Every finding on record at Springbrook Nursing and Rehabilitation Center

Based on observations, record review, and interviews with the Medical Director and staff, the facility failed to follow a physician's order for continuous oxygen for Resident #22 and failed to clarify an order for monitoring oxygen saturations and oxygen use for Resident #77. The deficient practice occurred for 2 of 3 residents reviewed for respiratory care (Resident #22 and Resident #77). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD). A review of Resident #22's medical record revealed an active order dated 3/19/2025 for continuous oxygen at 2 Liters per minute (Lpm) every day and night shift. Review of the quarterly Minimum Data Set (MDS) assessment completed on 6/30/2026 revealed that Resident #22 was cognitively intact and received oxygen therapy. Review of the comprehensive care plan last revised on 6/30/2026, included a focus area for Resident #22 that stated, potential for or actual ineffective breathing pattern related to COPD and the resident remains on O2 (oxygen) therapy. Review of Resident #22's Medication Administration Record (MAR) for July 2026 revealed an order for continuous oxygen at 2 Lpm and oxygen saturations were recorded every day and night shift from 7/1/2026 through 7/27/2026. Medication Aide (MA) #1 recorded that Resident #22 received oxygen the morning of 7/27/2026. Review of Resident #22's medical record from 7/1/2026 through 7/28/2026 revealed no documentation of refusals for Resident #22's use of oxygen therapy. An observation on 7/27/2026 at 10:37AM revealed a cautionary oxygen in use sign upon entry to Resident #22's room. Resident #22 was observed in her bed with no oxygen on and no oxygen tank on the back of her wheelchair or oxygen concentrator in her room. Resident #22 did not exhibit any shortness of breath or distress.An observation of Resident #22 at 7/27/2026 at 12:51PM revealed she was sitting in her wheelchair in her room. There was no oxygen on the back of her wheelchair or oxygen concentrator in her room. Resident #22 was not receiving oxygen. Resident #22 did not exhibit any shortness of breath or distress.Resident #22 was observed sitting in her wheelchair in her room on 7/28/2026 at 8:25AM. There was no oxygen tank on the back of her wheelchair or oxygen concentrator in her room. Resident #22 was receiving no oxygen, and no oxygen tubing was visible in her room. Resident #22 did not exhibit any shortness of breath or distress.Resident #22 was observed in her wheelchair in the hallway on 7/28/2026 at 1:40PM with no oxygen tank on her wheelchair and she was not receiving oxygen. Resident #22 did not exhibit any shortness of breath or distress. During an interview with Resident #22 on 7/29/2026 at 8:36AM, she stated she did not need oxygen and did not want to wear it. During an interview on 7/28/2026 at 1:55PM MA #1 stated Resident #22 received oxygen as needed. MA #1confirmed she was familiar with Resident #22 and was asked to show the oxygen order for Resident #22. Upon looking in the Electronic Medical Record (EMR), MA #1 confirmed Resident #22 had a Physician's order for continuous oxygen therapy and indicated she was unaware that Resident #22 had a Physician's order for continuous oxygen therapy. MA #1 also confirmed she recorded on the MAR, on 7/27/2026, that Resident #22 received oxygen at 2 Lpm. MA #1 stated Resident #22 would refuse to use oxygen frequently. An interview with Nurse #1 on 7/28/2026 at 1:59PM revealed she was the Head Nurse on the hall and was familiar with Resident #22. Nurse #1 indicated that Resident #22 was not receiving oxygen continuously. After reviewing Physician orders during the interview Nurse #1, stated she was unaware Resident #22 was to receive continuous oxygen therapy. Resident #22 was observed in the hallway at 7/28/2026 at 2:52PM with no oxygen in use. MA #1 was asked to check Resident #22's oxygen saturation level and MA #1 used a pulse oximeter (a small device that clips onto finger to measure how much oxygen was in the blood). The result was read at 94% and MA #1 confirmed that was considered good for Resident #22. During an interview with the Director of Nursing (DON) on 7/29/2026 at 3:40PM, the DON stated staff should follow the orders as written, including Resident #22's continuous oxygen order and to document refusals if they were not followed. During an interview with the Medical Director on 7/29/2026 at 11:31AM, the Medical Director stated if a resident had an order for continuous oxygen, he would expect to see the resident always receiving oxygen. If the resident was not using oxygen, he would ask the staff to check the resident's oxygen saturation and assess if the resident still needed continuous oxygen. The Medical Director confirmed he would expect staff to follow the residents' orders. When asked why Resident #22 was not wearing her oxygen continuously, he confirmed she should have been reassessed for an as needed order instead of a continuous order. An interview was conducted with the Administrator on 7/30/2026 at 11:14AM. The Administrator stated staff should follow all orders, including continuous oxygen orders. 2. Resident #77 was admitted to the facility on [DATE] with diagnosis including chronic systolic congestive heart failure (CHF), sequela of cerebral infarction, and dysphagia. Review of the comprehensive care plan created on 4/8/2026, last reviewed on 7/20/2026, included a focus area for Resident #77 that stated, potential for or actual ineffective breathing pattern related to diagnosis of CHF. Resident #77's goal was to demonstrate effective respiratory pattern of rate, rhythm, and depth with oxygen saturation level per physician orders. Resident #77's intervention included oxygen therapy as ordered. Review of the medical record revealed an active standing orders initiated on 4/8/2026 If O2 (oxygen) saturation was less than 91%, may use O2 at 2 Lpm via nasal cannula and titrate at 1 Lpm until O2 saturation was greater than 93% and call physician; if O2 saturation was greater than or equal to 90%, may use O2 at 2 Lpm via nasal cannula for comfort and call physician in the morning or immediately if further evaluation was needed; and if O2 saturation decreased, shortness of breath, presence of respiratory distress or nursing evaluation indicated need for further assess/investigation, notify physician immediately.Review of the admission Minimum Data Set (MDS) assessment, completed on 4/14/2026, revealed that Resident #77 had severe cognitive impairment and received oxygen therapy. A review of Resident #77's medical record revealed on 5/2/2026 the Medical Director entered an order that stated, Monitor oxygen if it is above 90% on room air do not put on oxygen. every 6 hours for monitoring. Review of Resident #77's Medication Administration Record (MAR) for July 2026 revealed an order to, Monitor oxygen if it is above 90% on room air do not put on oxygen. every 6 hours for monitoring. Resident #77's oxygen saturation was monitored and documented every 6 hours through 7/28/26 at 12:00PM. There was no documentation in the MAR to indicate if the resident was on room air when the oxygen saturations were checked. All oxygen saturations recorded were at or above 91% and the highest was 97%. A review of Resident 77's vital signs documented in the medical record from 7/1/2026 through 7/26/26 revealed the oxygen saturation was documented as taken while Resident #77 was using room air on 2 instances. On 7/16/2026 at 5:08AM, Resident #77's oxygen saturation was 92% on room air and on 7/19/2026 at 4:38AM, Residents #77's oxygen saturation was 94% on room air. All other entries were documented while Resident #77 was using oxygen via nasal cannula. A physician progress note dated 7/15/2026 with summary of a 7/10/2026 visit with Resident #77, stated Resident #77 was sitting up in her room with 2 liters of oxygen via nasal cannula in place. Review of the quarterly MDS assessment completed on 7/14/2026 revealed that Resident #77 had severe cognitive impairment and received oxygen therapy. A review of Resident #77's vital signs documented in the medical record revealed her oxygen saturation on 7/27/2026 at 12:02PM was 95% while Resident #77 was on oxygen via nasal cannula recorded by Nurse #1. An observation conducted on 7/27/2026 at 12:18PM revealed Resident #77 with a nasal cannula with tubing connected to an oxygen concentrator machine. A review of Resident #77's vital signs documented in the medical record revealed her oxygen saturation on 7/28/2026 at 12:06PM was 95% while Resident #77 was on oxygen via nasal cannula recorded by Nurse #1. An interview with Nurse #1 on 7/28/2026 at 2:18PM confirmed she measured Resident #77's oxygen saturation at 95% on 7/28/2026 at 12:06PM. Resident #77 was observed on 7/29/2026 at 11:06AM, with MA #2 present, she confirmed Resident #77 was receiving 3.5 Lpm of oxygen via nasal cannula. An interview with Nurse #2 on 7/29/2026 at 11:53AM revealed she just removed Resident #77's oxygen via nasal cannula because her oxygen saturation was above 90%. During an interview with the Director of Nursing (DON) on 7/29/2026 at 3:40PM, the DON reviewed Resident #77's order dated 5/2/2026 to Monitor oxygen if it is above 90% on room air do not put on oxygen. every 6 hours for monitoring, and stated staff should follow all orders as written. The DON confirmed Resident #77's oxygen saturation should have been obtained on room air per the order and not have her oxygen on if her oxygen saturation was above 90%. An interview with the Medical Director was conducted on 7/29/2026 at 11:31AM. The Medical Director confirmed he would expect staff to follow the Physician's orders. After review of Resident #77's order with the Medical Director that stated, Monitor oxygen if it is above 90% on room air do not put on oxygen. every 6 hours for monitoring, the Medical Director confirmed that if Resident #77 was receiving oxygen there should be an order for how much oxygen to be delivered to her. The Medical Director confirmed if Resident #77 received too much oxygen it would not cause harm to her based on her current need for oxygen. An interview with the Administrator on 7/30/2026 at 11:14AM confirmed staff should follow all orders.

Based on record review, interviews with the Pharmacist, Medical Director, and staff, the facility failed to address a recommendation made by the Pharmacist based on the monthly Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #9). The findings included:Resident #9 was admitted to the facility on [DATE]with diagnosis including chronic kidney disease. The resident had a recent hospitalization from 2/8/2026 through 2/13/2026.A review of Resident #9's medical record revealed a medication order for cyanocobalamin (vitamin B12) 1000 micrograms (mcg) 1 tablet to be given once daily ordered on 2/13/2026.Review of Resident #9's Medication Administration Record (MAR) from February 2026 confirmed Resident #9 received vitamin B12 1000mcg once daily 2/14/2026-2/28/2026.Another review of Resident #9's medical record revealed a pharmacy recommendation dated 2/16/2026 from the Pharmacist's Medication Regimen Review (MRR). The recommendation suggested reducing the dose of cyanocobalamin based on 2/11/2026 hospital labs that indicated a B12 level greater than 2000 picograms (trillionth of a gram) per milliliter (pg/mL; normal range was between 213-816 pg/mL). The recommendation had a slash mark indicating agree and the signature and date line were blank.Review of the comprehensive care plan revised on 6/3/2026 revealed Resident #9 had a vitamin B12 deficiency. Interventions included labs would be ordered and results reported promptly to Physician.A telephone interview was conducted on 7/29/2026 at 10:13AM with the Pharmacist who performed the 2/16/2026 MRR for Resident #9. The Pharmacist's administrative team would send an email to the DON and Administrator when all the monthly MRRs were completed. The Pharmacist stated the DON was to ensure the recommendation was reviewed by the Provider. The Pharmacist stated that when a new DON was hired, she would go to the facility and conduct training on the pharmacy's policy and processes related to how the Pharmacist's recommendations would be delivered to the facility. After the Pharmacist gave the recommendation and the Provider agreed to the recommendation, she stated she would expect to see the change by the next MRR and must have missed that, on her 3/18/2026 MRR, when no change was made on Resident #9's vitamin B12 dosing. When asked if a B12 level >2000 pg/L had potential for harm, the Pharmacist stated she would defer that question to the Provider.The Director of Nursing (DON) was interviewed on 7/29/2026 at 3:40PM. The DON stated he would get the Pharmacist's recommendations from the pharmacy via email and make sure the provider received them. Once the provider received the recommendation, the provider would agree or disagree with the recommendation. If the order was agreed upon and new orders were needed, the provider would then put in the orders. The DON stated if the provider agreed with Resident #9's vitamin B12 dose being decreased then the order should have been changed as soon as possible, ideally within a week. The DON observed Resident #9's medical chart and confirmed the recommendation was made 2/16/2026 and the vitamin B12 dose was not lowered until 4/2/2026, after the facility received the vitamin B12 lab results from 4/1/2026. The DON did not know what had occurred after the 2/16/2026 pharmacist's recommendation as the DON was not employed at that time. He assumed it was missed by Nurse Practitioner #2 that was no longer employed with the facility. An interview with the Medical Director on 7/29/2026 at 11:31AM revealed that the DON received the monthly MRR pharmacy recommendations from the pharmacy. The Medical Director stated the process of the Provider reviewing the Pharmacist's recommendation had changed due to Nurse Practitioner #1 leaving the facility about 6 months ago. The Medical Director stated a pharmacy recommendation, with a dose change that was agreed upon by the Provider, should be updated by the Provider in the resident's medical chart within a week. The Medical Director observed the 2/16/2026 Pharmacist's recommendation for Resident #9 and stated he would agree to the recommendation. The Medical Director stated this was not reviewed by him, as he always signed and dated his reviews. The Medical Director stated he was currently performing the review of the pharmacy recommendations as Nurse Practitioner #3 started about a month ago and had not learned the process yet. The Medical Director said he had no concerns for Resident #9 having a B12 level >2000 pg/L.The Administrator was interviewed on 7/30/2026 at 11:14AM. She confirmed she received monthly emails sent from the pharmacy to the DON with the Pharmacist's recommendations from the MRR. She stated the DON handled the recommendations. The Administrator also stated that if there was an urgent change the pharmacy would call.

Based on observations and staff interviews, the facility failed to remove expired medications in 1 of 3 medication carts (100-Hall) and remove an unopened expired medication in 1 of 2 medication storage rooms (500, 600, 700, and 800 hall medication storage room) reviewed for medication storage and labeling.The findings included: 1. An observation on 07/29/2026 at 3:43 PM revealed the 100-Hall medication cart had one over the counter bottle of Bisacodyl (Laxative) 5 milligrams that expired in April 2026. The bottle had 5 tablets left in it. The 100-Hall medication cart also had a bottle of Simethicone (Gas Relief) 80 milligrams that expired in June 2026. The bottle was a quarter full as confirmed by Nurse #3. An interview with Nurse #3 occurred on 07/29/2026 at 3:49 PM. Nurse #3 stated that every nurse was responsible for checking medication carts every day for expired medications. Nurse #3 indicated that she only checked for expired medications on the medications she was administering. Nurse #3 explained she had not administered the Bisacodyl and the Simethicone, so she was unaware the medications were expired. An interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 07/30/2026 at 2:18 PM. The ADON stated the main medication cart nurse, or Medication Aide, was responsible for checking the medication carts weekly for expired medications. The ADON explained that the night shift staff checked to make sure dates were written on the medication bottles when they were opened and checked for expiration dates on medications, the day shift staff followed that process as well. The DON and ADON stated that the Unit Manager audited the medication carts biweekly. An interview was conducted with the Administrator on 07/30/2026 at 2:46 PM. The Administrator stated that nurses were supposed to be checking the medication carts weekly and the Unit Managers also checked the carts weekly for expired medications. The Administrator stated the facility has had Per Diem (as needed) nurses working 100-Hall medication cart which could account for the breakdown in their process. 2. An observation with Medication Aide #2 occurred on 07/29/2026 at 4:08 PM for halls 500,600,700, and 800 medication storage room revealed an unopened bottle of Vitamin D3 25 micrograms on the shelf available for use. The bottle contained 100 tablets. The medication expired in June 2026. Medication Aide #2 was interviewed on 07/29/2026 at 4:08 PM. Medication Aide #2 stated that the Central Supply Manager was responsible for the medication room supplies. Medication Aide #2 explained she was unsure when supplies were restocked or checked. An interview with the Central Supply Manager occurred on 07/30/2026 at 10:56 AM. The Central Supply Manager stated that he checked expiration dates on medications every week on Tuesdays and Thursdays in both medication storage rooms. The Central Supply Manager expressed he made sure the medications were not expired when restocking the medications in the cabinets. The Central Supply Manager stated that he rechecked the medications the first thing in the morning at the beginning of his shifts. The Central Supply Manager stated he may have overlooked the medication when he was checking or maybe someone else put the medication back on the shelf instead of discarding it. An interview with Assistant Director of Nursing (ADON) occurred on 07/30/2026 at 2:18 PM. The ADON stated the Central Supply Manager was supposed to check the dates of medications when stocking and discard the medications that were expired. The ADON expressed that nurses should double and triple check when obtaining over the counter medications from the medication storage rooms for expired medications. The ADON stated the Central Supply Manager should be spot checking the medications for expiration dates and placing the new medications towards the back of the cabinet. During an interview with the Administrator on 07/30/2026 at 2:46 PM, The Administrator discussed the process of supplies being sent to the facility. The Administrator stated the final check was making sure there were no expired medications and throwing away any expired medications that were found. The Administrator stated the process failed due to the Central Supply Manager having to perform two job duties while the Maintenance Director was on leave.

Based on record review and staff interviews, the facility failed to accurately complete the daily nurse staffing information for 37 out of 44 days reviewed for posted nurse staffing (6/16/2026, 6/18/2026, 6/20/2026, 6/21/2026, 6/23/2026, 6/25/2026 through 7/7/2026, 7/9/2026 through 7/16/2026, 7/18/2026 through 7/23/2026, and 7/25/2026 through 7/29/2026).The findings included:A review of the facility's daily nurse staffing information from 6/16/2026 through 7/29/2026 revealed the following:The daily nurse staffing information dated 6/16/2026 revealed a census of 96. Review of the facility's detailed census report dated 6/16/2026 revealed a census of 97.The daily nurse staffing information dated 6/18/2026 revealed a census of 97. Review of the facility's detailed census report dated 6/18/2026 revealed a census of 96.The daily nurse staffing information dated 6/20/2026 revealed a census of 98. Review of the facility's detailed census report dated 6/20/2026 revealed a census of 97.The daily nurse staffing information dated 6/21/2026 revealed a census of 97. Review of the facility's detailed census report dated 6/21/2026 revealed a census of 95.The daily nurse staffing information dated 6/23/2026 revealed a census of 96. Review of the facility's detailed census report dated 6/23/2026 revealed a census of 97.The daily nurse staffing information dated 6/25/2026 revealed a census of 99. Review of the facility's detailed census report dated 6/25/2026 revealed a census of 97.The daily nurse staffing information dated 6/26/2026 revealed a census of 97. Review of the facility's detailed census report dated 6/26/2026 revealed a census of 99.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 6/27/2026, 6/28/2026, 6/29/2026, 6/30/2026, 7/1/2026, 7/2/2026, 7/3/2026, 7/4/2026, 7/5/2026, 7/6/2026, and 7/7/2026. The daily nurse staffing information dated 7/9/2026 revealed a census of 91. Review of the facility's detailed census report dated 7/9/2026 revealed a census of 92.The daily nurse staffing information dated 7/10/2026 revealed a census of 92. Review of the facility's detailed census report dated 7/10/2026 revealed a census of 93.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 7/11/2026 and 7/12/2026Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated 7/13/2026 and census was documented as 90. Review of the facility's detailed census report dated 7/13/2026 revealed a census of 91.The daily nurse staffing information dated 7/14/2026 revealed a census of 91. Review of the facility's detailed census report dated 7/14/2026 revealed a census of 92.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated 7/15/2026 and census was documented as 92. Review of the facility's detailed census report dated 7/15/2026 revealed a census of 94.The daily nurse staffing information dated 7/16/2026 revealed a census of 94. Review of the facility's detailed census report dated 7/16/2026 revealed a census of 93.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 7/18/2026 and 7/19/2026.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated 7/20/2026 and census was documented as 92. Review of the facility's detailed census report dated 7/20/2026 revealed a census of 93.The daily nurse staffing information dated 7/21/2026 revealed a census of 93. Review of the facility's detailed census report dated 7/21/2026 revealed a census of 95.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 7/22/2026.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated 7/23/2026 and census was documented as 96. Review of the facility's detailed census report dated 7/23/2026 revealed a census of 95.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 7/25/2026 and 7/26/2026.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated 7/27/2026 and census was documented as 92. Review of the facility's detailed census report dated 7/27/2026 revealed a census of 93.Only the morning shift (7:00AM - 3:00PM) resident census was documented on the daily nurse staffing information dated: 7/28/2026.The census and facility name was not documented on the daily nurse staffing information dated 7/29/2026.An interview with the Staffing Scheduler on 7/29/2026 at 12:49 PM revealed she was currently the one responsible for the nurse staffing information along with the Receptionist. The Receptionist would become fully responsible once she was fully trained. The Staffing Scheduler also stated that the Accounts Receivable Representative gave her the census number daily. The Staffing Scheduler stated the Administrator reviewed the nurse staffing information for accuracy. The nurse staffing information from 6/16/2026 through 7/29/2026 was reviewed with the Staffing Scheduler and she confirmed the nurse staffing information did not contain all the required information and the resident census' were not always correct. She stated the missed census recordings and facility name was an oversight, and the Accounts Receivable Representative gave the wrong census number.The Receptionist was interviewed on 7/30/2026 at 8:21AM. The Receptionist revealed she was new and still learning so sometimes posted the nurse staffing information. The Receptionist stated she retrieved the census from the Accounts Receivable Representative and the Staffing Scheduler, or the Director of Nursing (DON) reviewed it.The Accounts Receivable Representative was interviewed on 7/30/2026 at 8:23AM. The Accounts Receivable Representative revealed she provided a copy of the daily census resident number to the Staffing Scheduler in the morning. The Accounts Receivable Representative confirmed the census number given included adjustments based on admissions or discharges.During an interview with the DON on 7/29/2026 at 3:40PM, it was confirmed that the Staffing Scheduler temporarily posted the daily nurse staffing information as the Receptionist was not fully trained. The DON stated the daily nurse staffing information should be posted with all the information filled in and accurate. The DON confirmed that the resident census must be recorded for all three shifts, the facility name must be recorded, and the resident census should be correct.In an interview with the Administrator on 7/30/2026 at 11:14AM, the Administrator confirmed the daily nurse staffing information should be accurate with all 3 shifts' census recorded. The Administrator also confirmed she reviewed the nurse staffing information and needed to do a better job.

Based on observations, record reviews, staff and Pharmacist interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 2 residents reviewed for misappropriation of property (Residents #299 and #300). The findings included: a. Resident #299 was admitted to the facility on [DATE]. A review of Resident #299's May 2024 Physician's orders revealed an order for Tramadol 50 milligrams (mg) 1 tablet by mouth every 4 hours as needed for moderate and severe pain. A review of a Pharmacy Narcotic Delivery Slip dated 5/31/24 revealed 2 medication cards each containing 30 pills of Tramadol 50 mg were delivered by the pharmacy and signed in as being received by 2 facility nurses. Resident #299 was discharged from the facility on 4/4/25. b. Resident #300 was admitted to the facility on [DATE]. A review of Resident #300's May 2024 Physician's orders revealed an order for Oxycodone 5 mg 1 tablet by mouth every 6 hours as needed for moderate pain. A review of a Pharmacy Narcotic Delivery Slip dated 5/31/24 revealed 2 medication cards each containing 30 pills of Oxycodone 5 mg were delivered by the pharmacy and signed in as being received by 2 facility nurses. Resident #300 was discharged from the facility on 3/10/25. A telephone interview was completed on 4/23/25 at 2:14 pm with Director of Nursing (DON) #2. DON #2 stated on 6/14/24 Nurse #1 observed during her morning medication pass Residents #299 and #300 were each missing 1 narcotic medication card containing 30 pills and the corresponding medication count sheet. DON #2 stated Nurse #1 revealed Resident #299 had 2 cards of Tramadol 50 mg and their corresponding count sheets and Resident #300 had 3 cards of Oxycodone 5 mg and their corresponding count sheets on 6/12/24 (the last day she worked) and now Resident #299 had 1 card of Tramadol 50 mg and the count sheet and Resident #300 had 2 cards of Oxycodone 5mg and their count sheets remaining. DON #2 stated Nurse #1 informed her during the narcotic medication count on 6/14/24 with the off going nightshift Nurse (Nurse #2), there was no discrepancy in the number of narcotic medication count sheets versus narcotic medication cards. DON #2 revealed an investigation was immediately initiated on 6/14/24, and the missing narcotic medications and the count sheets were unable to be located. DON #2 stated during the investigation it was discovered Nurse #2 had written on the Shift Change Controlled Substance Count Check form 2 narcotic medication prescription numbers of medications she had removed and allegedly sent back to the pharmacy on 6/13/24. DON #2 stated Nurse #2 had not written the residents' names by the prescription numbers or the reason for returning the medications, which is required. DON #2 stated the pharmacy was called and the prescription numbers were discovered to be fictious, and the pharmacy had not received any narcotic medications for Residents #299 or #300. DON #2 stated an audit of all narcotic medications, and their count sheets were completed, and no concerns were noted. The DON stated the State Agency, Department of Social Services, Police Department, Drug Enforcement Agency, and reported Nurse #2 to the Board of Nursing for alleged drug diversion were notified of the suspected misappropriation of narcotic medications. DON #2 stated she attempted to contact Nurse #2 to have her come in for an interview but was unsuccessful. The DON stated she notified the staffing agency that employed Nurse #2 of the suspicion and to also have Nurse #2 placed on the do not return list. DON #2 stated the facility replaced Residents #299 and #300's medication and at no time were they without pain medication. DON #2 stated the facility put a Performance Improvement Plan in place following the event. An interview was completed on 4/23/25 at 2:36 pm with Medication Aide #1. Medication Aide #1 stated she worked on the dayshift on 6/13/24 and did not recall any discrepancies in the narcotic medication count cards or count sheets. Medication Aide #1 stated she did not normally work that medication cart, so she would not have immediately recognized if any narcotic medication cards were missing. An interview was completed on 4/23/25 at 2:49 pm with Unit Nurse Manager #1. Unit Nurse Manager #1 stated Nurse #1 notified her of her suspicion of Residents #299 and #300 each missing 1 full narcotic medication card on 6/14/24. Unit Nurse Manager #1 stated she notified DON #2, and an investigation was initiated. Unit Nurse Manager # 1 stated a 100% audit was completed of all the medication carts and medication storage rooms, and the missing medications were unable to be located. Unit Nurse Manager #1 stated she continued to randomly audit narcotic medication count sheets, shift to shift narcotic counts, and Shift Change Controlled Substance Count Check sheets for discrepancies and has had no further concerns. A telephone interview was completed on 4/24/25 at 8:38 am with Nurse #1. Nurse #1 stated she was frequently assigned to care for Residents #299 and #300 during the dayshift. Nurse # 1 stated she was scheduled to work dayshift on 6/10/24, 6/11/24, 6/12/24, and 6/14/24. Nurse #1 stated she recalled on 6/12/24 Resident #299 had 2 full cards of narcotic medication and Resident #300 had 1 partial narcotic medication card and 2 full cards of narcotic medication. Nurse #1 stated when she completed her shift-to-shift narcotic medication count with Nurse #2 at the beginning of her dayshift on 6/14/24 the narcotic medication count was correct, and the number of narcotic medication count sheets matched the total number of narcotic medication cards. Nurse #1 stated it was during her morning medication when she noticed Residents #299 and #300 were each missing a card of narcotic medication and the corresponding medication count sheet. Nurse #1 stated both residents rarely requested the as needed narcotic pain medication, therefore a whole card should not have been used in the time she was away from the facility. Nurse #1 stated she searched the medication cart and medication storage room and was unable to locate the missing medication. Nurse #1 stated she alerted Unit Nurse Manager #1 and DON #2 of the missing medications. A telephone interview was completed on 4/24/25 at 8:44 am with Administrator #2. Administrator #2 stated DON #2 notified her of the missing narcotic medications on 6/14/24 and an investigation was started. Administrator #2 stated the missing narcotic medications, and their count sheets were unable to be located. Administrator #2 stated multiple attempts were made to contact Nurse #2, but they were unsuccessful. Administrator #2 stated the staffing agency that employed Nurse #2 was notified of the allegations and to not send Nurse #2 back into the facility. Administrator #2 stated a narcotic medication diversion report for Nurse #2 was filed with the Board of Nursing. A telephone interview was completed on 4/24/25 at 11:00 am with the facility's Pharmacist. The Pharmacist verified the pharmacy did not receive any cards of Tramadol 50 mg for Resident #299 or Oxycodone 5 mg for Resident #300 on or around 6/13/24. A telephone interview was completed on 4/24/25 at 11:13 am with Nurse #3. Nurse #3 was unable to recall if she signed in narcotic medications for Residents #299 and #300 on 5/31/24. Nurse #3 stated it was the facility's policy to have 2 nurses count and sign verifying the medication on the Pharmacy Narcotic Delivery Slip matched the medication delivered. An attempt to contact the investigating officer on 4/24/25 at 11:25 am was made, however it was unsuccessful. An interview was completed at 1:37 pm with Administrator #1. Administrator #1 stated she was not employed at the facility during the time of the misappropriation of the residents' narcotic medication. Administrator #1 stated she has had no concern of misappropriation of narcotic medication since becoming Administrator of the facility. Multiple attempts made to contact Nurse #2 were unsuccessful. The facility provided the following corrective action plan with a date of 6/14/24 to begin monitoring and a completion date of 6/18/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 06/14/2024 Resident #2 was assessed for pain by the Unit Manager and found to have no changes in pain level. The physician was notified with no new orders. At no time was resident without access to prescribed pain medication. On 06/14/2024 the following agencies were notified regarding the incident of unaccounted for narcotics: Local Police (1:30pm), Adult Protective Services (1:32pm) and the State Agency (2:07pm.) The Pharmacy was notified on 06/18/2024 for replacement of medications. On 06/18/2024 the Drug Enforcement Agency notification was made by the Administrator via an online reporting system. The Staffing Agency was notified by the Director of Nursing regarding suspected misappropriation of narcotic medication and the removal of their employee from our schedule as well as her being added to a do not return list for the facility. The agency indicated that they would initiate an investigation and report to the Board of Nursing. On 7/12/24 Nurse #3 the facility initiated a report of alleged narcotic drug diversion to the NC State Board of Nursing. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/14/24 the Unit Nurse Managers completed an audit of the last 30 days of ordered narcotic medications to ensure the medications were in the medication carts, administered, or returned to the pharmacy per protocol. The Director of Nursing (DON) will initiate an investigation for any identified areas of concern. On 6/14/24 the DON/Unit Nurse Managers completed an audit of 100% of all residents' Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication cart to ensure there were no discrepancies in the count of the medications. On 6/14/24 the DON/Designee will inspect the narcotic blister pill packages for any tampering of medications. On 6/14/24 the Unit Nurse Managers initiated assessments of all residents for pain. The Charge Nurse will address and initiate non-pharmacological interventions, pain medication, and/or Physician notification for any identified areas of concern during the audit. The audit will be completed by 6/14/24. On 6/14/24 the Unit Nurse Managers completed interviews with all alert and oriented residents regarding (1) Do you have any concerns with medication administration to include pain medication? A concern form will be completed for any identified areas of concern. On 6/18/24 the Human Resources Coordinator will complete an audit of all nurses and medication aides license verifications and HCPI checks. All areas of concern will be addressed during the audit. On 6/14/24 the Nursing Supervisor reviewed packing slips for the past 30 days to ensure all narcotic medications were checked in appropriately and accounted for. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/14/24 the Nursing Supervisor initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include the definition, implications, and the process for returning narcotic medications. All in-services will be completed on 6/18/24. After 6/18/24, all nurses or medication aides that have not worked and received the in-service will complete upon their next scheduled shift. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. The decision to monitor the system for monitoring of narcotics was made on 06/14/2024 by the Administrator and Director of Nursing and presented to the Quality Assurance Committee on 06/14/2024. 100% of all ordered narcotic medications will be reviewed by the DON/Unit Nurse Manager weekly x 4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the narcotic medications are being administered or have been returned to the pharmacy as required per policy and there are no signs of drug diversion utilizing the Controlled Substance Audit tool. All areas of concern will be addressed during the audit including reeducating nurses. The DON will review and initial the audits weekly x 4 weeks then monthly x 1 month to ensure all areas of concern are addressed appropriately. The Administrator or DON will present the findings of the Audit Tools to the QAPI Committee monthly for 2 months. The QAPI Committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. Alleged date of compliance: 6/18/24

Based on record review and interviews of the staff, physician, and family member, the facility failed to follow the resident's hospital physican order from the discharge summary for sliding scale insulin which included blood glucose checks (normal range 70 to 120) before meals and at bedtime and to check a resident with diabetes blood glucose as indicated in the standing orders when staff was unable to wake him for 1 of 9 residents reviewed for diabetic care (Resident #1). Findings included: Resident #1's hospital discharge summary dated 8/1/24 documented diagnoses of diabetes, diabetic right foot ulcer, and amputation of the right fifth toe. The resident had blood glucose checks before every meal (3) and at bedtime. The discharge summary included Resident #1's insulin medication orders as follows: - Lispro 100 units/milliliter solution pen-injector. Inject subcutaneous (below the skin) 15 units before meals, sliding scale (fast acting insulin that requires blood glucose check before meals and at bedtime to determine the amount of insulin in addition or less according to the blood glucose level). - Lantus 100 units/milliliter solution pen-injector. Inject subcutaneous 20 units at bedtime, sliding scale (long-acting insulin that required a blood glucose check before administration). Resident #1 was admitted to the facility on [DATE] for orthopedic after care of right fifth toe amputation from diabetic ulcer and had the diagnosis of diabetes. Resident #1's physician orders for insulin dated 8/1/24 were as follows (entered by Nurse #4): - Lispro 100 units/milliliter solution pen-injector. Inject subcutaneous (below the skin) 15 units before meals for diabetes. (This order was not the same as the hospital discharge summary, the sliding scale and accompanying blood glucose check before meals and at bedtime was missing). - Lantus 100 units/milliliter solution pen-injector. Inject subcutaneous 20 units at bedtime for diabetes. (This order was not the same as the hospital discharge summary, the blood glucose check was missing). Resident #1 had standing orders dated 8/1/24 as follows: - Accu-checks (fingerstick blood glucose) before meals and at bedtime for all diabetics, diet controlled, or on oral agents, or insulin for 7 days. Notify the physician of results on day 8. Call the physician for blood sugar less than 60 or greater than 500. - For blood sugars less than 60 give orange juice with two packs of sugar. Recheck in 15 minutes. If still less than 60 contact the physician. For blood sugars greater than 500 contact the physician. Resident #1 had a baseline care plan dated 8/1/24 that addressed his aftercare orthopedic needs and diabetic care. On 8/28/24 at 12:50 pm Nurse #4 was interviewed. Nurse #4 stated that she was the admitting nurse for Resident #1 on 8/1/24 at 5:00 pm. Nurse #4 stated she entered the resident's orders into the electronic medical record including medication from the resident's hospital discharge summary. The summary had the insulin type and dosage and documented sliding scale next to it. Nurse #4 stated she called the physician on 8/1/24 to discuss the Lantus insulin which was long acting because the hospital order had sliding scale. She explained long-acting insulin doses were prescribed with the same dosage and were not given on a sliding scale. Nurse #4 further explained the physician directed her to give the Lantus, as ordered with no sliding scale. She indicated there was no directive received from the physician related to checking blood glucose levels (as indicated in the standing orders). Nurse #4 stated she did not recall if there was short acting insulin because the resident was admitted after mealtime. The nurse further stated she had not checked the resident's blood glucose. She indicated her shift ended at 8:00 pm and she had not administered insulin. Nurse #4 stated Resident #1's admission was her first admission she completed by herself as she usually worked the night shift. She reported there was a feature in the medication record to initiate for nurses to check the blood glucose before giving the Lantus. Nurse #4 stated she was not aware of this feature and was informed during education when she returned to work 8/5/24. She further stated that feature was normally initiated for all new admits receiving Lantus and she had not initiated this feature with the Lantus order for Resident #1. Nurse #4 commented 20 Units of Lantus was a lot of insulin, and a nurse would check the blood glucose before administering. The Lispro short acting insulin had a sliding scale automatically appear in the medication record parameter to choose. But it didn't automatically appear as expected when the order was put in the record. Nurse #4 stated she was not aware the sliding scale with blood glucose check for Lispro insulin before meals and at bedtime had not been initiated with the order to appear in the MAR (Medication Administration Record). Nurse #4 observed the resident's August MAR during interview and could see there was no parameter for sliding scale for the Lispro insulin or blood glucose check before the Lantus administration. Nurse #4 stated she discussed Resident #1 with the Director of Nursing (DON) and Admission Nurse on Monday 8/5/24 when she returned to work that the sliding scale was missed. The DON provided education on how to initiate the blood glucose check with Lantus insulin and how to initiate sliding scale and blood glucose checks with Lispro insulin in the record to appear in the MAR for nurses to check. A review of Resident #1's MAR for 8/1/24 - 8/3/24 revealed he was administered Lispro 100 units/milliliter solution pen-injector 15 units before meals and Lantus 100 units/milliliter solution pen-injector 20 units at bedtime for diabetes. There was no documentation of sliding scale along with the Lispro (short acting insulin) and no blood glucose fingerstick checks before meals and at bedtime prior to the Lantus (long-acting insulin) being administered. A review of Resident #1's nurses' notes for his admission (8/1/24 - 8/3/24) revealed no documentation of fingerstick blood glucose being completed. Resident #1's lab glucose blood draw on 8/2/24 and result on 8/3/24 was 69 (range 70 - 99 normal) for admission. A review of the nurses' documented shift-change report revealed Resident #1 had a fingerstick blood glucose check on 8/3/24 at 4:30 pm with a value of 167 entered by Nurse #1. On 8/27/24 at 1:40 pm an interview was conducted Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 8/3/24 day shift, 7:00 am to 7:00 pm. Nurse #1 stated that the resident was ordered 15 units of Lispro, which was fast acting, before meals. Nurse #1 stated that the resident had no have sliding scale orders in his record and the hospital discharge summary was not available. She stated that 15 units of Lispro was a lot of insulin to administer without checking the blood glucose. Nurse #1 stated she checked the resident's blood glucose without an order before administering the insulin twice on her shift as a nursing judgement. Nurse #1 stated she had never seen a resident with fast acting insulin not have an order to check the blood glucose before meals and at bedtime and had not asked the physician for an order. Nurse #4 stated she reported the blood glucose level taken to nursing staff at shift change and documented one result in the 24-hour shift report. Nurse #1 had not seen any documentation of other blood glucose checks in the 24-hour report, had not received verbal report, or documented in the resident's record. Nurse #1 stated that nurses documented blood glucose in the progress notes if there was no place on the MAR. Nurse #1 stated she had not documented the resident's blood glucose she took in the nursing progress notes. A Nurse's' note dated 8/4/24 by Nurse #2 was created at 1:08 am revealed Resident #1 was sent out to the hospital on 8/3/24 at 11:40 pm. The staff went into the resident's room to change him around 11:00 pm and he was unresponsive and had foam at his mouth. The resident's vital signs were blood pressure 151/109, pulse 63, temperature 98.1 Fahrenheit, respirations 20, and oxygen saturation 94% (normal range 90 to 100%) on room air. When Emergency Medical Services arrived, the resident's blood glucose was 24. The resident was taken to the hospital for further evaluation. On 8/29/24 at 12:15 pm an interview was conducted with Nurse #2. Nurse #2 stated she was assigned to Resident #1 on 8/3/24 7:00 pm to 7:00 am. Nurse #2 received in nursing shift report that the resident was a deep sleeper and difficult to arouse at night. Nurse #2 stated she administered Lantus insulin and Oxycodone at 9:30 pm and the resident was alert and awake. At approximately 11:00 pm or so, Nursing Assistant (NA) #1 reported to Nurse #2 that she could not arouse the resident, and he had some foam around his mouth. The resident was not in any apparent distress and was breathing on his own. His color was unchanged. Nurse #2 stated she tried to wake the resident, and he would not wake. She tried sternal rub and the resident moaned. Nurse #2 stated she took the resident's vital signs, and they were normal for him except the blood pressure was higher. Nurse #2 stated she had NA #1 remain with the resident and she called the physician. The physician provided an order to send the resident out. She indicated she called 911 and Emergency Medical Services (EMS) arrived in about 7 minutes. She reported the whole process took about 15 to 20 minutes Nurse #2 indicated the resident was observed and remained stable breathing on his own until EMS arrived. Nurse #2 stated she had not believed the resident had a blood glucose issue because he had the foam around his mouth and could have had a seizure. The physician had not ordered a blood glucose check and ordered for the resident to be sent out. On 8/29/24 at 12:35 pm an interview was conducted with NA #1. NA #1 stated she was assigned to Resident #1 on 8/3/24 7:00 pm to 7:00 am shift. NA #1 stated that during her usual rounds at approximately 11:00 pm she observed the resident lying in his bed supine. The resident appeared comfortable as if he was sleeping. She indicated when she went to arouse the resident for nighttime care she noticed some foam around his mouth. She indicated she tried to wake the resident by shaking him and he did not arouse. NA #1 stated the resident's color was normal and could see he was breathing on his own. NA #1 indicated she went and got Nurse #2. The nurse tried to arouse the resident and received very little response, and he would not wake up. NA #2 stated that the nurse took the resident's vital signs, and they were normal except the blood pressure was high. The resident was breathing on his own. She reported the time from finding the resident and calling the physician and then EMS was about 15 to 20 minutes. Resident #1's EMS record documented first set of vital signs at 11:39 pm on 8/3/24 were blood pressure 216/99, pulse 116, respirations 20, and oxygen saturation 93% on room air. The resident was unresponsive. The blood glucose was 24 and intravenous therapy was started for hypoglycemia. Resident #1's hospital record documented he was seen in the Emergency Department on 8/4/24 and was diagnosed with sepsis from his right foot ulcer/recent toe amputation which caused renal failure and profound hypoglycemia. The hypoglycemia was resistant to treatment until the sepsis was treated. On 8/27/24 at 4:55 pm an interview was conducted with the physician. The physician stated that the resident had just been admitted (8/1/24) and he had not seen the resident yet. The physician stated he looked at the resident's orders and agreed/signed upon admission. The physician was aware that the hospital discharge summary order for insulin included sliding scale which would mean before meals and at bedtime blood glucose check. He stated his impression was that the nursing staff was checking the resident's blood glucose. He revealed this appeared to have been missed. The physician stated that he was not aware of the admitting blood glucose lab reported on 8/3/24 of 69, he would be looking at the finger stick blood glucose checks 4 times a day by staff to determine the significance. There were 3 finger stick blood glucose checks (one was documented) and one blood glucose lab over the 2 days the resident was at the facility. The physician also commented that he was scheduled to see the resident on 8/4/24 and would have seen the lab drawn blood glucose of 69 resulted on 8/3/24. On 8/29/24 at 2:14 pm a follow up interview was conducted with the physician. The physician stated that he was on call on 8/3/24, all weekend. The physician had not remembered the particulars of Resident #1. He stated if the staff used the airway, breathing, and circulation check for an emergency and the vital signs were stable, it was acceptable to call him and not 911 immediately. The physician reported the staff call 911 for emergencies and not the physician when residents were not stable, or the cause of change was known. A fingerstick glucose check could be part of the emergency assessment. The physician indicated if the nurse was unsure of the cause of the change, as was in this case a seizure was suspected, it was acceptable to contact him first and received direction since the resident had been assessed and vital signs were stable. EMS was close by, arrived quickly, and addressed the issue. The point was the resident needed a higher level of care and the nurse had sought this. The outcome was unchanged. The resident had sepsis from his recent foot surgical site that needed treatment to control the hypoglycemia. On 8/28/24 at 1:30 pm the Director of Nursing (DON) was interviewed. The DON stated when Resident #1 was admitted on [DATE], the physician had not provided orders for blood glucose check by fingerstick before meals and at bedtime, which is part of sliding scale. (The standing orders said check blood glucose before meals and at bedtime for 7 days.) The DON stated all residents in the facility that had short acting insulin ordered had a blood glucose check before meals and at bedtime. She indicated she could see how there was confusion due to the Lantus order from the hospital discharge summary noted sliding scale, however, you would check the blood glucose before administration. The DON stated the physician would have added the sliding scale before meals and at bedtime for the Lispro insulin on Sunday 8/4/24 when the physician would have come in to see the resident. She reported if the resident had signs and symptoms of a change, we would have called the physician and informed him of the assessment. The facility provided the following corrective action plan with a completion date of 8/8/24: 1. Corrective action for resident(s) affected by the alleged deficient practice: Resident #1 was sent to the hospital on 8/3/24 for hypoglycemia and altered mental status. The resident was treated at the hospital for hypoglycemia and sepsis that caused the hypoglycemia. The resident had not returned to the facility. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: On 8/6/24, the DON/Unit Manager initiated an audit of all diabetic residents to ensure orders are in place for fingerstick as ordered by the physician. The Unit Managers contacted the physician for any residents on diabetic medications identified without a fingerstick order to validate need for monitoring. A justification note was documented in the clinical record by the Unit Managers for any diabetic resident that the physician does not want blood sugar obtained. Orders were written for all other diabetic residents that require blood sugar monitoring. The audit was completed on 8/8/24. On 8/6/24, the DON/Unit Manager initiated an audit of all residents receiving insulin to ensure sliding scare was initiated per physician orders when indicated or the physician was notified if the order did not specify amount/type of insulin to be administered based on fasting blood glucose level, frequency to be administered, and/or parameters for notification of the physician. The DON/Unit Manager addressed all concerns identified during the audit to include verifying with the physician the need for sliding scale insulin, updating the Medication Administration Record when indicated and education of all nursing staff. The audit was completed on 8/8/24. On 8/6/24, the DON/Unit Manager initiated an audit of all newly written standing orders for glucose monitoring for residents on diabetic medications from 8/1/24-8/6/24. This audit was to ensure that standing orders were activated and completed per physician orders. The DON/Unit Managers addressed all concerns identified during the audit to include but not limited to activating orders when indicated and/or education of staff. The audit was completed on 8/8/24. 3. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: All nursing staff participated in in-services entitled hypoglycemia, observations of and reporting changes in resident's condition, acute changes, when to notify the physician by telephone, and emergency management by the Director of Nursing completed on 8/8/24 4. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. Beginning 8/5/24, the Admissions Nurse/Unit Managers/ADON will review discharge summary for all new admissions/readmissions 5 times a week for discharge summary, for 4 weeks, then monthly for 1 month utilizing the Diabetic Audit Tool. This audit is to ensure all residents admitted with diagnosis of diabetes have blood glucose monitoring orders in place and/or validate with the physician the need for blood glucose monitoring and to ensure the nurse verified with the physician any sliding scale insulin order that does not specify amount/type of insulin to be administered based on fasting blood sugar level, frequency to be administered, and/or parameters for notification of the physician before transcribing to the Medication Administration Record. The Director of Nursing will review the Diabetic Audit Tool 5 times a week for 4 weeks, then monthly for 1 month to ensure all concerns are addressed. The Admissions Nurse/Unit Manager will audit all newly written standing orders to include orders for glucose monitoring utilizing the Standing Orders Audit Tool 5 times a week for 4 weeks, then monthly for 1 moth. This audit is to ensure standing orders were activated and medication and/or glucose monitoring completed per physicians' orders. The Admissions Nurse/Unit Managers will address all concerns identified during the audit to include activating orders when indicated and/or retraining of staff. The DON will review the audit 5 times a week for 4 weeks, then monthly for 1 month to ensure all concerns are addressed. The Director of Nursing will present the findings of the Diabetic Audit Tool and the Standing Orders Audit Tool to the Quality Assurance Performance Improvement (QAPI) committee monthly for 2 months for review and to determine trends and/or issues that may need further interventions put into placed and to determine the need for further frequency monitoring. Ad hoc QAPI meeting held on 8/8/24. Compliance Date: 8/9/24 Validation of the corrective action plan was completed on 8/30/24: There was a signed roster of clinical staff who received in-service for sliding scale insulin blood glucose monitoring, how to input admission orders and activate standing orders, and to verify any unclear admission orders with the hospital and physician. The nursing staff also participated in acute changes, hypoglycemia, when to notify the physician, and emergency management for the in-services. The medication record was reviewed for eight diabetic residents with insulin. All residents had orders for blood glucose monitoring and sliding scale for short acting insulin. There was documentation of initial audit as well as on-going monitoring audits as part of the quality assurance plan. Nurses #1, #2, #3, and #4, NA #1, the Admitting Nursing, the Director of Nursing, and the physician were all interviewed and were able to state nursing received education for diabetic residents admitted with insulin orders and the need for blood glucose checks and sliding scale for fast-acting insulin and to evaluate blood glucose when a diabetic resident had received insulin or oral anti-glycemic medication and there was a change in status. The completion date of 8/9/24 was validated.

Based on record review and resident and staff interviews, the facility failed to protect a cognitively intact resident from verbal and physical abuse by a family member when Family Member #1 threw cold tea and water onto Resident #1, put her hands around Resident #1's throat, threatened to kill her and pushed Resident #1 onto the bed. This resulted in redness to Resident #1's neck. Resident #1 was sent to the Emergency Department (ED) for evaluation and returned the same day with a diagnosis of the strain of the neck muscle. Staff reported the resident appeared out of breath, nervous, and shocked following the incident. A reasonable person would have experienced feelings such as fear, anxiety, and humiliation. This was for 1 of 4 residents reviewed for abuse. Findings included: Resident #51 was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation, chronic obstructive pulmonary disease, and chronic pain syndrome. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of a nurse progress note written by Agency Nurse #1 completed for Resident #1 dated 5/17/24 at 8:15 PM revealed that Resident #1 walked out of the room to the hallway using her walker, stated Family Member #1 threw tea and water on her and choked her. Resident #1 was drenched in tea (cold tea) and water. Vital signs were taken and oxygen 2 liters given via nasal canula. The residents' skin was assessed, and redness was noted on her neck. Tylenol was given for general pain. The Nurse Practitioner was made aware and an order was received to be sent to ER (emergency room ) for evaluation and treatment. Agency Nurse #1 did not respond to attempts to contact her via telephone for an interview. In an interview on 6/04/24 at 2:49 PM Nurse #1 revealed she had been working on Resident #1's discharge on 5/17/24 as she was scheduled to discharge home that day. Family Member #1 arrived and made multiple excuses for why she could not take Resident #1 home. Nurse #1 revealed that after talking with Family Member #1, she (Family Member #1) went to Resident #1's room, Nurse #1 believed to discuss the discharge with the resident and closed the door. Nurse #1 revealed she was with the Social Worker (SW) approximately 20-30 minutes later when they (Nurse #1 and the SW) saw Family Member #1 walking fast down the hall and noticed that her necklace was broken. When asked what happened to her necklace Family Member #1 began cursing, stated Resident #1 broke the necklace and she (Family Member #1) continued walking. Nurse #1 indicated she went to check on the resident and saw Resident #1 out of her room and overheard her telling Agency Nurse #1 that Family Member #1 tried to choke her. She indicated Resident #1 seemed out of breath so Nurse #1 provided her with oxygen and encouraged her to take deep breaths and calm down. Resident #1 indicated Family Member #1 had thrown tea (cold tea) and water on her, tried to choke her by putting her (Family Member #1's) hands around her throat, and then pushed her back onto her bed. Family Member #2 then pulled Family Member #1 off the resident. Nurse #1 revealed the resident's shirt and pants were wet, and there was liquid on the chair and floor in her room. Nurse #1 revealed she immediately reported the incident to the Director of Nursing (DON) who went to check on the resident. Nurse #1 reported that Resident #1 seemed shocked about what had happened and out of breath as she had waited all day to discharge home and Family Member #1 refused. In an interview on 6/04/24 at 3:00 PM the SW revealed on 5/17/24 she had been working with the Family Member #1 from 11:30 AM till 4:00 PM arranging Resident #1's discharge. She indicated shortly afterwards she saw Family Member #1 in the hall and noticed her necklace was broken. When she asked what had happened, Family Member #1 began cursing Resident #1 and accused her (Resident #1) of breaking her necklace. The SW indicated Nurse #1 was with her and left to check on Resident #1. The SW reported after the incident, she and Nurse #1 encouraged Resident #1 to remain in the facility over the weekend so they could arrange a safe discharge on the following Monday. She indicated Resident #1 was nervous and shaken by the incident. The SW indicated while working with Family Member #1 she had no indication the incident would occur. In a telephone interview with Resident #1 on 6/04/24 at 1:59 PM she reported that 5/17/24 was the first time anything like that had happened and she did not want to talk about it anymore. A review of the hospital discharge summary dated 5/17/24 at 6:55 PM documented Resident #1 was brought in from the nursing facility for evaluation of possible injuries from an assault by Family Member #1 who was supposed to take her home today. Family Member #1 was reportedly trying to choke Resident #1 and was pulled away quickly. She has been arrested. Resident #1 notes pain in the left paraspinal muscles (muscles that support the back) but no anterior neck pain. Resident #1 was diagnosed with left neck strain. No other injuries were noted on the exam. Resident #1 was discharged back to nursing. Resident #1 was noted to take acetaminophen for discomfort. Review of the Police Report completed on 5/17/24 at 4:56 PM documented the police received a report of a Crime Incident of Assault-Physical the facility. The police investigation was still in process. In an interview on 6/04/24 at 12:56 PM the Director of Nursing (DON) indicated that Family Member #1 arrived on 5/17/24 to discuss plans for Resident #1's discharge home. She revealed the SW had 24-hour care lined up, however Family Member #1 was stalling and decided to not follow through with the discharge plan. The DON revealed the SW reported to her the family was upset, and she sent Nurse #1 down to see Resident #1, who then reported the incident to her. The DON indicated staff remained with Resident #1 and when interviewed by the police, Resident #1, repeated the same story. Resident #1 stated she told Family Member #1 she wanted to go home, and Family Member #1 went crazy on her. Resident #1 reported Family Member #1 said she would kill her, put her hands around her neck and pushed her back onto her bed and if Family Member #2 had not pulled her away, she may have been hurt. The DON reported Resident #1 had light red marks underneath her chin and complained of some neck pain. They called the Medical Doctor and received the order to send to the ED for evaluation. Resident #1 returned from the ED that same day with no new orders, and to follow up with her own physician. During that time, Family Member #1 and Family Member #2 returned to the facility, were stopped from entering the facility and the police arrested Family Member #1. The DON revealed Resident #1 agreed to stay the weekend, to allow time to arrange a safe discharge and on the following Monday (5/20/24) she went home with a family friend and with 24-hour services in place. In an interview on 6/04/24 at 12:53 PM the Administrator indicated she was not in the building on 5/17/24 when Resident #1 reported that Family Member #1 had thrown cold tea and water on her. She indicated the DON immediately notified the police. She reported Family Member #1 was arrested later that evening when she returned to the facility. The Administrator reported that they had no prior indication Family Member #1 would become physical with Resident #1. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 5/17/24 the resident notified the Charge Nurse that during a visit at the facility Family Member #1 threw a glass of tea and attempted to throw a glass of water on the resident then put her hands around the resident's neck and stated, I will kill you. The resident stated Family Member #1 pushed the resident hard back onto the bed, hitting the resident's leg with her shoe. Family Member #2 intervened, and both the Family Member #1 and Family Member #2 left the facility. On 5/17/24 at approximately 4:45pm, the Social Worker and the Unit Manager reported to the Director of Nursing that an altercation had occurred between the resident and the Family Member #1. The Unit Manager completed a skin assessment on the resident which revealed red marks on both sides of her neck. The resident complained of neck pain. On 5/17/24 At approximately 5:00 pm, the Unit Manager notified the physician of altercation and resident assessment with a new order to send the resident to the emergency department for evaluation. The staff stayed with the resident for emotional support. On 5/17/24 at approximately 4:50 pm, the Director of Nursing notified the local police department of alleged family to resident abuse. On 5/17/24 at approximately 5:25pm, the Director of Nursing notified Adult Protective Services (APS) of alleged family to resident abuse. On 5/17/24 at approximately 5:45pm the local police arrived and interviewed the resident with the same findings as the facility. During this time, Family Member #1 arrived back at the facility and was intercepted by the receptionist and police. On 5/17/24 at approximately 6:10 pm, the resident was transported to the Emergency Department. On 5/17/24 at approximately 6:30 pm, all current staff were educated, and a sign with a picture of Family Member #1 and Family Member #2 was placed at the front screening desk and time clock that the Family Member #1 and Family Member #2 were not allowed to visit. On 5/17/24 at approximately 11:45pm, the resident returned from the hospital with a diagnosis of strain of neck muscle, and alleged assault. There were no new orders received. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 5/17/24, skin checks were initiated on all residents who are unable to report signs/symptoms of abuse by the hall nurse. A skin check assessment tool will be utilized with documentation in the electronic medical record. The skin checks were completed by 5/20/24 with no identified areas of concern. On 5/17/24, the Social Worker interviewed all alert and oriented residents regarding abuse. Questionnaires included: Do you know what abuse means? Are there any instances that you felt you were abused in any way that has not been addressed to include verbal abuse and/or abuse by family or visitors? Do you know who to report abuse to? Do you feel safe here? There were no additional concerns identified during resident interviews. Residents were educated on abuse to include domestic abuse and how to report abuse by the Social Worker during the interviews. The interviews were completed by 5/20/24. On 5/17/24, the Director of Nursing initiated questionnaires with all nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding: Do you know of any resident that you have witnessed or that has reported abuse to you that has not been addressed to include abuse by resident family and/or visitor? If yes: Please explain. The Administrator and/or DON will address all concerns identified during the questionnaires to include but not limited to assessment of the resident and reporting concerns per facility guidelines. The questionnaires were completed by 5/20/24. After 5/20/24, any staff that had not worked or who had not completed the questionnaire will complete it upon the next scheduled shift. On 5/17/24, the Director of Nursing initiated an audit of all resident progress notes for the past 30 days. This audit is to identify any concerns related to abuse to include but not limited to verbal abuse and/or abuse by family or visitors. The DON will address all concerns identified during the audit to include assessment of the resident and reporting concerns per facility protocol. Audit was completed by 5/20/24. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 5/17/24 the facility posted a picture of Family Member #1 and Family Member #2 at the front screening desk and time clock to ensure they are not permitted in the facility. On 5/17/24 the DON initiated in-services with all nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding Abuse to include the definition of, domestic, verbal, and physical abuse, immediately removing/protecting resident from abuse and reporting abuse to the Administrator and/or DON. In-service was completed by 5/20/24. After 5/20/24, any staff who had not completed the in-service will complete it prior to the next scheduled work shift. Proactively the facility mailed in-services to any staff who had not worked or completed the in-service with instructions to read, sign and return to the Administrator and/or DON prior to the next scheduled work shift. All newly hired staff will be in service during orientation regarding Abuse. On 5/20/24 Abuse Quizzes was initiated by the Unit Managers and Social Workers with all nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist. The quizzes included questions regarding (1) What to do first if you witness a resident being abused to include abuse by a family member or visitor? (2) If you witness abuse, when do you report it? (3) Who do you report abuse to? (4) if a family member is verbally or physically abusive to a resident, what do you do? (5) Who is the abuse officer/coordinator? The purpose of the abuse quizzes is to ensure that all staff display successful knowledge and understanding of abuse to include domestic abuse, intervening when abuse is witnessed or suspected and reporting abuse. The abuse quizzes were completed by 5/20/24. After 5/20/24, any remaining staff that had not worked and not received the quizzes will complete it upon next scheduled shift. On 5/20/24, the Social Worker and Activities Director held an impromptu Resident Council Meeting with alert and oriented residents to review the definition of abuse to include domestic abuse, signs, and symptoms of abuse, what to do in an abusive situation and reporting abuse. The Social Worker educated any alert and oriented resident who did not attend the meeting 1:1. The education was completed by 5/20/24. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The IDT team to include the Administrator, DON, ADON, Unit Managers, and Social Worker, will review resident progress notes utilizing the Concerns Audit tool 5 times a week x 4 weeks during the IDT meeting. This audit is to identify any concerns related to abuse to include but not limited to verbal abuse and/or abuse by family or visitors. The Administrator and DON will address all concerns identified during the audit to determine if further actions are needed. The Social Worker will interview 10 alert and oriented residents regarding abuse weekly x 4 weeks utilizing the abuse questionnaire. Questionnaires included: Do you know what abuse means? Are there any instances that you felt you were abused in any way that has not been addressed to include verbal abuse and/or abuse by family or visitors? Do you know who to report abuse to? Do you feel safe here? The Social Worker will address all concerns identified during the questionnaires to include notification of the Administrator and/or DON per facility protocol. 10 Abuse Quizzes will be completed by the Unit Managers, Treatment nurse, RN Supervisors and/or Quality Assurance Nurse with staff weekly x 4 weeks to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist. The quizzes are to ensure staff maintain knowledge and understanding of the abuse policy, reporting abuse and protection of the resident. The Nursing Supervisor, Staff Facilitator and Quality Assurance nurse will address all areas of concern identified during the quiz to include re-education of staff. The DON and/or Administrator will review quizzes weekly x 4 weeks to ensure all concerns are addressed. Audits will be reviewed by Quality Assurance and Performance Improvement (QAPI) monthly for 3 months to ensure compliance is achieved and maintained. Include dates when corrective action will be completed: 5/21/24 Onsite validation was completed on 6/05/24 through staff interviews, and record review. Staff were interviewed to validate in-services completed on domestic, verbal and physical abuse and reporting abuse to the Administrator and/or DON. A review of the audits of resident progress notes for past abuse and a review of skin checks for all residents unable to report signs/symptoms of abuse were confirmed to be completed. Review of the questionnaires for all alert and oriented residents interviewed for abuse and review of the questionnaires for all staff do they know of any resident who had been abused were verified. Review of the Abuse quizzes for all staff and the Concerns Audit tool revealed no concerns. Review of residents' progress notes audited for past abuse and resident interviews verified no additional issues were identified. The facility's action plan was validated to be completed as of 5/21/24.

Based on observations, record review and staff, Physician, and resident interviews the facility failed to prevent a significant medication error when Nurse #1 administered Resident #63 medications prescribed to Resident #340 to include carvedilol (a medication classified as a beta blocker used to lower the heart rate and high blood pressure) 25 milligram (mg), losartan (a medication to treat high blood pressure) 25 mg, hydralazine (a medication to treat high blood pressure) 100 mg, and apixaban (a medication to thin the blood) 5 mg on 01/14/24. Resident #63 had previously received her own prescribed carvedilol 25 mg and losartan 100 mg that morning prior to receiving Resident #340's medication which resulted in duplicate medication. Resident #63 was transported by Emergency Medical Services to the hospital emergency department (ED) where she required intravenous (IV) (directly into the vein) administration of norepinephrine (a medication used to treat life threatening hypotension) to increase her blood pressure, 2 liters of IV fluids, and was admitted to critical care management for treatment to prevent life-threatening conditions of shock and toxidrome (a syndrome caused by dangerous levels for toxins in the body, often the consequence of a drug overdose). This deficient practice affected 1 of 5 residents reviewed for significant medication errors. Findings included: Resident #63 was admitted to the facility on [DATE] with a diagnosis that included hypertension, heart failure, cirrhosis of the liver, and renal failure. The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was cognitively intact and received an antiplatelet (medication to prevent blood cells called platelets from clumping together to form a clot). Review of the January 2024 physician orders for Resident #63 revealed orders for carvedilol 25 mg and losartan 100 mg. Resident #63 had no orders for hydralazine 100 mg or apixaban 5 mg. Review of the January 2024 Medication Administration Record (MAR) revealed that on 01/14/24 at 8:00 am Resident #63 received all her scheduled medications as ordered to include, carvedilol 25 mg and losartan 100 mg, as evidenced by nursing initials for Nurse #1 and a checkmark on the MAR. Resident #340 was admitted to the facility on [DATE]. Resident #340's physician orders included carvedilol 25 milligram (mg), losartan 25 mg, hydralazine 100 mg, and apixaban 5 mg. In a record review of a medication error incident report completed by the Assistant Director of Nursing (ADON) dated 01/14/24 at 10:45 am it was revealed that a medication error had occurred for Resident #63 when the medication nurse (Nurse #1) scanned medication for administration prescribed to Resident # 340 (who had the same first name as Resident #63) and instead administered the medication to Resident #63. The review further revealed that the medication nurse (Nurse #1) identified Resident #63 by her first name only. Resident #63 received medications not prescribed to her that included: losartan 25 mg, carvedilol 25 mg, and apixaban 5 mg. A record review of a Facility Witness Statement dated 01/14/24 written by Nurse #1 revealed that Nurse #1 administered medication intended for another resident to Resident #63. It further revealed that she entered Resident #63's room and called her by her first name, and Resident #63 answered. Nurse #1 then administered the medication [intended for Resident #340] to Resident #63. As she was exiting Resident #1's room she realized she administered the medication to the wrong resident. The review further revealed that Nurse #1 immediately notified the DON who informed her to notify the Physician and she then paged Physician #2 and he responded and informed Nurse #1 to send Resident #63 to the hospital. She indicated she called EMS and then assessed the resident until EMS arrived. She then notified the family of the medication error, and that Resident #1 was sent to the hospital for monitoring. The completion of this document was signed as witnessed by the DON and the Assistant Director of Nursing (ADON). Review of a nursing progress note written by Nurse #1 dated 01/14/24 at 3:36 pm revealed Resident #63 received her medications 8:00 am. She remained in bed and stated she was feeling better. At 11:00 am, Nurse #1 scanned and prepared another resident's [Resident # 640] medications, walked into Resident #63's room and identified her by first name. Resident #63 received duplicates of carvedilol and losartan as well as a single dose of apixaban. On exiting the room Nurse #1 became aware of the mistake. She checked Resident #63's B/P with results of 159/86 (increased blood pressure) and rechecked 30 min. later with results of 110/68 (decreased blood pressure). Notified the on-call Physician #2. Orders were received from Physician #2 to send Resident #63 to the emergency department. The family member was notified. EMS arrived and transported Resident #63 to the hospital on 01/14/24 at 12:15 pm. Review of a nursing progress note written by Nurse #1 dated 01/14/24 at 4:02 pm revealed that this note was an addition to Nurse #1's note dated 1/14/24 at 3:36 pm. The documentation indicated that Resident #63 remained alert and oriented, awake and answering questions appropriately. Respirations remained unlabored, at a rate of 16 when emergency medical services arrived. Resident #63's skin was documented as warm, dry, and pale. She denied pain and stated, I'm just really tired. Resident #63 sat up and moved to the gurney with the assistance of the emergency medical technician. An NA remained with Resident #63 until she was transported. In a phone interview with Nurse #1 on 02/08/24 at 11:24 am it was revealed that she was the weekend supervisor on 01/14/24 and had been assigned to Resident #63's unit that day after another nurse did not show up for her shift. She further stated that she was not typically assigned to a medication cart and was unfamiliar with the resident and unit. Nurse #1 stated she had given Resident #63 her prescribed medications around 8:00 am on 01/14/24. She further stated that around noon on 1/14/24 she prepared medications prescribed for Resident #340, who had the same first name as Resident #63. Resident #340 resided in the room next to Resident #63. Nurse #1 stated she entered Resident #63's room with the medications she had prepared for Resident #340 in error. She stated she only looked at the first name on the room door name plate and called Resident #63 by her first name and that Resident #63 responded yes. She further added that she did not verify Resident #63's last name or date of birth and did not compare the picture on the MAR like she should have. Nurse #1 indicated that she then gave the medication that she had prepared for Resident #340 to Resident #63 and by the time she got back to the medication cart she realized that she had given the wrong medication to Resident #63. She stated that she immediately called the DON and then called Physician #2 and was instructed to send Resident #63 to the hospital for further evaluation and monitoring. The interview further revealed Nurse #1 had checked Resident #63's blood pressure right after she realized she gave Resident #63 the wrong medications and re-checked her blood pressure again 20 minutes later and she noted that Resident #63's blood pressure was lower the second time. She stated she called Emergency Medical Services (EMS) and the resident was sent to the hospital for further evaluation and monitoring. She then notified the family. Nurse #1 stated that she was stressed on 01/14/24 because she wasn't familiar with that unit. She further added that the call bell system was not working, and residents were given handbells to call for assistance and she was trying to assist in answering the handbell calls. She added she was behind on administering medications and other residents had come to the medication cart and asked for their medication. She further added that family members of other residents came to her to ask questions, and this caused her to be rushed and she just didn't verify the identity of Resident #63 like she should have. Review of progress note written by Physician #2, the Medical Director, on 01/14/24 at 12:04 pm revealed that he was contacted by a nurse that a resident had a medication error and was given another resident's medications. The note further revealed that Resident #63 had received her own carvedilol 25 mg and losartan 100 mg and in addition received another carvedilol 25 mg, another losartan 100 mg, and received hydralazine 100 mg. In addition, she is quite anemic with a hemoglobin of 7.5 and she received apixaban. The review indicated that Resident #63 could not be monitored safely in the facility and should be monitored on telemetry (continuous heart monitoring), so she was sent to the hospital to be closely monitored. Review of the EMS report dated 01/14/24 revealed EMS responded to a call to the facility because staff gave Resident #63 someone else's medication. The primary impression on the report was documented as poisoning/drug ingestion. Blood pressures monitored during EMS transport to the hospital emergency department indicated blood pressures of, at 12:22 pm 130/54; at 12:34 pm 103/57; at 12:40 pm 108/60; at 12:46 108/63; and at 12:51 95/50. An IV catheter was inserted at 12:48 pm and a saline lock (a short section of tubing attached to the end of an IV catheter that is filled with normal saline solution and then capped to close off the tubing until medications are ready to be administered). The record review further revealed that staff reported to EMS that they had given Resident #63 her prescribed medication and 30 minutes later gave her someone else's medication. It was reported to EMS that Resident #63 was given an extra 25 mg of carvedilol, and extra 100 mg of losartan and was given 2 other medications, that included, apixaban 5 mg and hydralazine 100 mg, not prescribed to her. EMS personnel assessed and monitored the resident continuously while enroute to the hospital. Review of hospital ED records dated 1/14/24 revealed Resident #63 was received in the ED on 01/14/24 from EMS for a chief complaint of hypotension. The original ED assessment and plan outlined and included the following (as written): 1. Unintentional drug administration 2. Hypotension a. Patient normally takes Coreg 25 mg and losartan 100 mg. b. Given additional doses of coreg [carvedilol] 25, losartan 100, hydralazine 100, and Eliquis [apibaxan] 5 by mistake at her facility. c. Monitor vitals. d. Given a 2-liter bolus [IV fluid administered at a rapid rate to improve cardiac output, correct low blood pressure and ensure sufficient renal blood flow] in ER and will continue IV fluid hydration. e. Start peripheral levophed [norepinephrine] and keep MAP [mean arterial pressure] greater than 65 and decrease if able. 3. Hypertension a. Hold home meds. The hospital record review further revealed that Resident #63's blood pressure was 102/67 when she arrived in the hospital emergency department at 12:55 pm and entered triage at 1:04 pm. She was oriented to person, place, and time, was at high risk of morbidity, and had high complexity. She was placed in observation. At 1:10 pm Resident #63's blood pressure was trending downward, and her MAP was <65, a bolus of intravenous fluids was hung to be administered. Vital signs were monitored every 10 minutes and blood chemistry studies were done. An electrocardiogram (EKG) (a test to detect heart problems) was done and revealed a prolonged QT [an irregular heart rhythm] wave abnormality. Poison control was consulted for recommendation in the care of Resident #63 because of the overdose of medication. Poison Control recommended norepinephrine already explained in the PS and to repeat an EKG to ensure the QT prolongation had resolved. At 3:54 pm her blood pressure dropped into 80s/40s, and the physician ordered Resident #63 to be admitted to the hospital to critical care. Resident #63 was discharged from the ED observation at 3:58 pm and admitted to the hospital in critical care, she continued to receive intravenous norepinephrine to treat low blood pressure. A Physician progress note dated 01/14/24 at 3:59 pm indicated that critical care was necessary to treat or prevent imminent or life-threatening deterioration for the following conditions: shock and toxidrome and that critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. At 5:36 pm Resident #63's blood pressure was 117/87 and her MAP was 96. Her blood pressure was monitored every 10 minutes. The medication error that resulted in the hospitalization of Resident #63 was resolved 48 hours after admission. Resident #63 was hospitalized for a total 4 days, the later portion to of the hospitalization was related to additional gastrointestinal issues that arose after being admitted to the hospital, that was later determined to not be related to the medication error. Resident #63 was discharged from the hospital on 01/19/24 to home with home health. In a phone interview with Resident #63 on 02/09/24 at 9:28 am she stated that she could recall that on 01/14/24 nurses (could not recall names) kept going in her room at the facility and asked how she felt. I told them I was tired and sleepy because I didn't not get much sleep the night before. She further stated that initially she did not know why staff kept asking her how she felt and then a nurse that she had never seen before told me she had given me my medication and another patient's blood pressure medication and blood thinner, and the doctor had recommended that I be sent to the hospital. She stated that one nurse came in and stayed with her until the rescue squad arrived indicating that she was not left alone during this timeframe. Resident #63 further indicated that she was feeling very sleepy and when the rescue squad arrived, she was taken to the hospital. She stated when she arrived at the hospital she was really scared, and her stomach started hurting and she got sick to her stomach. She stated her blood pressure then bottomed out and they went to working on me trying to get my blood pressure back up. She described the stomach pain that she had as a 9 on a 0/10 scale used to measure intensity of pain (0 being no pain and 10 being the worst pain). Resident #63 stated she was in the emergency department all night and then was admitted to the hospital. She stated the doctor told her that her stomach pain occurred because her blood pressure bottomed out. She further added that she was in the intensive care step down unit and had monitors on her that checked her heart, she received fluids and medications intravenously through an IV, and they had to call poison control. Resident #63 stated that when the nurse at the facility brought her Resident #340's medications that she didn't question it because they always brought her medication throughout the day, and she trusted that it was her medication. She stated that they usually asked her for her full name and birthdate but didn't think Nurse #1 asked her that day and just said my first name. In a phone interview with Physician #2 (the Medical Director) on 02/06/24 at 12:15 pm it was revealed that Nurse #1 notified him by phone of a medication error in which she administered another resident's medication to Resident #63. She told him that she had already administered Resident #63 her own prescribed medications on the morning of 1/14/24. Physician #2 recalled that she had given Resident #63 blood pressure reducing medications and a blood thinner not prescribed to her. He further added that she received her own prescribed carvedilol and losartan and then received duplicate doses of carvedilol (beta blocker) and losartan, as well as apixaban (a blood thinner). Physician #2 stated that when Nurse #1 called him Resident #63's vital signs were not concerning to him at that time, but he anticipated what the outcome could be, and he felt that she would need monitoring at the hospital because of the medication error so he called the hospital emergency department himself to give them report on Resident #63. He added he was concerned that she could go into heart block and her pulse rate would decrease down into the 30's and her blood pressure could decrease, and she would become unconscious and all of the medications that she received would cause her blood pressure to decrease. He stated if the blood pressure became too low that it could cause kidney function problems. He further stated that she had cirrhosis of the liver and that caused concerns of bleeding because of the blood thinner. He stated it could take a few days for the beta blocker to clear her system. He stated the resident was at risk for harm and required monitoring, stating if her blood pressure became too low that she would require care in the Intensive Care Unit at the hospital. Physician #2 stated that he felt the situation was handled appropriately by the facility and he was contacted immediately. In a review of an Investigational Summary completed by the facility dated 01/14/24 addressed to the Quality Assurance Committee revealed that a Medication Error occurred on 01/14/24 and that a dayshift nurse had administered the wrong medication to Resident #63 in error. Resident #63 was sent to the emergency department for monitoring related to Resident #63 received increased dosage of blood pressure medication and a blood thinner. The investigational summary revealed there were 3 residents with the same first name on the same unit and the nurse entered Resident #63's room and called the resident by her first name. She then gave Resident #63 the wrong medication. In an interview with the Director of Nursing (DON) on 02/8/24 at 11:05 am it was revealed that she was aware of a medication error that occurred on 01/14/24 by Nurse #1. The DON stated that Nurse #1 called her right away on 01/14/24 to report that she had made a medication error and gave Resident #340's medication to Resident #63 in error and that Resident #63 had already received her own prescribed medication, which caused her to receive duplicate blood pressure medication. The DON further added that the medication error could cause Resident #63 to become hypotensive and could have caused cardiac issues in a resident with a cardiac diagnosis. She stated the resident was sent to hospital for routine monitoring. She stated that Nurse #1 was a supervisor and was not usually assigned to a medication cart. Another nurse had called out on 01/14/24 and Nurse #1 was assigned to the medication cart. The DON stated that Nurse #1 should have verified the resident using full name first and last, picture on the electronic medication administration record (e-MAR) and if she was still unsure, she should have asked someone that was familiar with the resident. The interview further revealed that the normal protocol for medication training for nurses was that they received medication administration training for 3 days with another nurse before they are assigned to a medication cart, and if they are not comfortable the training is extended until they are comfortable. They learn to use e-MAR and how to scan meds. Nurses also received computer-based on-line training that included the five rights of medication administration and how to identify a resident. To identify a resident the nurse should compare the picture on the e-MAR to the resident, knock on door and ask the resident their full name. If the resident is not alert and oriented and cannot tell you who they are then the nurse should compare the picture on the e-MAR to the resident and ask a staff member that is familiar with that resident. The DON stated that Nurse #1 received the required medication administration training. Nurse #1 was re-educated but was not disciplined because she resigned from her position right away. Review of medication administration training transcript for Nurse #1 revealed that she had completed computer-based learning modules titled Medication Administration Safety on 08/30/23 and Medication Scanning on 01/10/24. In an interview with the Administrator on 02/06/24 at 12:37 pm it was revealed that she was aware of the medication error regarding Resident #63 and that the nurse immediately notified the DON and the Medical Director, and they decided that due to the type of monitoring required that the resident would be sent to the hospital for further evaluation and treatment. She stated she felt that the medication error occurred because the nurse had distractions of a family member repeatedly coming to the med cart to ask questions and Nurse #1 got distracted and should have just put her medication cart up for the time being. This was the first time this nurse had made any medication errors. The interview further revealed Nurse #1 was very upset that it had occurred and told her that she had other residents with the same first name as Resident #63 and she gave Resident #340's medication to Resident #63 because they had the same first name. She stated after the error occurred the facility did a 100 percent audit for all residents with like names and assessed other resident to make sure they got their meds accordingly, she stated they did some medication pass audits with nurses. The interview further revealed that a Performance Improvement Plan was done and the plan was still in progress. The Administrator stated Nurse #1 should have done the 6 rights of medication administration to include asking the resident her name, first and last name and verifying it with the e-MAR and the picture on e-MAR. The Administrator was notified of Immediate Jeopardy on 02/06/24 at 3:10 pm. The Administrator provided the following corrective action plan with a compliance date of 01/18/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice On 01/14/24, Nurse #1 prepared Resident #340's medication at the medication cart. She entered the room of Resident #63, who has the same first name as Resident #340. She called the resident's first name, and the resident responded. The nurse then administered Resident #340's medications to Resident #63 in error. While exiting the room, the nurse realized she had given the resident the wrong medication. The nurse immediately assessed the resident and obtained vital signs. Blood pressure 159/78, heart rate 77, respiratory rate, 16-18, the resident remained alert and oriented, and able to answer all questions appropriately. The nurse notified the Director of Nursing (DON) and the physician of the medication error, and the resident was sent to the emergency room for monitoring per the physician's recommendations. The resident was admitted to the hospital for monitoring of medications administered in error and was treated with medication for low blood pressure, which was resolved within 24 hours. On 01/16/24, a root cause analysis was completed by the Administrator and Director of Nursing. The root cause of the medication error was determined to be Nurse #1 administered medication to Resident #63 without appropriately confirming the resident's complete name and utilizing the resident's picture in the electronic medical record as an identifier. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 01/16/2024, the Assistant Director of Nursing (ADON) and Unit Manager initiated an audit of all residents for signs and symptoms of acute changes in condition to investigate the cause of the change and ensure the change was not related to significant medication errors. There were no areas of concern identified during the audit. The audit was completed by 01/17/2024. On 01/16/2024, an audit of all progress notes for the past 14 days was initiated by the DON. This audit was to identify any documentation related to a resident with an acute change from a significant medication error to ensure the resident was assessed, interventions were initiated, and the physician was notified for further recommendations. There were no areas of concern identified during the audit. The audit was completed by 01/17/2024. On 01/17/2024, the ADON and Unit Manager initiated Medication Pass Audits with all nurses and medication aides including agency. This audit was to ensure (1) the nurses and/or medication aides administer medications per the physician's order (2) staff utilize the rights of medication administration to include the right medication and to the right resident by asking the resident their full name and using the picture in the electronic medication administration record as an identifier and (3) staff demonstrated what to do if resident, family or staff interrupt during medication administration to avoid errors. This includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The ADON and Unit Manager addressed all concerns identified during the audit including reeducation of staff if indicated. There were no other significant medication errors identified during the audit. The audit was completed by 01/17/2024. After 01/17/2024, any nurse or medication aide including agency who has not worked or completed the medication pass audit completed it upon the next scheduled work shift. On 01/16/2024, the ADON initiated an audit of all residents with like names and proximity of room locations. Name alerts were placed on the medication administration record (MAR) for residents with similar names and rooms within close proximity of each other. The ADON addressed all concerns identified during the audit, including posting name alerts in the medical record. The audit was completed by 01/17/2024. On 01/16/2024, the DON completed an audit of all incident reports for the past 30 days to identify any medication administration concerns resulting in medication errors. No additional concerns were identified during the audit. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 01/14/2024, ADON initiated an in-service with all nurses and medication aides to include agency regarding the?Rights of Medication Administration. The education emphasized (1) administering medications per physician order, (2) the rights of medication administration including but not limited to the right medication to the right resident, and (3) disposing of medications if not administered immediately (4) how to identify residents with emphasis on asking resident to state full name and utilizing electronic record photo to verify residents prior to administering medications (5) what to do if you are still not sure of the resident's identity i.e. ask a staff member familiar with the resident to verify their identity and (6) what to do if residents, family or staff interrupt during medication administration to avoid errors which includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The in-service was completed by 01/17/2024. After 01/17/2024, any nurse or medication aide including agency who had not worked or completed the education completed it prior to the next scheduled shift.? All newly hired nurses and medication aides including agency will be educated by the Director of Nursing or Nurse Supervisor during orientation, prior to performing medication administration, regarding the?Rights of Medication Administration including (1) administering medications per physician order, (2) the rights of medication administration including but not limited to the right medication to the right resident, and (3) disposing of medications if not administered immediately (4) how to identify residents with emphasis on asking resident to state full name and utilizing electronic record photo to verify residents prior to administering medications (5) what to do if you are still not sure of the resident's identity i.e. ask a staff member familiar with the resident to verify their identity and (6) what to do if residents, family or staff interrupt during medication administration to avoid errors which includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The Administrator will track to ensure the education is completed by utilizing the staff new hire and/or agency orientation checklist. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to monitor the system for prevention of significant medication errors was made on 1/16/24 by the Administrator and Director of Nursing and presented to the Quality Assurance Committee on 1/16/24. The ADON and Unit Manager will complete 5?Medication Pass Audits?across all shifts with nurses and medication aides weekly x 6 weeks then monthly x 2 months. This audit is to ensure (1) the nurses and/or medication aides administers medications per the physician's order (2) staff utilizes the rights of medication administration to include the right medication and to the right resident (3) the staff utilizes the appropriate technique when identifying residents and (4) staff demonstrates what to do if resident, family or staff interrupt during medication administration to avoid errors. The ADON and Unit Manager will address all concerns identified during the?Medication Pass Audits, including re-training of the nurse and/or medication aide. The Administrator will review the Medication Pass Audits weekly x 4 weeks to ensure all concerns are addressed. The Interdisciplinary Team, including, the DON, ADON, Minimum Data Set (MDS) nurse, and Nurse Supervisor will review progress notes 5 x week x 6 weeks then monthly x 2 months. This audit is to identify any documentation related to a resident with an acute change from a significant medication error to ensure the resident was assessed, interventions were initiated, and the physician was notified for further recommendations. The Director of Nursing will immediately address all areas of concerns identified during the audit, including resident assessment, notification of the physician for further recommendations with documentation in the electronic record, and staff re-training. The Administrator will review the progress note audit weekly x 6 weeks then monthly x 2 months to ensure all concerns were addressed. The Interdisciplinary Team, including, the DON, ADON, Minimum Data Set (MDS) nurse, and Nurse Supervisor will review incident reports weekly x 6 weeks then monthly x 2 months. This audit is to identify any medication administration concerns resulting in medication errors to ensure appropriate interventions were initiated, the physician notified, and the resident assessed as indicated. The Director of Nursing will immediately address concerns identified during the audit, including resident assessment, notification of the physician for further recommendations with documentation in the electronic record, and staff re-training. The Administrator will review the incident report audit weekly x 6 weeks then monthly x 2 months to ensure all concerns are addressed. The Administrator/DON will forward the results of the Medication Pass Audits, Progress Note Reviews, and Incident Report review to the Quality Assurance Performance Improvement (QAPI) Committee including the Medical Director, DON, Administrator, Social Worker, Dietary Manager, ADON, Therapy Director, and Activity Director, monthly x 4 months. The QAPI Committee will meet monthly x 4 months and review the Medication Pass Audits, Progress Note Reviews, and Incident Report review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Alleged Compliance Date: 01/18/24 Validation of the corrective action was completed on 02/8/24. This included staff interviews with nurses regarding the 6 rights of medication administration to include resident identification prior to administration of medication as well as observations of medication passes to ensure the 6 rights of medicat [TRUNCATED]

Based on observations and staff interviews, the facility failed to maintain a dumpster that was in good condition and free of leaks and to maintain the dumpster area free of debris for 1 of 1 dumpster. This practice had the potential to attract pests and rodents. Findings included: Observation of the facility's dumpster area on 2/07/24 at 1:30 PM with the Regional Nutrition Consultant revealed an area of a black substance around the dumpster which extended about 10 feet toward the road. This area of black substance had a strong odor of refuse. The area observed under the dumpster had approximately 3 inches of black debris which had a strong odor of refuse. The area behind the dumpster and the recycle container but inside the dumpster area fence had several items. These items included a broom, dustpan, shovel, 3 2x4 wood boards, 1 full bag labeled topsoil, 1 partial bag labeled topsoil, and 1 approximately sized 10 feet by 8 feet rusted, gray metal frame with 6 open areas. During an interview on 2/07/24 at 2:10 PM with the Dietary Manager he stated that the dumpster had been leaking for months. He also stated that he was unaware of the items behind the dumpster and did not know why they were there. During an observation and interview with the Administrator on 2/07/24 at 1:45 PM she stated that the dumpster had been leaking for a week and they were working to get a new dumpster. She stated she was unaware of the items behind the dumpster and did not know why they were there.

Based on observations, record review, resident, staff, Nurse Practitioner (NP) and Physician interviews the facility failed to obtain a physician's order for the use of supplemental oxygen (Residents #68 and #37), assess a resident receiving respiratory medications via nebulizer (Resident #8), change oxygen tubing and humidification bottles in accordance with the manufacturer's instructions (Residents #68 and #37), and administer oxygen in accordance with the Physician's order (Resident #30) for 4 of 5 residents reviewed for respiratory care. The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. A physician's order dated 2/2/24 for Resident #8 indicated a time limited order for respiratory medication to be administered via nebulizer every 6 hours through 2/6/24. Resident #8 was observed receiving medication via the nebulizer for a respiratory treatment on 2/5/24 at 1:45 PM. During an interview with Resident #8 on 2/5/24 at 1:47 PM she stated she had a cough/cold for a few days. Review of the Medication Administration Record (MAR) revealed that nebulizer treatments were documented as given to Resident #8 every 6 hours 2/2/24 through 2/6/24 as ordered. The Resident's vital signs record revealed oxygen saturation levels (O2 sats) were documented as completed on 2/5/24 at 5:17 PM. There were no other O2 sats documented for the period of 2/2/24 through 2/6/24. A review of Resident #8's progress notes dated 2/2/24 through 2/6/24 revealed that respiratory assessments such as lung sounds and response to nebulizer treatments were not documented at any time during the prescribed respiratory medication use. An interview with Nurse #4 on 2/9/24 at 8:36 AM revealed assessments of O2 sats and lung sounds should be documented on Resident #8 before and after a nebulizer treatment along with a progress note once a shift. If the nebulizer treatment was not effective, he would contact the Physician or NP. He did not have to contact them as treatments had been effective. He was unable to say why he did not document an assessment or progress note on 2/5/24 after nebulizer treatments except that he may have been overwhelmed as he was the Admissions Nurse and did not regularly work on the floor. An interview with Nurse #5 on 2/9/24 at 8:27 AM revealed assessments of O2 sats and lung sounds should be documented on Resident #8 before and after a nebulizer treatment along with a progress note once a shift. If the nebulizer treatment was not effective, she would contact the Physician or NP. She further stated that all treatments she had provided were effective. She was unable to say why she did not document an assessment or progress note after nebulizer treatments on 2/6/24. In an interview with the Director of Nursing (DON) on 2/9/24 at 9:05 AM she stated Nursing should complete O2 sats and lung sounds both before and after a nebulizer treatment and document in the resident's chart along with a progress note after each treatment. She further indicated if a treatment was not effective, they should contact the Physician or Nurse Practitioner. She was not aware assessments were not being documented on Resident #8 during the 5 days she was prescribed the medication for cough/congestion. An interview with the NP on 2/9/24 at 10:15 AM revealed Nursing would assess a resident before and after receiving a nebulizer treatment. She further stated the assessment would include lung sounds, O2 sats and effectiveness and would be documented in the chart after each treatment including a progress note each shift. The NP indicated she used the Nursing progress notes as updates on a resident's illness and treatment effectiveness. She was not aware assessments were not being documented on Resident #8 during the 5 days she was prescribed the medication for cough/congestion. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included pneumonia, acute respiratory failure, and chronic obstructive pulmonary disease (COPD) A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact, had shortness of breath, and received oxygen therapy. A review of Resident #37's care plan dated 1/18/24 indicated a focus of potential for ineffective breathing pattern related to Congestive Heart Failure and Chronic Obstructive Pulmonary disease with a goal that the resident's airway would be maintained through next review. Interventions included oxygen therapy as ordered. A review of Resident #37's Physician orders revealed there was no order for oxygen use. An observation of Resident #37 on 2/5/24 at 3:27 PM revealed she was using portable supplemental oxygen via nasal cannula in her wheelchair in the common area. Upon further observation it was noted the cannula was not dated as to when it was changed last. An observation of Resident #37's bedroom on 2/5/24 at 3:45 PM revealed an oxygen concentrator with a nasal cannula and humidification bottle attached. Upon further observation it was noted the cannula was not dated as to when it was changed last. An observation of the humidification bottle for the oxygen concentrator in her room revealed a date of 12/28/23 was connected for use and was empty. A review of the manufacturer's recommendations on 2/8/24 at 1:45 PM revealed oxygen tubing and humidification bottles should be changed every 7 days. During an interview with the Central Supply Manager on 2/8/24 at 1:30 PM, he indicated he restocked the medication storage rooms for Nursing staff to have access to nasal cannulas and humidification bottles. He further stated they could access the central supply room after hours if needed. In an interview with Nurse #10 on 2/7/24 at 6:11 AM on third shift she stated she did not know who was responsible for changing oxygen tubing and humidification bottles as it was not indicated anywhere that she had seen. Nurse #10 stated the only way she knew if someone was on oxygen was if the resident had an order in the Medication Administration Record (MAR). She further stated she did not know who was responsible for transcribing orders into the MAR or overseeing the process. In an interview with a nurse familiar with Resident #37, Nurse #4, on 2/9/24 at 8:36 AM he revealed he did not know who was responsible for changing oxygen tubing or humidification bottles. He further stated he would expect it to be in the MAR on the day and shift it was due. Nurse #4 revealed the only way he knew if a resident was on oxygen was if they had an order in the MAR or if it was reported to him at shift change. He further stated she did not know who was responsible for transcribing orders into the MAR or overseeing the process. During an interview with the Director of Nursing (DON) on 2/6/24 at 1:07 PM she stated night shift was responsible for changing oxygen tubing and humidification bottles once a week on Sundays and should be labeled with the date by the Nurse. She further stated they were to be changed weekly as that is standard practice. The DON was not aware it was not being done and was unaware there was no schedule for changing the tubing and humidification bottles that Nursing could refer to. She further stated she did not have a policy regarding the care of oxygen equipment. The DON was unaware that Resident #37 did not have an order for the use of oxygen. She further stated that a Nurse would have entered the order for oxygen when it was received from the Physician or NP. When asked how nurses would know when to change the oxygen tubing and humidification bottles, she stated, They should just know. An interview with Physician #2 on 2/7/24 at 11:30 AM revealed he was unaware Resident #37 did not have an order for oxygen. He further stated Resident #37 should have an order for oxygen and that the order must not have been transcribed by Nursing. He further stated oxygen tubing and humidification bottles should be changed per manufacturer recommendations or per facility policy. 3. Resident #68 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and acute respiratory failure. A review of Resident #68's care plan dated 10/3/23 indicated a focus of Potential for Ineffective Breathing Pattern related to Chronic Obstructive Pulmonary disease and Pulmonary Edema with a goal that the resident's airway would be maintained through next review. Interventions included oxygen therapy as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact, had shortness of breath and was coded as receiving oxygen therapy. A review of Resident #68's Physician orders indicated there was no order for oxygen use. An observation of Resident #68 on 2/5/24 at 11:33 AM revealed he was using portable supplemental oxygen via nasal cannula while in his wheelchair. Upon further observation it was noted the cannula was not dated as to when it was changed last. An observation of Resident #68's bedroom on 2/5/24 at 11:45 AM revealed an oxygen concentrator with a nasal cannula and humidification bottle attached. Upon further observation it was noted neither the cannula nor the humidification bottle were dated as to when they were changed last. A review of the manufacturer's recommendations on 2/8/24 at 1:45 PM revealed oxygen tubing and humidification bottles should be changed every 7 days. During an interview with the Central Supply Manager on 2/8/24 at 1:30 PM, he indicated he restocked the medication stock rooms for Nursing staff to have access to nasal cannulas and humidification bottles. He further stated they could access the central supply room after hours if needed. In an interview with Nurse #10 on 2/7/24 at 6:11 AM on third shift she stated she did not know who was responsible for changing oxygen tubing and humidification bottles as it was not indicated anywhere that she has seen. She further stated she was unaware of who was responsible for transcribing oxygen orders into the MAR. An interview with Nurse #4 on 2/9/24 at 8:36 AM revealed he did not know who was responsible for changing oxygen tubing or humidification bottles. He further stated he would expect it to be in the MAR on the day and shift it was due. He further stated he was unaware of who was responsible for monitoring and entering oxygen orders into the MAR. During an interview with the Director of Nursing (DON) on 2/6/24 at 1:07 PM she stated night shift was responsible for changing oxygen tubing and humidification bottles once a week on Sundays and should be labeled with the date by the Nurse. She further stated they were to be changed weekly as that is standard practice. The DON was not aware it was not being done and was unaware there was no schedule for changing the tubing and humidification bottles that Nursing could refer to. She further stated she did not have a policy regarding the care of oxygen equipment. The DON was unaware that Resident #68 did not have an order for the use of oxygen. When asked how nurses would know when to change the oxygen tubing and humidification bottles she stated, They should just know. An interview with Physician #1 on 2/8/24 at 1:15 PM revealed he was unaware Resident #68 did not have an order for oxygen. He further stated Resident #68 should have an order for oxygen. He further stated oxygen tubing and humidification bottles should be changed per manufacturer recommendations or per facility policy. 41009 4. Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and congestive heart failure. A review of the current comprehensive care plan for Resident #30 revealed a focus area initiated on 5/22/23 for ineffective breathing pattern. The goal, last revised on 12/15/23, was for Resident #30 to demonstrate an effective respiratory pattern with an appropriate oxygen (O2) saturation level through the next review. An intervention was O2 therapy as ordered. A review of the physician's orders for Resident #30 revealed a current active physician's order initiated on 5/23/23 of oxygen 3 liters (l) by nasal cannula (NC) every day and night shift for COPD. A review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He did not use oxygen therapy or BiPap (Bilevel positive airway pressure). On 2/5/24 at 12:32 PM an observation of Resident #30 revealed he was in bed. He was not observed to be receiving oxygen. He was wearing a BiPap machine. An interview with Resident #30 at that time indicated he did not use oxygen. He stated he kept his BiPap on all the time except when he was out of the bed. He went on to say he could put this on and take it off by himself. He stated he was using his home BiPap machine in the facility. He further indicated he was not experiencing any breathing issues or feeling short of breath. On 2/6/24 at 12:11 PM an observation of Resident #30 revealed he was in bed. He was not observed to be receiving oxygen. An interview with Resident #30 at that time indicated he was not having any breathing difficulties. On 2/7/24 at 8:23 AM an observation of Resident #30 indicated he was not observed to be receiving oxygen. He did not appear to be having any breathing issues or be short of breath. On 2/7/24 at 8:24 AM an interview with Nurse Aide (NA) #3 indicated she was very familiar with Resident #30. She stated she was caring for him today and cared for him every day this week on the day shift. She went on to say she cared for him regularly. She further indicated Resident #30 did not use oxygen. NA #3 stated Resident #30's had not been having any difficulties breathing. On 2/7/24 at 7:24 PM a telephone interview with Nurse #3 indicated she was caring for Resident #30 at that time. She stated she was familiar with him and had cared for him before. She went on to say she documented on Resident #30's Medication Administration Record (MAR) on 2/2/24, 2/3/24 and 2/4/24 that he was receiving O2 3L per NC continuously because she misunderstood the order. She stated Resident #30 wore his BiPap continuously and she thought that meant he was receiving oxygen through it. She stated she had just spoken with Resident #30 and observed his BiPap machine, and he was not receiving any oxygen. On 2/8/24 at 9:18 AM a follow up interview with Nurse #3 indicated she put an O2 concentrator in Resident #30's room last night and placed his O2 at 3L per NC under his BiPap. She stated Resident #30 had not had an O2 concentrator in his room prior to that and had not been receiving O2. On 2/8/24 a review of a nursing progress note for Resident #30 written by Nurse #3 dated 2/8/24 at 4:15 AM revealed Resident #30's oxygen was placed in his nose via nasal cannula at 3 liters at the beginning of shift. Nurse #3 continued to have to tell Resident #30 to keep oxygen in nose. When Nurse #3 went into the room to give Resident #30 medication, Resident #30 had taken the O2 out of his nose. Nurse #3 educated to resident that he needed to keep O2 on per the physician's order, but Resident stated, NO. On 2/8/24 at 9:38 AM in an interview the Director of Nursing stated Resident #30 had a current active physician's order for O2 at 3L per NC continuously and he should be receiving this in accordance with the physician's order. She went on to say if there was a question about a physician's order, the nurse caring for Resident #30 should clarify with the physician. On 2/8/24 at 3:45 PM a telephone interview with Physician #3 indicated if a resident had a physician's order for the administration of O2, the order should be followed. On 2/9/24 at 11:39 AM an interview with the Administrator indicated physician's orders for O2 should be followed. She went on to say if Resident #30 had a physician's order for O2, he should be receiving it. She further indicated if Resident #30 had been doing fine without O2 or had been refusing it, the physician should have been contacted to have the order clarified or discontinued.

Based on observations and staff interviews, the facility failed to don a clean pair of disposable gloves prior to the start of tray line, failed to ensure dietary staff had their hair restrained during food production and failed to serve a food item within safe temperature range. These practices had the potential to affect food served to residents. Findings included: 1. During a food temperature observation on 2/07/24 at 11:42 AM the Cook was observed wearing disposable gloves. While wearing the same pair of disposable gloves, he was observed to take a container of food from the stove, open the meal cart door using the handle, close the meal cart door, and pick up a large pot of mashed potatoes from the stove and place it on the counter. While wearing the same disposable gloves, the Cook then picked up a serving spoon with one hand and a small plastic bowl with the other hand. While picking up the small plastic bowl, he placed two gloved fingers inside the bowl to aid in picking up the bowl. He was then observed to put a scoop of mashed potatoes inside the bowl. The Cook was observed to fill several bowls by placing two gloved fingers inside the bowl to aid in picking up the bowl. An interview on 2/07/24 at 1:50 PM with the Cook revealed that he had not changed his disposable gloves after handling other objects such as the stove handle, meal tray carts and food containers prior to plating the mashed potatoes. He also revealed that he had placed his gloved fingers into the bowls prior to putting the mashed potatoes in them. He stated he did this out of the stress of the day and the rush to get the food out to the residents. The Cook revealed that he had food safety training and was also serve safe certified. An interview on 2/07/24 at 2:10 PM with the Dietary Manager revealed he did not know why the Cook had not changed his disposable gloves prior to plating the mashed potatoes. An interview with the Administrator on 2/08/24 at 2:36 PM revealed that she did not know why the Cook had not changed his disposable gloves prior to plating the mashed potatoes. 2. During a food temperature observation on 2/07/24 at 11:42 AM Dietary Aide #1 and Dietary Aide #2 were observed to be wearing hair nets that covered the front portion of their hair but did not cover the back of their hair. Dietary Aide #1 had shoulder length hair which was approximately 6 inches unrestrained below her hair net. Dietary Aide #2 had chin length hair which was approximately 3 inches unrestrained below her hair net. Both Dietary Aides were in the food preparation area with Dietary Aide #2 observed to be slicing tomatoes. An interview on 2/07/24 at 1:57 PM with Dietary Aide #2 revealed that she did not know that her hair was not under the hair net on the back of her head. She stated that she had her hair in the hair net that morning and it must have just fallen out. She stated that she had received training and knew her hair was supposed to be secured under a hair net while in the food preparation area. An interview on 2/07/24 at 2:05 PM with Dietary Aide #2 revealed that she did not know her hair was not under a hair net. She stated that she usually used 2 hair nets to secure her hair and 1 of them must have fallen off. She stated that she had received training and knew her hair was supposed to be secured under a hair net while in the food preparation area. An interview on 2/07/24 at 2:10 PM with the Dietary Manager revealed that Dietary Aides #1 and #2's hair nets must have just 'come undone'. An interview with the Administrator on 2/08/24 at 2:36 PM revealed that she did not know why the Dietary Aides hair had not been secured in hair nets. 48230 3. An observation of food temperatures in the steam table at a satellite kitchen on 2/7/24 at 12:22 PM revealed creamed corn that was measured 87 degrees Fahrenheit (F) by Dietary Aide #1 with a dial thermometer. The temperatures were done at the start of the tray line. On 2/7/24 at 12:25 PM an observation of the lunch meal in the satellite kitchen revealed Dietary Aide #1 proceeded to plate the corn for a Resident and a Nursing Assistant (NA) #2 took it to the Resident before the error was brought to their attention. The NA removed the plate from the Resident. Dietary Aide #1 had an NA take the remaining corn to the kitchen to be reheated. An observation of the temperature of the reheated creamed corn on 2/7/24 at 12:40 PM revealed a temperature of 140 degrees F measured by Dietary Aide #1 with a dial thermometer. An interview with Dietary Aide #1 on 2/7/24 at 12:30 PM revealed she was aware food on the steam table was to be held at a minimum of 135 degrees F. She further stated she did not know that the creamed corn had to be held at a minimum of 135 degrees F. Dietary Aide #1 stated she had training about the steam table when she was first hired 4 months ago which included infection control, proper temperatures and their part in potential for foodborne illness. In an interview with the Dietary Manager (DM) on 2/8/24 at 8:45 AM he stated he trained new employees in proper food distribution when they were first hired and when an issue came up. The new employee was then teamed up with a more experienced employee for further training. He further stated he held monthly staff meetings and did in-services at that time as well He was able to state that the minimum temperature for food on the steam table was 135 degrees F and if a temperature was below that, the food must be taken back to the kitchen to be reheated and not served to Residents due to the risk of food borne pathogens. In an interview with the Administrator on 2/8/24 at 2:30 PM she stated that she was not aware of any hot food temperatures below 135 degrees F on the steam table recently. She further stated she was unaware the creamed corn that had a temperature of 87 degrees F was served to a Resident. The Administrator believed that a high turnover rate in kitchen staff led to lack of education leading to the creamed corn being served below safe temperatures.

Based on observations, record review and resident, staff, Nurse Practitioner (NP), and Physician interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 3/9/21 complaint survey and the 8/20/21 and 9/22/22 recertification and complaint investigation surveys. This was for 7 deficiencies in the areas of F550 Dignity, F677 Activities of Daily Living, F684 Quality of Care/Professional Standards, F693 Tube Feeding, F695 Respiratory Care, F812 Food Preparation and Storage, and F842 Accuracy of Records. These deficiencies were recited on the current recertification and complaint investigation survey of 2/13/24. The continued failure of the facility during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F550: Based on observations, record review and staff interviews the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 stood at Resident #7's bedside while feeding Resident #7. This was for 1 of 2 residents reviewed for dignity. A reasonable person might feel a lack of dignity when NA #4 stood while feeding them. During the 8/20/21 recertification and complaint investigation survey the facility was cited for failing to provide a dignified dining experience. During the 9/22/22 recertification and complaint investigation survey the facility was cited for failing to provide incontinence care. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated she felt the reasons in each example were different. She went on to say she felt the continued difficulties were a result of changing staff. F677: Based on observations, record review and staff interviews, the facility failed to rinse soap from a resident's skin during a dependent resident's bed bath and to provide nail care for 1 of 9 residents reviewed for activities of daily living (Resident #57). During the 3/9/21 complaint investigation survey the facility was cited for failing to trim fingernails. During the 8/20/21 recertification and complaint investigation survey the facility was cited for failing to provide showers or bed baths. During the 9/22/22 recertification and complaint investigation survey the facility was cited for failing to provide incontinence care and failing to rinse soap per the manufacturer's direction during a bath. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated although staff training had been done, and audits performed to ensure correction of these issues, she felt due to the amount of agency staff the facility employed, Nurse Aides (NAs) just weren't taking their time. She went on to say although there was not a lack of staff, they were being pulled in a lot of different directions. F684: Based on record review and staff and physician interviews the facility failed to obtain daily weights as ordered by the physician for 1 of 6 residents (Resident #30) reviewed for respiratory care. During the 8/20/21 recertification and complaint investigation survey the facility was cited for failing to transcribe orders and have medications available. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated she felt the repeat issues were different. She went on to say she attributed this to changing staff. F693: Based on observation, record review, and staff interviews, the facility failed to change a tube feeding syringe daily or store a tube feeding syringe with the plunger separated from the barrel for 1 of 1 resident reviewed for enteral feeding management (Resident #57). During the 9/22/22 recertification and complaint investigation survey the facility was cited for failing to provide tube feeding as ordered. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated she felt the repeat issues were different. She went on to say she attributed this to changing staff. F695: Based on observations, record review, resident, staff, Nurse Practitioner (NP) and Physician interviews the facility failed to obtain a physician's order for the use of supplemental oxygen (Residents #68 and #37), assess a resident receiving respiratory medications via nebulizer (Resident #8), change oxygen tubing and humidification bottles in accordance with the manufacturer's instructions (Residents #68 and #37), and administer oxygen in accordance with the Physician's order (Resident #30) for 4 of 5 residents reviewed for respiratory care. During the 9/22/22 recertification and complaint investigation survey the facility was cited for failing to notify the physician of a pulmonary consult recommendation. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated she felt the repeat issues were different. She went on to say she attributed this to changing staff. F812: Based on observations and staff interviews, the facility failed to don a clean pair of disposable gloves prior to the start of tray line, failed to ensure dietary staff had their hair restrained during food production and failed to serve a food item within safe temperature range. These practices had the potential to affect food served to residents. During the 8/20/21 recertification and complaint investigation survey the facility was cited for failing to label food. During the 9/22/22 recertification and complaint investigation survey the facility was cited for failing to wear hair covering and failing to dry plate covers. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated for the hair covering, although training and auditing had been done, there were changes in staff and there had been no follow-through. F842: Based on observations, record review, and resident and staff interviews the facility failed to maintain accurate documentation of the administration of oxygen (O2) (Resident #30) and the completion of wound treatments (Resident #75). This was for 2 of 21 residents reviewed for accurate documentation. During the 3/9/21 complaint investigation survey the facility was cited for failing to maintain accurate documentation record of meal intake and wound care. On 2/9/24 at 11:59 AM during an interview, the Administrator discussed the facility's QAA process. She stated the last issue with documentation happened 3 years ago. She went on to say she felt the facility had been doing great with documentation so maybe they were just forgetting to document again.

Based on observations, record review and staff interviews the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 stood at Resident #7's bedside while feeding Resident #7. This was for 1 of 2 residents reviewed for dignity. A reasonable person might feel a lack of dignity when NA #4 stood while feeding them. Findings included: Resident #7 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #7's current comprehensive care plan revealed a focus area initiated on 7/21/23 for activities of daily living. The goal, last revised on 11/7/23, was for Resident #7's care to be completed with staff support. An intervention was dependent for eating. A review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She had functional limitation of range of motion of both upper extremities. She was dependent for eating. On 2/5/24 starting at 12:54 PM a continuous observation of Resident #7's lunch meal was conducted in her room. NA #4 was observed to feed Resident #7 while standing beside Resident #7's bed. A chair was available in Resident #7's room. At 1:06 PM NA #4 was observed still standing while feeding Resident #7. At 1:09 PM, after Resident #7 indicated she was finished eating, NA #4 was observed to conclude the feeding activity and remove Resident #7's lunch meal from the room. An interview with NA #4 at that time indicated she was familiar with Resident #7 and frequently fed her meals. NA #4 stated she always stood beside Resident #7's bed when she fed her. She stated she always stood when feeding residents as she preferred this. She went on to say she had worked at the facility for 9 years and she had never been instructed to sit beside residents when feeding. On 2/8/24 at 9:57 AM an interview with the Director of Nursing indicated standing while feeding residents was a dignity issue. She stated NA #4 should have been seated and at eye level with Resident #7 while she was feeding her. She went on to say NA #4 should have known this. She further indicated in-service training had begun for all NAs regarding this issue. On 2/9/24 at 11:39 AM an interview with the Administrator indicated NAs should be seated at eye level with residents while feeding them.

Based on record review and interviews with the Responsible Party (RP) and staff, the facility failed to facilitate the inclusion of a cognitively intact resident and her RP in the care planning process for 1 of 1 resident reviewed for the care planning process (Resident #287). The findings included: Resident #287 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #287 was cognitively intact. A review of the care plan for Resident #287 revealed it was last revised on 2/28/23. A record review for Resident #287 revealed there were no care plan meetings documented nor was there documentation of attempts to contact or conversations with the RP. On 2/10/24 at 1:10 PM an interview with Resident #287's RP revealed she and the Resident were not invited to care plan meetings until a few days before the Resident's passing on 10/30/23. An interview with Social Worker #1 on 2/7/24 at 12:21 PM revealed she held care plan meetings upon admission, approximately every three months in conjunction with the MDS assessment schedule and in the event of a significant change in the Resident's health. These meetings were documented in the care plan notes section of the medical record and noted everyone who attended and what was discussed. She further stated any contact or attempt to contact the Resident or their RP regarding care plan meetings should be documented. Social Worker #1 was unable to explain why there were no notes for Resident #287 about care plan meetings. On 2/8/24 at 2:30 PM an interview with the Administrator revealed Care Plan meetings were held quarterly and annually and were to be documented, including all who attended, and the topics discussed. Any contact with the Resident or RP would have been documented in the care plan section of the electronic record. The Administrator further stated she knew there was a lack of documentation about care plan meetings, and scheduling of care plan meetings had been an issue.

Based on record review and staff interviewed, the facility failed to complete a recapitulation of stay for 1 of 1 resident reviewed for a planned discharge from the facility to home (Resident #137). Findings included: Resident #137 was admitted to the facility on [DATE] and discharged home on 2/17/23. The discharge Minimum Data Set, dated dated dated [DATE] revealed Resident #137 was coded as moderately impaired cognition. Review of Resident #137's electronic health record revealed a discharge summary dated 2/17/23. Further review of the discharge summary revealed that it did not include the required elements of customary routine, cognitive patterns, communication, vision, mod and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses and health conditions, dental and nutritional status, skin condition, activity pursuit, medications, or special treatments and procedures. An interview on 2/07/24 at 11:01 AM with the Social Worker (SW) revealed she was aware of the requirement for a recapitulation summary. She stated that based on the requirements, the discharge summary for Resident #137 did not include all the required elements. She stated that she initiated the summary, and each section entered their portion. She also stated that nursing printed, reviewed, and provided a copy to the resident at discharge. The SW stated she was not employed at the facility in February 2023 and could not say why it was not completed with the required elements. An interview on 2/08/24 at 3:04 PM with the Administrator revealed that she was aware of the requirement for a recapitulation summary and did not know why Resident #137's did not contain the required elements.

Based on observations, record review and staff interviews, the facility failed to rinse soap from a resident's skin during a dependent resident's bed bath and to provide nail care for 1 of 9 residents reviewed for activities of daily living (Resident #57). Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus. The quarterly Minimum Data Set 1/10/24 revealed Resident #57 was coded as cognitively intact. He was also coded to be dependent on staff for all activities of daily living (ADL). He was coded for rejection of care 1-3 days. Review of Resident #57's care plan revised 1/16/24 included an ADL focus with a shower/bath of two person assist as needed. During an observation on 2/08/24 at 9:49 AM, Nursing Assistants (NA) #1 and #2 were observed to provide a bed bath for Resident #57. NA #2 gathered bathing supplies which included a basin of warm water, washcloths, towel, body oil, bottle of body wash, deodorant, and premoistened wipes pack. NA #2 squirted the body wash into the basin of warm water, washed Resident #57's face, arms, upper body, legs, and feet and dried all areas. NA #2 did not rinse the body wash off the resident. NA#2 continued the bed bath by placing the premoistened wipes into the basin of warm soapy water and washed the resident's perineal area. NA #2 dried the perineal area and did not rinse the body wash off the perineal area. NA #2 placed the premoistened wipes into the basin of warm soapy water and wiped the urinary catheter. NA #2 did not rinse the body wash off the urinary catheter. A clean gown and brief were placed on the resident. The lift transfer sling was placed under the resident, and he was transferred to a chair. NA #1 and NA #2 gathered the used linen, emptied the basin, and put all toiletries away. During the bed bath observation, NA #1 provided Resident #57 positioning assistance. During the bed bath observation (2/08/24 at 9:49 AM), the resident was observed to have 1/4 inch to 1/2 inch long yellow fingernails which had brown debris under several of them on his left hand. His toenails were observed to be pale yellow, thick, misshaped with dry patches of skin around them. An interview on 2/08/24 at 10:40 AM with NA #1 and NA #2 revealed that they were unaware that the body wash required rinsing. NA #2 went to Resident #57's room and returned to the interview with the body wash bottle. She confirmed that the bottle of body wash read to rinse thoroughly. She stated she did not rinse the body wash and had not read the bottle. She stated that she did not provide nail care for any residents. NA #2 stated that she thought the unit nurse provided nail care. NA #2 stated that she had not notified the unit nurse that Resident #57's fingernails needed to be cut. NA #2 confirmed that she had worked with Resident #57 frequently and he was on her assignment today. NA #1 stated that she provided positioning and transfer assistance for NA #2 during the resident's bed bath. An interview on 2/08/24 at 2:13 PM with Nurse #1 revealed she worked regularly with Resident #57. She stated she had tried to cut his nails in the past, but he had refused. She stated that she had not documented the attempt. She was unaware that he currently needed to have his nails cut. She stated that she cleaned his fingernails during his bath. An interview and observation on 2/08/24 at 11:45 AM with the Director of Nursing (DON) and the Corporate Nurse Consultant revealed that Resident #57 did have 1/4 inch to 1/2 inch long yellow fingernails with brown debris under several of the nails on his left hand. She stated that they needed to be trimmed and cleaned. The DON stated that the NA should have rinsed the body wash off Resident #57. The DON stated that nurses cut diabetic resident nails and she did not know why Resident #57's fingernails were not cut. An interview with the Administrator on 2/08/24 at 2:42 PM revealed that the staff had been trained on rinsing the body wash and nail care. She did not know why it had not been done.

Based on record review and staff and physician interviews the facility failed to obtain daily weights as ordered by the physician for 1 of 6 residents (Resident #30) reviewed for respiratory care. Findings included: Resident #30 was admitted to the facility on [DATE] a diagnoses of congestive heart failure (CHF). A review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was taking a diuretic (water pill). On 2/5/24 a review of the current active physician's orders for Resident #30 revealed a physician's order dated 6/3/23 for daily weights one time a day for CHF to be done before 7:00 AM. A review of Resident #30's Medication Administration Record for February 2024 revealed in part the physician's order for daily weights at 6:30 AM. There was no documentation that a weight was obtained on 2/3/24 or 2/5/24. Additionally, there was no documentation of a refusal. A review of Resident #30's progress notes for 2/3/24 and 2/5/24 revealed no documentation he refused his daily weight on those dates. On 2/7/24 at 9:35 AM an interview with Nurse Aide (NA) #5 indicated she was assigned to care for Resident #30 on 2/3/24 and 2/5/24 at 6:30 AM. She stated she was new to Resident #30's hall and recalled asking Resident #30's nurse about him at the beginning of her first shift on 2/3/24. She went on to say the nurse did not ever mention anything to her about Resident #30 needing a daily weight and she had not attempted to get one. On 2/7/24 at 9:44 AM an interview with Nurse #3 indicated she was assigned to Resident #30 on 2/3/24 and 2/5/24 at 6:30 AM. She stated she recalled letting Resident #30's NA know that he needed a daily weight on those days. She went on to say she had not followed up to ensure they were done because she had gotten behind on her medication pass on those mornings. On 2/8/24 at 9:38 AM an interview with the Director of Nursing (DON) indicated the nurse assigned to Resident #30 on the days when his daily weight needed to be done should be following up with the NA to ensure it was done. On 2/8/24 at 3:45 PM an interview with Physician #2 indicated the daily weights were initiated for Resident #30 to monitor his CHF status. He stated Resident #30 had been stable and managed clinically for his CHF. He went on to say he could probably discontinue Resident #30's daily weights. Physician #2 stated if a resident had a physician's order for daily weights, they should be obtained.

Based on observation, record review, staff and physician interviews, the facility failed to: 1) obtain a written physician's order for the use of a urinary catheter (Resident #30 and #57) and 2) ensure the consulting physician's recommendation for the urinary catheter changes were entered into the medical record (Resident #30). This was for 2 of 4 residents reviewed for urinary catheter. Findings included: 1. Resident #30 was admitted to the facility on [DATE]. A review of a hospital discharge summary for Resident #30 dated 12/21/23 revealed in part he was admitted to the hospital on 12/15/23 for penile cellulitis (skin infection) and balanitis (inflammation of the foreskin and head of penis). It further revealed an indwelling urinary catheter was placed. A review of a Nursing Admission/Reentry assessment dated [DATE] revealed in part Resident #30 was readmitted to the facility with an indwelling urinary catheter. A review of a urology Report of Consult form for Resident #30 dated 1/10/24 revealed in part Resident #30's indwelling urinary catheter was changed. It further revealed a recommendation to exchange the indwelling urinary catheter every 4 to 5 weeks. A review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He had an indwelling urinary catheter. On 2/5/24 at 12:32 PM an observation of Resident #30 revealed he had an indwelling urinary catheter. An interview with Resident #30 at that time indicated he was not having any issues with his catheter. He stated Nurse Aides (NAs) kept the area clean. On 2/7/24 a review of Resident #30's current active physician's orders did not reveal orders for an indwelling urinary catheter or exchange of the indwelling urinary catheter every 4 to 5 weeks as recommended by the urologist. On 2/9/24 at 9:03 AM an interview with the Nurse Practitioner (NP) indicated according to Resident #30's hospital discharge summary dated 12/21/23 he had an indwelling catheter placed because of a neurogenic bladder (bladder dysfunction) and balanitis. She stated Resident #30 should have a current order for this. She went on to say she previously reviewed the Consult Report recommendations from the urologist dated 1/10/24 and had agreed with the recommendations as evidenced by her initials on the document. The NP stated the facility should have a process in place where the order for the indwelling urinary catheter was entered by nursing when he came back to the facility with it and where nursing entered the urology recommendation order. On 2/9/24 at 9:14 AM an interview with NA #3 indicated she was assigned to Resident #30 that day. She stated she had been assigned to care for him frequently and was very familiar with him. She stated Resident #30 had an indwelling urinary catheter since he last came back from the hospital a couple of months ago. She went on to say she emptied the urine from the catheter bag and cleaned the area each shift. She further indicated Resident #30 was not having any issues with his urinary catheter, had not complained of anything, and his urine was clear. On 2/9/24 at 9:18 AM an interview with Nurse #9 indicated she was assigned to care for Resident #30 that day and was familiar with him. She stated Resident #30 had an indwelling urinary catheter. She went on to say he had this in place since she began caring for him on 1/15/24. She further indicated Resident #30 was not having any issues with his catheter. On 2/9/24 at 9:25 AM an interview with the Director of Nursing indicated she was aware of the urology recommendation dated 1/10/24 for Resident #30 to have his indwelling urinary catheter exchanged every 4 to 5 weeks. She stated she reviewed all consulting physician's recommendations and entered these orders herself. She further indicated she recalled entering this order for Resident #30, but she did not see it now. She stated she did not know what had happened to it. On 2/9/24 at 9:46 AM an interview with Nurse #4 indicated he was the facility's Admissions Nurse. He stated he recalled receiving report from the hospital when Resident #30 was admitted back into the facility. He went on to say he had been aware that Resident #30 had an indwelling urinary catheter at that time. He further indicated he recalled putting the order for the catheter into the computer system but did not see it now. He stated he did not know what happened to it. On 2/9/24 at 11:39 AM an interview with the Administrator indicated Resident #30 should have a current active order for his indwelling urinary catheter. She went on to say he should also have a current active order for the consulting urologists recommendation. 40200 2. Resident #57 was admitted to the facility on [DATE] with diagnoses which included obstructive uropathy. The quarterly Minimum Data Set 1/10/24 revealed Resident #57 was coded as cognitively intact. He was also coded to have an indwelling urinary catheter. Resident #57's care plan last revised 1/16/24 revealed a focus for altered pattern of urinary elimination with indwelling catheter. An observation on 2/05/24 at 12:42 PM revealed Resident #57 lying in bed with a urinary catheter bag hanging on the side of his bed. Review of Resident #57's electronic health record physician's orders revealed no order for a urinary catheter. An interview 2/08/24 at 11:26 AM with the Director of Nursing (DON) revealed that Resident #57 did not have an order for a urinary catheter. The DON stated she did not know why he did not have a physician's order for a urinary catheter. An interview with the Administrator on 2/09/24 at 10:47 AM revealed that she did not know why Resident #57 did not have an order for a urinary catheter.

Based on observation, record review, and staff interviews, the facility failed to change a tube feeding syringe daily or store a tube feeding syringe with the plunger separated from the barrel for 1 of 1 resident reviewed for enteral feeding management (Resident #57). Findings included: Resident #57 was admitted to the facility on [DATE]. The quarterly Minimum Data Set 1/10/24 revealed Resident #57 was coded as cognitively intact. He was also coded to have a feeding tube. An observation on 2/05/24 at 12:42 PM revealed that the tube feeding syringe plunger and barrel were stored together in a bag hanging on the infusion pump stand at the bedside. The outside of the bag was dated 2/05/24. An observation on 2/06/24 at 7:48 AM revealed that the tube feeding syringe plunger and barrel were stored together in a bag hanging on the infusion pump stand at the bedside. The outside of the bag had 2/05/24 written on it with a '6' written over the '5'. An observation on 2/07/24 at 1:35 PM revealed that the tube feeding syringe plunger and barrel were stored together in a bag hanging on the infusion pump stand at the bedside. The outside of the bag was dated with the same 2/05/24 with '6' written over the '5'. An observation on 2/08/24 at 10:00 AM revealed that the tube feeding syringe plunger and barrel were stored together in a bag hanging on the infusion pump stand at the bedside. The outside of the bag was dated with the same 2/05/24 with '6' written over the '5'. An observation and interview 2/08/24 at 11:45 AM with the Director of Nursing (DON) revealed that Resident #57's tube feeding syringe were stored together in a bag hanging on the infusion pump stand at the bedside. The outside of the bag was dated 2/05/24 with '6' written over the '5'. The DON stated the tube feeding syringes should be changed every 24 hours and it was night shift's responsibility to change them. She also stated that the plunger and barrel should be stored separately and did not know why they were not. An interview on 2/08/24 at 2:21 PM with Nurse #2 revealed that Resident #57 received tube feeding flushes three times per day. She stated that today she used the tube feeding syringe hanging on the infusion pump stand in his room for his morning tube flush. She stated that she had not noted the date on the syringe bag. She stated she was taught to wash the tube feeding syringe plunger and barrel, let them dry, and then place them back together in the bag for storage which is what she had done. An interview with the Administrator on 2/09/24 at 2:52 PM revealed that she did not know why Resident #57 tube feeding syringe had not been changed daily or the plunger and barrel stored separately.

Based on observations, record review, and resident and staff interviews the facility failed to maintain accurate documentation of the administration of oxygen (O2) (Resident #30) and the completion of wound treatments (Resident #75). This was for 2 of 21 residents reviewed for accurate documentation. Findings included: 1. On 2/5/24 at 12:32 PM an observation of Resident #30 revealed he was in bed. He was not observed to be receiving oxygen. He was wearing a BiPap machine. An interview with Resident #30 at that time indicated he did not use oxygen. A review of Resident #30's February 2024 Medication Administration Record (MAR) on 2/7/24 revealed in part a physician's order with a start date of 5/23/23 for O2 3 liters (L) per nasal cannula (NC) continuously. It further revealed documentation by Nurse #3 on 2/2/24, 2/3/24 and 2/4/24 and by Nurse #4 on 2/7/24 that this was administered. On 2/7/24 at 7:24 PM a telephone interview with Nurse #3 indicated she documented on Resident #30's MAR on 2/2/24, 2/3/24 and 2/4/24 that he was receiving O2 3L per NC continuously because she misunderstood the order. She stated Resident #30 had not been receiving any oxygen. She further indicated her documentation that Resident #30 received O2 on those days had been in error. On 2/8/24 at 11:22 AM an interview with Nurse #4 indicated he documented on Resident #30's MAR on 2/7/24 that he was receiving O2 3L per NC continuously in error. He stated he had not seen Resident #30 being administered O2 via any source and had misunderstood. On 2/8/24 at 9:38 AM an interview with the Director of Nursing indicated Nurses should not be documenting that Resident #30 was being administered O2 if he was not. She went on to say documentation in Resident #30's medical record should be accurate and reflect the care they were actually receiving. On 2/9/24 at 11:39 AM an interview with the Administrator indicated the documentation in resident's medical record should be accurate. 40200 2. a. Review of physician's orders revealed an order dated 12/16/23 and discontinued on 1/17/24 for the left ischium (a bone in the hip) wound to be cleaned, patted dry, apply collagenase ointment, calcium alginate, and cover with a foam border dressing daily for wound care. Review of Resident #75's Treatment Administration Record (TAR) for January 2024 revealed there were no signatures on 1/01, 1/06, 1/07, and 1/13. b. Review of physician's orders revealed an order dated 1/17/24 and discontinued on 1/30/24 for the left ischium wound to be cleaned, patted dry, apply silver alginate, and cover with a foam border dressing daily for wound care. Review of Resident #75's Treatment Administration Record (TAR) for January 2024 revealed there were no signatures on 1/21, 1/26, 1/27, and 1/30. c. Review of physician's orders revealed an order dated 12/16/23 and discontinued on 1/30/24 for the right ischium wound to be cleaned, patted dry, apply silver alginate, and cover with a foam border dressing daily for wound care. Review of Resident #75's Treatment Administration Record (TAR) for January 2024 revealed there were no signatures on 1/01, 1/06, 1/07, 1/13, 1/21, 1/26, 1/27, and 1/30. d. Review of physician's orders revealed an order dated 1/17/24 for the sacrum wound to be cleaned, patted dry, apply silver alginate, and cover with a foam border dressing every Monday, Wednesday, and Friday for wound care. Review of Resident #75's Treatment Administration Record (TAR) for January 2024 revealed there was no signatures on 1/26. An interview on 2/08/24 at 3:57 PM with Nurse #2 revealed that she was regularly assigned to Resident #75's hall. She stated that she was responsible for providing wound care if the Wound Treatment Nurse was not available. She stated that she provided the wound care on 1/01, 1/06, 1/07, 1/21, and 1/30, but had forgotten to sign off that it was completed. Interviews were attempted for hall Nurses #11 and #12 for 1/13, 1/26, and 1/27 but were unsuccessful. An interview on 2/08/24 at 3:02 PM with the Administrator revealed that she was unaware of the wound care documentation not being signed as completed.

Based on record review and staff and physician interviews the facility failed to consult with a resident's physician regarding the development of a pressure wound on the heel for 1 of 3 residents (Resident #188) reviewed for pressure ulcers. On 02/08/19 home health services assessed the pressure ulcer to Resident #188's right heel as being a stage III wound measuring 2 x 2 x 0.5 cm with drainage. Findings included: Resident #188 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Nursing Notes from 11/28/18 to 02/07/19 revealed no documentation of the physician being notified of Resident #188's heel wound. Review of the Flowsheet of Non-Ulcer Skin Conditions dated 11/28/18, completed by the nursing home's Wound Care Nurse (WCN), revealed Resident #188 had a pink ruptured right heel blister. There was no pain or infection present. There were no measurements of the wound and no description of the area surrounding the wound. The treatment was to apply [MEDICATION NAME] and a transparent film dressing every other day. There was no physician notification date on the form. Review of the physician's orders [REDACTED].#188's right heel with Normal Saline, apply [MEDICATION NAME], and then cover with a transparent dressing with foam every other day for a ruptured blister. The order was initialed by the physician on 12/04/18. Review of the Care Plan initiated on 11/29/18 revealed a ruptured blister had been noted on Resident #188's right heel. The goal was for the ruptured blister to heal without complications through the next review. Interventions included to keep pressure off of the right heel and to perform treatments as ordered and to notify the physician of any changes. Review of the physician progress notes [REDACTED].#188's ruptured right heel blister. Review of the physician progress notes [REDACTED].#188's ruptured right heel blister. Review of the Flowsheet of Non-Ulcer Skin Conditions dated 01/03/19, completed by the nursing home's WCN, revealed Resident #188 had a pink ruptured right heel blister that was improving. The area surrounding the wound was intact. There was no pain or infection present. There were no measurements of the wound. The treatment was to continue [MEDICATION NAME] and a transparent film dressing with foam every other day. There was no physician notification date on the form. Review of the physician progress notes [REDACTED].#188's ruptured right heel blister. Review of the Flowsheet of Non-Ulcer Skin Conditions dated 01/23/19, completed by the nursing home's WCN, revealed Resident #188 had a pink ruptured right heel blister that was improving. The area surrounding the wound was intact. There was no pain or infection present. There were no measurements of the wound. The treatment was to continue [MEDICATION NAME] and transparent film dressing with foam every other day. There was no physician notification date on the form. Review of the physician progress notes [REDACTED].#188's ruptured right heel blister. Review of the Flowsheet of Non-Ulcer Skin Conditions dated 01/31/19, competed by the nursing home's WCN revealed Resident #188 had a pink ruptured right heel blister that was improving. The area surrounding the wound was intact. There was no pain or infection present. There were no measurements of the wound. The treatment was to continue [MEDICATION NAME] and transparent film dressing with foam every other day. There was no physician notification date on the form. Record review revealed Resident #188 was discharged from the facility to home with Home Health on 02/07/19. Review of the Home Health Comprehensive Adult assessment dated [DATE] revealed Resident #188 had a stage 3 pressure wound on the right heel. The wound measured 2cm by 2cm and was 0.5cm deep. There was full thickness skin loss involving damage or necrosis of subcutaneous tissue. There was a small amount of thin, watery, pale, red/pink drainage from the wound. The wound bed was pink with less than 25% of the wound covered with [MEDICATION NAME] tissue. The skin color surrounding the wound was normal for the resident. In an interview on 02/20/19 at 1:55 PM the nursing home's WCN indicated Resident #188 had a fluid filled blister on the bottom of the right heel that developed from the positioning of Resident #188's foot on the mattress. She stated she did not know how long the blister was in place prior to its rupture but it was not there on admission. She indicated that a ruptured blister would be considered a stage 2 pressure wound. The WCN indicated that a pressure wound should be assessed weekly and should include measurements, staging, drainage, infection, odor, a description of the wound bed and a description of the surrounding skin. She stated that she had not notified Resident #188's physician regarding the ruptured blister but she had begun a treatment using the standing orders. She indicated she did not perform a skin assessment when Resident #188 was discharged from the facility because she was not aware the resident was being discharged . In an interview on 02/20/19 at approximately 1:20 PM the Assistant Director of Nursing (ADON) verified that she supervised the nursing home's WCN and indicated that she had started working at the facility on 01/02/19 which was after the wound was discovered and so she had not notified the physician of the wound. In a telephone interview on 02/21/19 at 11:37 AM Physician #2 stated he was aware that Resident #188 had had a wound on the ankle but was unaware that there was a wound on the right heel. He indicated if the wound had started as a blister and then ruptured he would expect a weekly wound assessment with measurements. The physician indicated that the facility had not notified him of the wound and he did not remember initialing any orders for treatment. In a follow-up interview on 02/21/19 at 1:45 PM the nursing home's WCN stated the physician's orders [REDACTED]. However, she stated since the physician had initialed the order on 12/04/18 that served as notification of the wound to the physician. In an interview on 02/22/19 at 9:14 AM the Director of Nursing (DON) stated that she expected the WCN or a staff nurse to notify the physician when a wound was discovered on a resident. She indicated that when a physician initialed an order it was considered notification but she expected the nurse to notify the physician of the wound sooner than six days after the wound was discovered. This would allow the physician the opportunity to provide treatment orders or to agree with the standing orders of the facility.