safe in this building. He stated he saw the roofing activity outside with the tarps which would not keep the facility watertight. He stated there were more tarps than membrane on the roof and the deteriorated roof should have been fixed. He explained the roof was flat and the heavy rains will cause the water to pool making it heavier which could cause the roof to collapse. He said, I have [AGE] years experience doing this job, and I am telling you no one should be in this building. He reiterated, I'm pointing out, there shouldn't be anyone in this building. There's a problem with this roof. The facility's Governing Body policy with no date read, The governing board shall be responsible for the management and operation of the facility. G. Provision of a safe physical environment equipped and staffed to maintain the facility. 4b Method of communication between the administrator and governing body.

Based on observation, interview and record review, the facility failed to ensure the roof was maintained to prevent water intrusion and subsequent failure of other life safety systems such as fire walls and possible ceiling collapse, which compromised the safety of 107 residents. On 7/11/2022, the facility failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. Several saturated ceiling tiles had fallen in resident rooms, with one that fell and cracked the light fixture above a resident's bed. Water intrusion was identified in the facility's dining room, activity room, medical storage room, resident rooms, kitchen, hallways, and offices. An onsite visit from a roofing contractor noted the roof was wet and spongy and needed to be totally replaced. These failures resulted in Immediate Jeopardy due to impending Hurricane [NAME] and the amount of rainfall that was predicted for the City of [NAME], where the facility was located. The facility had a flat roof which allowed water to pool and water intrusion could result in electrical shortages and ceiling collapse. This placed the facility's 107 residents at risk for serious harm, injury, or death. Findings: Cross Reference F835, and F837 On 9/26/22 at 12:23 PM, the Administrator explained he became aware of the roof leaks about two to three weeks ago. He said he was not aware of the basins that were placed between the roof and the drop ceiling and believed the water leaks were from condensation from the air conditioning system. He stated they began making calls to roofing companies and a roofing contractor was currently assessing the roof. On 9/26/22 at 11:50 AM, Life Safety Code surveyors joined the roofing contractor on the roof of the facility. The contractor said he was called to patch the roof but he could not guarantee his work. He explained the roof was wet and in bad condition and pointed out areas where water had pooled. He noted the entire roof was soggy from being wet in the past and said the whole roof needed to be replaced. He also pointed out where the membrane of the roof was not adhering to the underlying roof material and where some of the patched areas he just finished were lifting from the roof. On 9/26/22 at 10:30 AM, the Maintenance Assistant stated he was hired on July 11, 2022 and we have several leaks throughout the facility. He said there were approximately 40 basins placed in the interstitial space between the facility's drop ceiling to catch water from the leaking roof and he had added 6 more basins since he started working at the facility. He explained the Administrator was aware of the roof leaks and had directed maintenance staff to develop a plan to check and empty the basins. He indicated that he and the former Maintenance Director developed and implemented a schedule to check and empty the basins each Monday, Wednesday and Friday. He noted the Administrator had agreed with the schedule to empty the basins. The Maintenance Assistant provided a map diagram of the locations of the basins throughout the facility and said the map identified where the basins were located so they would not need to search for them. He stated the roof issues and building repairs were discussed several times at the daily meetings with all department heads present including the Administrator. He identified that on 9/14/22, pieces of ceiling tile fell in the dining room, when residents were eating dinner, but added none of the residents were hit by debris. On 9/26/22 at 4:25 PM, during a telephone interview, the former Maintenance Director stated he learned about the water intrusion on the first day he worked, September 12, 2022. He stated he met with the Maintenance Assistant to get an understanding of the day-to-day duties and was told the first thing they needed to do was empty the basins in the ceiling. The previous Maintenance Director acknowledged he spoke to the Administrator the first day he worked regarding the water intrusion. He stated he tried to express his concerns about the roof leaks to the Administrator, but the Administrator dismissed the leaks as condensation from the facility's Heating, Ventilation, and Air Conditioning (HVAC) system. He told the Administrator there were leaks in areas that did not have any HVAC pipes/ducts. The former Maintenance Director noted the Administrator did not want to address the roof leaks due to the cost of the repairs and said the Administrator told him the issue will resolve in the Winter when the rainy season ended. He said the following week he went up on the roof and saw the roof was a mess. He said he called the Regional Operations Director to address the roof leaks and she said she was aware of the roof situation but did not realize it was so bad. He said she told him she would talk to the Administrator on Thursday when he returned to work. The previous Maintenance Director said he asked the Regional Operations Director if she could do something sooner and explained to her that a ceiling tile fell and hit a resident's bed rail and basins fell through the ceiling tiles in the dining room, activity room and medical supply room. He said it was fortunate that none of the residents were hit with the falling tiles. On 9/26/22 at 6:24 PM, during a telephone interview, Licensed Practical Nurse (LPN) C recalled it was near the end of her shift when a Certified Nursing Assistant told her the ceiling was leaking in resident #1's room. The LPN said, The water started to drip more and the ceiling square was about to fall. The other nurse and I moved resident #1 right away to another room. On 9/27/22 at 11:45 AM, the Maintenance Consultant stated the roofing company was at the facility and the plan was to place a felt cover on the roof and overlap tarps to keep the water out. He said the tarps will have sandbags and be nailed to keep them on the roof during the storm. On 9/27/22 at 11:55 AM, the City of [NAME] Fire Inspector arrived at the facility. He had concerns about the water pooling on the roof and expressed concern for the residents' safety due to a potential roof collapse with the impending hurricane due to hit the area the next day. On 9/27/22 at 1:07 PM, a tour of the facility was completed with City of [NAME] Code Enforcement Officers. The dining room had an area 5 feet by 12 feet that was roped off where the ceiling tiles had fallen. The medication storage room had water dripping from the ceiling and there was a trash can on the left side of the wall and a bucket on the right to collect dripping water. There was a cotton sheet on the floor of the storage room saturated with water. The 100 and 200 hallways had wet and stained ceiling tiles. One of the ceiling panels was separating from the ceiling and Code Enforcement said it was from water damage. In the 200 hall across from room 231, there was a wet, discolored ceiling tile with a sprinkler head protruding from the tile. Code Enforcement staff stated that mold had started to develop on the ceiling tile. Code Enforcement looked above the ceiling tiles in several areas of the facility and confirmed there were basins between the ceiling and roof. The Code Enforcement Team recommended residents in the facility be evacuated due to the damaged roof and impending hurricane. On 9/27/22 at 1:50 PM, the City of [NAME] Chief Building Inspector arrived and stated he would not feel safe in this building. He stated he saw the roofing activity outside with the tarps which would not keep the facility watertight. He stated there were more tarp than membrane on the roof and the deteriorated roof should have been fixed. He explained the roof was flat and the expected heavy rains from the hurricane would cause water to pool which could cause the roof to collapse. He said, I have [AGE] years' experience doing this job, and I am telling you no one should be in this building. It is a life safety consideration that I just shared with you. He acknowledged the residents needed to be evacuated from the facility due to the compromised roof. He added that with the impending hurricane, no one should be in the facility and an electrician should disconnect the power, tag, and lock the electrical box.

Based on observation, interview, and record review, the facility failed to prevent a physically impaired vulnerable resident from exiting the facility and failed to ensure the exit door was alarmed or monitored by staff for 1 of 1 resident reviewed for actual elopement, of a total sample of 7 residents reviewed for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been hit by a car or become lost. On 11/07/21 at approximately 12:42 PM, resident #1 exited the facility through an unlocked exit door on the North Wing long hallway. The door alarm was disarmed by an unknown staff member to allow outside family visitation and was not turned back on. Resident #1 walked away from the facility, crossed a two-lane street and an intersection before stopping in a vacant lot. The facility was unaware of resident #1's whereabouts until approximately 12:50 PM, when staff returning from lunch retrieved him from the vacant lot where he clung to a tree for support. The facility's failure to ensure the North Wing long hallway exit door alarm was armed contributed to resident #1's elopement and resulted in Immediate Jeopardy starting on 11/07/21. The Immediate Jeopardy was removed on 11/09/21. F689 was determined to be past noncompliance. The facility was in substantial compliance on 11/24/21. Findings: Resident #1, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included cancer of the bone and blood cells, muscle weakness, difficulty walking, bone degeneration of the left arm, chronic respiratory failure, heart failure, and chronic obstructive pulmonary disease. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/02/21 revealed resident #1 was hospitalized for a primary diagnosis of a fall at home. He was alert, oriented, and followed instructions but required a surrogate to make healthcare decisions. The form indicated resident #1 used continuous oxygen at 3 liters per minute, ambulated with a walker, and transferred with assistance. Review of resident #1's medical record revealed an Observation Detail List Report admission evaluation dated 11/03/21 which showed he had clear speech and no memory deficits. The document revealed resident #1 had left upper extremity weakness and fracture to the left arm. The evaluation revealed the resident used a walker to maintain safety and needed partial to moderate assistance to walk and turn. The document included an elopement risk evaluation which indicated he had no behaviors or history that placed him at risk for elopement. Therefore, the facility did not develop an elopement care plan for resident #1. A Fall Risk assessment tool dated 11/03/21 deemed resident #1 to be a moderate fall risk with a score of 12. Contributing factors identified were a history of falls in the last 6 months, his age, medications, and his need for assistance with ambulation. An Event Report dated Sunday, 11/07/21 revealed resident #1 was observed outside the facility by a staff member. The resident was returned to the facility via wheelchair and assessed by the Advanced Practice Registered Nurse (APRN) who was in the building at the time. The APRN gave an order to send the resident to the hospital for further evaluation of acute onset mental status change. Resident #1 returned to the facility later that day with no new orders. On 12/26/21 at 2:37 PM, the elopement incident was discussed with the Administrator, Social Service Director (SSD), and the Risk Manager (RM). The RM described resident #1 as alert and oriented to person, place and time when he was admitted on [DATE]. She explained he was cognitively intact and dependent on continuous supplemental oxygen. The SSD stated she reviewed video footage during the incident investigation which showed at 12:42 PM, resident #1 left his room, made an immediate left turn and exited the North Wing long hallway door to the outside. The SSD stated Patient Care Attendant (PCA) A, was walking towards the facility and recognized resident #1 as he walked down the street away from the facility. She stated housekeeper B was in her car in the employee parking lot and saw resident #1 as he walked by. The SSD stated PCA A caught up with resident #1 and remained with him while housekeeper B ran back to the facility to get a wheelchair and notify the assigned nurse. On 12/26/21 at approximately 2:45 PM, the Administrator explained at the time of the elopement the North Wing long hallway door was the only exterior exit door in the facility that did not have a magnetic lock. He stated the door had a basic screamer alarm that could be turned on and off with a key. He explained the door remained unlocked as it was a fire egress door and opened immediately if pushed from the inside. The Administrator stated during the incident investigation he discovered the screamer alarm on that door was disarmed. He explained visitation at the time of the elopement was held in the covered alcove outside the North Wing long hallway door. He stated the process was nurses turned off the screamer alarm with a key to allow a resident to go out to the alcove for visits. Nurses were supposed to turn the alarm back on immediately. At the end of the visit, the resident would knock at the door and the nurse would repeat the process to disarm and re-arm the alarm. The Administrator stated the facility did not have video footage of the staff member who turned the screamer alarm prior to the incident. On 12/26/21 at approximately 2:50 PM, the RM stated the facility's root cause analysis was the North Wing long hallway door screamer alarm was left disarmed. She acknowledged that prior to the elopement incident, agency nurses were not educated on the facility's protocols and procedures related to door security. The RM stated at the time of the elopement incident, the Director of Maintenance checked all exit doors and alarms daily, but only Monday through Friday. Resident #1's elopement route was retraced on 12/26/21 at 5:35 PM. Resident #1 left his room and walked directly to the North Wing long hallway door and exited the facility. He left the covered alcove outside the door and walked down the sloped driveway to the sidewalk. He followed the cracked and uneven sidewalk in front of the facility, stepped off the curb into the middle of the street and crossed to the other side. The resident proceeded along the sidewalk, crossed an intersection, stepped up and over a curb and headed into a vacant lot. The lot was located approximately 350 feet away from a heavily trafficked four lane road. He was found clinging to a tree in the vacant lot approximately 350 feet away from the facility's exit door. On 12/26/21 at 12:23 PM, the South Wing Unit Manager (UM) stated she arrived at work on Sunday 11/07/21 at the same time resident #1 was brought back inside by staff. She recalled she assessed resident #1 with the APRN on his return to the building. She confirmed he had an acute change in mental status compared to his baseline admission assessment. On 12/26/21 at 12:30 PM, the APRN stated she assessed resident #1 on two occasions before the elopement incident on 11/07/21. She explained he was usually oriented to person, place and time, but on return to the facility after he eloped, he was oriented only to himself. The APRN explained the resident required continuous oxygen therapy and might have been confused as a result of not having supplemental oxygen during his time outside the facility. On 12/26/21 at 4:26 PM, in a telephone interview, resident #1's daughter stated resident #1 lived at home with her prior to his admission to the facility. She confirmed the facility informed her of her father's elopement. She acknowledged her father was usually alert and oriented, but occasionally had confusion in the late afternoon and evenings. On 12/27/21 in interviews at 12:10 PM and 1:57 PM, the Director of Maintenance stated all exterior exit doors were checked twice daily by maintenance staff at approximately 8:00 AM and 5:00 PM, on the weekdays. He confirmed the North Wing long hallway door was the only exterior exit door in the facility that did not have a magnetic lock. He explained the door remained unlocked for fire egress purposes and had a screamer alarm that would sound when the door was opened but only if the alarm was engaged. The Director of Maintenance stated the door should only be used in emergency situations. He acknowledged that an unlocked door was a security concern. He stated prior to the elopement, he informed Administration of this concern and requested installation of a magnetic lock to enhance security on more than one occasion. The Director of Maintenance recalled he was told the concern would be escalated to the owner. During review of the Exterior Door Daily Inspection logs from 11/01/21 to 12/27/21 with the Director of Maintenance, he provided documentation that showed the last door and alarm check prior to resident #1's elopement was performed on Friday 11/05/21. He explained door checks were not conducted on the weekends prior to the elopement. On 12/27/21 at 1:06 PM, in a telephone interview, Registered Nurse (RN) C stated she was assigned to care for resident #1 on the day he eloped from the facility. RN C explained she worked for a staffing agency and never received education or instruction on door operation or arming and disarming the door alarm. She stated she had a key to the door but denied ever letting anyone outside or turning the alarm off. She stated the North Wing long hallway door was used for outside visitation on the previous day, Saturday 11/06/21 and on that morning, Sunday 11/07/21. RN C stated she did not know when the alarm was turned off and acknowledged the alarm could have been off since visitation on Saturday. She recalled someone informed her resident #1 was outside, and she retrieved an oxygen canister and his wheelchair, then ran to the vacant lot. RN C said, He looked winded and was hugging a tree so he would not fall. On 12/28/21 at 10:43 AM, the Rehab Director stated resident #1 was not safe to walk independently due to left sided weakness, exercise intolerance and balance issues. She confirmed she was the Manager on Duty on 11/07/21 and did not hear an exterior exit door alarm that day. She explained the screamer alarm at the North Wing long hallway door was very loud, and she or any staff in the vicinity would have heard it. The Rehab Director confirmed she was never required to check the exit doors when she was the weekend Manager on Duty prior to the elopement. On 12/28/21 at 2:50 PM, Housekeeper B stated she saw a man walking on the sidewalk in front of the facility as she pulled her car into the staff parking lot. She stated while seated in her car she saw the man cross to the other side of the street. As he got closer, housekeeper B stated she recognized him as resident #1. She recalled that as she got out of the car to approach him, resident #1 picked up his speed, crossed the intersection and headed towards the vacant lot. Housekeeper B stated she noticed PCA A approaching resident #1 from the East. She recalled PCA A ran toward resident #1 and waited with him while she went to notify the nurse. On 12/27/21 at 4:28 PM, the RM stated the North Wing long hallway door's screamer alarm should have been turned off and back on immediately, only for the time necessary to allow residents to pass through. She stated the process for outside visitation should have been followed on both weekdays and weekends. Review of the job description for Director of Maintenance dated November 2018, revealed duties and responsibilities included ensuring equipment was maintained to provide a safe environment. Review of the job description for Administrator dated November 2018, revealed duties and responsibilities included, Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas. Additional duties and responsibilities included, ensuring the facility was maintained in a safe manner and had the equipment required to meet the needs of the facility and residents. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On 11/07/21, resident #1 was returned to facility by staff and assessed by the APRN. His vital signs were stable, and he had no visible injuries. The APRN gave orders to send resident #1 to the hospital for acute mental status changes. *On 11/07/21, the Medical Director, Administrator, Director of Nursing, and Risk Manager were notified of event. *On 11/07/21, the Maintenance Director immediately secured and alarmed the North Long Hallway exit door. All other doors were checked for function and security. *On 11/07/21, a full head count of 99 residents was completed by the UM with all present in the building. *On 11/07/21, all visitations in the outside alcoves stopped immediately. Process revised for all visitation to come through the front lobby and check in with the receptionist desk only. *On 11/07/21, education started on 7 AM-3 PM shift for Elopement, Abuse, Neglect, and door security/function, 24 staff completed. Elopement drills completed with staff on duty 3 PM-11 PM shift. *On 11/07/21, resident #1 returned from the hospital with no new orders. Resident was alert and oriented and placed on 1:1 (one to one) for increased supervision. *On 11/08/21, an ad hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held with the Medical Director and all department heads. Topics discussed included: Elopement, Abuse, and Neglect and door function. *On 11/08/21, a Performance Improvement plan was developed and approved by the Medical Director and interdisciplinary team to check all doors on Saturday and Sunday in addition to checking doors twice daily Monday through Friday. *On 11/08/21, resident # 1's room was moved furthest from an exit door in the facility. *On 11/08/21, a third party door company was contacted, and magnetic lock ordered for North Long Hall exit door. *On 11/08/21, all Department Heads (18) were educated on Manager on Duty exterior door checks and revised visitation process on weekends. *On 11/08/21, a review of elopement assessments and revision of care plans as needed for all residents in the facility to ensure accurate census of 98. *On 11/09/21, 100% of staff education was completed. 19 nurses, 44 CNAs, 10 dietary staff, 19 therapists, 18 administrative staff, and 9 housekeepers, totaling 116 staff. On 11/09/21, the Immediate Jeopardy was removed. * On 11/10/21, elopement re-assessments of all residents in facility completed, no new elopement risk identified. * On 11/10/21, an elopement drill was completed for 7 AM to 3 PM shift (43 staff participated). *On 11/10/21, a quote from door company obtained for installation of magnetic lock as soon as possible. *On 11/11/21, an elopement drill was completed for 11 PM to 7 AM shift (23 staff participated). *On 11/17/21, a QAPI meeting held with Medical Director and all department heads. Audits of door checks revealed 100% compliance. Audits of staff education revealed 100% compliance regarding understanding of door function and security, elopement, abuse, and visitation. All topics added to new employee education. *On 11/18/21, an elopement drill was completed for 3 PM to 11 PM shift (32 staff participated). * On 11/19/21, an elopement drill was competed for 11 PM to 7 AM shift (22 staff participated) and the 7 AM to 3 PM shift (45 staff participated). *On 11/24/21, a magnetic lock was installed to the North Wing long hallway door. Invoice validated installation of magnetic lock with keypad on 11/24/21. *On 11/24/21, department heads and Managers on duty educated on exterior door locks and magnetic locks, 18 present. *On 11/24/21, an elopement drill was completed for 3 PM to 11 PM shift (30 staff participated). Interviews conducted on 12/28/21 with 25 staff members representing all shifts (9 Certified Nursing Assistants, 3 Licensed Practical Nurses, 1 RN, 3 PCAs, 1 Physical Therapist, 1 Floor Tech, 2 housekeepers, 4 dietary staff, and 1 activities assistant) indicated they were knowledgeable of the elopement policy and procedures, door security, alarm procedures and the visitation process. The surveyors validated the education with attendance sheets for elopement drills and in-services. Review of QAPI audits revealed daily door monitoring was conducted per performance improvement plan. The sample was expanded to include 6 additional residents who were at risk for elopement. Observations, interviews, and/or record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #2, #3, #4, #5, #6, and #7. The survey team determined based on the facility's corrective actions, the facility was in substantial compliance on 11/24/21.

Based on observation, record review and interview, the facility failed to maintain the dumpster area in a sanitary manner and ensure the dumpster lids remained closed, to prevent the harborage and feeding of pests. Finding: On Sunday, 8/8/21 at 9:20 AM, the facility's dumpster was over filled with clear garbage bags and the lids to the dumpster were pushed all the way back. The clear garbage bags were filled with milk/food cartons, personal protection equipment and other facility refuse. On the ground in front and back of the dumpster were 2 face shields and clear garbage bags filled with refuse as well as other debris. On 8/8/21 at 9:27 AM, the Assistant Maintenance Staff stated the dumpster does not get emptied on Sundays. He did not explain why the dumpster lids were not closed and stated he had never seen the dumpster this full. He acknowledged there were garbage bags on the ground, on the lids of the dumpster, as well as other debris on the ground. On 8/11/21 at 11:44 AM, the Maintenance Director said the dumpster was emptied by a disposal company everyday except Sundays. He stated the disposal company did not empty the dumpster on Saturday and he provided an email conversation with the disposal company. Review of the emails revealed the disposal company made no actual claim the garbage pick up was missed, only that the facility had called that garbage pick up was skipped. The Maintenance Director stated that neither he nor his assistant worked this past Saturday but there was one floor technician on the weekend. He explained the floor technicians removed the garbage from the facility and put it into the dumpster. He added the Nurses and Certified Nursing Assistants did not bring trash out to the dumpster. The only other staff that brought trash to the dumpster were dietary staff. He stated that floor technicians were aware to call him if there were any facility issues but he did not receive any phone calls that the dumpster was over filled. He stated he only learned the dumpster was over filled and the dumpster lids were left open, when he came to the facility.

Based on observation, interview and record review, the facility failed to ensure medications were ordered timely upon admission. The facility also failed to get physician authorization for giving medication outside of the prescribed time for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 49 residents (resident #156). Findings: Resident #156 was a [AGE] year-old woman admitted to the facility on [DATE] at 12 PM. Her diagnoses included metabolic [CONDITION(S)], [CONDITION(S)], delusional disorder, dementia, anxiety disorder and [CONDITION(S)]. A review of the physician admission orders included a written prescription for antianxiety medication, [MEDICATION(S)] 1 milligram tablet at bedtime. Review of the Medication Administration Record (MAR) from 8/06/21 to 8/09/21 documented that [MEDICATION(S)] was scheduled to be given at 9 PM. A review of the MAR noted on 8/06/21 at 10:23 PM, [MEDICATION(S)] was not administered as the drug was not available. On 8/07/21 at 9:53 PM, a note on the MAR showed the medication was not given as not delivered from pharmacy. On 8/08/21 at 9:51 PM and 8/09/21 at 10:29 PM, the MAR showed [MEDICATION(S)] was not given as it was not available. A review of the MAR showed [MEDICATION(S)] was given on 8/10/21 at 3:51 AM. On 8/11/21 at 1 PM, resident #156 was lying in her bed. She was awake and alert. She said she wanted to go home. She said she was at the nursing home because of a urinary tract infection but was feeling better. On 8/11/21 at 4:14 PM, Registered Nurse (RN) A said that resident #156 was very difficult to awaken yesterday. She acknowledged there was not a written progress note from the nurse that gave the [MEDICATION(S)] outside the scheduled hour on 8/10/21 at 4 AM. RN A acknowledged the resident may have been difficult to arouse as she received the medication at close to 4:00 AM. She said she had informed the Director of Nursing (DON) and the physician about the resident being very sleepy. She added the resident was seen by the physician and was awake and alert today. On 8/11/21 at 4:28 PM, RN B said he worked the 3-11 PM shift on 8/08/21. He did not give a reason why resident #156 did not receive her 9 PM dose of [MEDICATION(S)] on 8/08/21. He did not explain why he did not order the medication from pharmacy on 8/08/21 when he identified and documented the [MEDICATION(S)] was not available at 9:51 PM. He said the medication arrived on his shift after midnight on 8/10/21. He said he gave the medication to the resident at 3:51 AM as she was crying. He acknowledged it was outside the prescribed time and he did not notify the physician before giving it. On 8/11/21 at 5:10 PM, the 3-11 PM Licensed Practical Nurse (C) said she worked the 3 to 11 PM shift on 8/06/21 and 8/09/21. LPN C acknowledged she did not administer [MEDICATION(S)] to resident #156. I was aware the medication was available in the emergency drug kit. I had to send the prescription to pharmacy to use it. It was late and I did not send it to the pharmacy on 8/06/21. I was off on 8/07/21 and 8/08/21. The nurse on duty should have followed up with the pharmacy. I did not remember if she had a written prescription. On 08/11/21 at 5:16 PM, the Director of Nursing said she spoke with RN B. She acknowledged he did not call the doctor when the medication was not given at the designated time. She said he gave the resident the medication as she was very agitated. On 8/11/21 at 5:23 PM, during a phone interview, the pharmacy technician said the written prescription for resident #156's [MEDICATION(S)] dated 8/06/21 was sent to the pharmacy on 8/09/21 and dispensed on midnight run. The technician said it was signed as delivered to the facility on [DATE] at 2:20 AM.

Based on observation, interview and record review, the facility failed to provide oxygen (O2) at the prescribed rate as per physician's order for 1 of 2 residents reviewed for respiratory care, (#47). Findings: Review of resident #47's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment, required extensive assistance with activities of daily living (ADL), used a wheelchair for mobility, was always incontinent of bowel and bladder, had trouble with breathing on exertion and when lying flat in bed and was receiving oxygen therapy. Review of resident #47's care plan documented he was at risk for respiratory distress. Approaches included to administer oxygen as ordered. Review of the resident's physician's orders dated 11/22/19 noted to administer O2 at 4-6 Liters (L)/minute via nasal cannula, continuous. Review of resident #47's nursing progress notes dated 01/13/20 at 1:00 PM, on 01/14/20 at 3:56 AM and 5:25 PM, on 1/15/20 at 3:52 AM and on 1/16/20 at 6:34 AM documented resident was receiving oxygen at 4 L/minute via nasal cannula. Observations conducted on 01/14/20 at 10:58 AM, and 4:33 PM on 01/15/20 at 9:02 AM, 2:31 PM and 5:06 PM and on 01/16/20 at 8:54 AM revealed resident #47's oxygen concentrator was set at 2.5 L/minute. On 01/16/20 at 9:26 AM, licensed practical nurse (LPN) C stated that resident #47 was receiving O2 at 4 [MI] LPN C confirmed the physician's order was for the O2 to be set at 4-6L/minute. Observation of resident #47's O2 concentrator with LPN C revealed his O2 was set at 2.5 L/minute. LPN C confirmed that the O2 was not being provided per physician's order. It should have been set at 4 L/minute and not at 2.5 L/minute. The north wing unit manager observed resident #47's O2 and confirmed the O2 was set at 2.5 L/minute. The unit manager did not explain why the oxygen was set at the wrong rate. Review of facility's procedure for Oxygen Administration, dated (MONTH) 2010, read, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order . for oxygen administration Review of the Facility Assessment, dated 11/27/19, read, . Intent: the facility provides person-centered, competent care that helps each person served to live their lives as they wish . We strive to deliver the highest quality care and exceed the expectations of those we serve The most frequent skilled services have been . oxygen administration . Management of medical conditions such as . [MEDICAL CONDITIONS], . pneumonia .