Every finding on record at Springtree Healthcare & Rehab Center

Based on staff interview and clinical record review, the facility staff failed to follow the comprehensive person-centered care plan for one of four residents in the survey sample, resident #1.The findings include: For resident #1 the facility staff failed to follow the comprehensive care plan that stated the resident was to be fed by staff.Resident #1's diagnoses included but were not limited to dementia, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease and gastroesophageal reflux disease.The annual minimum data set (MDS) assessment with an assessment reference date of 11/19/25 was reviewed. Resident #1 was assessed to have severely impaired cognitive skills for daily decision making, the resident also had little interest or pleasure in doing things, poor appetite or overeating, and feeling tired or having little energy nearly every day over the two week look back period. Resident #1 was assessed to require set up assistance or clean up assistance with meals during the lookback period. The assessment also captured a significant weight gain that was not prescribed or planned during the look back period. During the look back period, resident #1 was able to feed self, according to the MDS.The comprehensive person-centered care plan included a focus that read, the resident is at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, DM (diabetes), HF (heart failure), dementia, hx (history) protein calorie malnutrition. Texture modified diet w/thickened liq. Sig (significant) wt (weight) fluctuation, most recently loss. This care plan focus was created on 10/31/2022 and revised on 12/28/25. Some of the interventions listed on the care plan were encouragement to eat, record meal % intake, supplements as ordered, and total assist for meals which had a revision date of 12/7/25, and weights as ordered.The documentation survey report which consists of the certified nursing assistant (CNA) documentation of meals and activities of daily living (ADLs) provided to resident #1 was reviewed for December 2025. The level of assistance for meals provided to resident #1 was documents as 05 which means set up assistance, and 06 which means independent for meals every day in December except 12/11/25 for the evening meal the resident was documented as being dependent. Out of 93 total meals served in the month of December resident #1 was documented as eating 76-100% for 48 meals, 51-75% for 31 meals, 26-50% for 9 meals and 0-25% for 5 meals which included 2 refusals, one on 12/25/25 and one on 12/31/25.The documentation survey report for January 2026 was reviewed. The level of assistance provided to the resident for meals was documented at independent for 3 shifts, set up or clean up assist for 5 shifts, supervision for two shifts, and dependent for 6 shifts and one refusal. The resident went to the hospital on 1/9/26 and did not return. Fourteen meals in January were documented with a meal percentage of 76-100%. Four meals were documented with a percentage of 51-75% and eight meals were documented with a percentage of 0-25%. On 3/11/26 at 1:14 PM Certified Nursing Assistant (CNA) #1 was interviewed. They stated they were very familiar with resident #1. CNA #1 stated that resident #1 was independent with meals at first but then toward the end we had to feed her. CNA #1 did not recall when staff started to feed the resident exactly but stated, I don't remember when she was put on the list, it wasn't too long before she went out to the hospital. When asked if the resident was feeding herself in December, around Christmas they stated, Yes, I think we didn't start feeding her until after that sometime. We would take her tray in and set her up and let her try to feed herself and go back and check on her. If she wasn't eating or needed help, we would help her. When asked if that was how it was done after resident #1 got put on the feed list, CNA #1 stated, Yes, we would set her up first because sometimes she could do it. The last week or two we just fed her though, I think I can't remember for sure, but we always made sure she ate. CNA #1 stated that they have a list on the unit for residents who need to be fed and when they come to work, they are assigned certain people on the list to feed each day. On our unit, we make sure all our residents are fed and eat. On 3/11/26 at 2:22 PM CNA #2 was interviewed. When asked about resident #1 and how she ate they stated, She was supervision at first. We would set her up and let her feed herself and we'd check on her and help her if she needed it. CNA #2 stated resident #1 could drink independently, Probably about a week before she died, I had to hold the cup for her. Her appetite and desire to drink really declined fast. When asked how the staff know who to feed, they stated, We have a list. If the residents name is in bold letters we feed them, but if it isn't in bold letters, we supervise like set them up and go back and check to see if they need help. When asked if the care plan had anything on it about whether or not to feed the resident they stated they didn't know, We just go by the list. CNA #2 stated she was not sure what resident #1's care plan said about eating. On 3/11/26 at 2:31 PM the Unit Manager (UM) was interviewed. When asked if they recalled when resident #1 was put on the list to be fed, they stated, She was always on the list but was just supervision at first. She had a rapid decline, a week or so before she went out, she was up in her chair in the day room watching TV. When asked how the staff know to feed residents they stated, We have a list if the name is in bold print, they are supposed to feed that person, if it isn't in bold, they set them up and go back and check to see if they need help or not. UM could not recall the timeframe but thinks resident #1's name was in bold print. On 3/11/26 at 4:37 CNA #3 was interviewed. They stated that resident #1 occasionally refused meals and that was the case on 12/25/25 and 12/31/25. Once we started having to feed her all the time there were times when she wouldn't open her mouth or would hold the food in her mouth and not swallow it. CNA #3 stated the resident was not able to hold a drink at the end but would frequently drink better than she would eat. CNA #3 could recall the timeframe of when the resident went from being set up or supervision to being a total feed. When asked what resident #1's care plan said about whether or not to feed her they stated they weren't sure what the care plan said.

Based on staff interview, clinical record review and facility document review, the facility staff failed to maintain acceptable levels of nutrition and hydration status for one of five residents in the survey sample, resident #1.The findings include:For resident #1 the facility staff failed to follow the Registered Dietician recommendations for weekly weights in September 2025 and October 2025 when the resident had experienced ongoing significant weight loss and failed to feed the resident per the comprehensive care plan interventions. Resident #1's diagnoses included but were not limited to dementia, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease and gastroesophageal reflux disease.The annual minimum data set (MDS) assessment with an assessment reference date of 11/19/25 was reviewed. Resident #1 was assessed to have severely impaired cognitive skills for daily decision making, the resident also had little interest or pleasure in doing things, poor appetite or overeating, and feeling tired or having little energy nearly every day over the two week look back period. Resident #1 was assessed to require set up assistance or clean up assistance with meals during the lookback period. The assessment also captured a significant weight gain that was not prescribed or planned during the look back period. The progress notes were reviewed. On 9/5/25 the Registered Dietician (RD) documented a weight change note that read in part, Sig (significant) wt (weight) loss likely r/t (related to) variable intake. Supplement previously decreased in Aug d/t (due to) apparent wt stability in the setting of good intake. On dysphagia mech (mechanically) altered diet, po (by mouth) intake ~75%. Receives 2.0 house supplement QD (every day). Recommend increase 2.0 supp (supplement) to BID (twice daily) and weekly weights x4 for monitoring. Discussed in wt mtg (meeting) with IDT (interdisciplinary team). The note documented the current weight to be 123 lbs. (pounds) which was a weight loss of 5% in 30 days and 7.5% in 90 days. On 10/4/25 the RD documented a weight change note that read in part, Sig wt loss noted and d/t variable intake. Nursing reports res (resident) recently not feeling well d/t respiratory illness. On dysphagia mech altered diet, po intake ~51-75% with 2.0 house suppl BID. Recommend increase of 2.0 suppl to TID (three times a day) and weekly wts x 4 for monitoring. Discussed in wt mtg w/IDT. The current weight was documented as 116 lbs. with 5% loss in 30 days, 7.5% loss in 90 days and a 10% loss in 180 days. On 11/7/25 the RD documented a weight change note that read in part, Sig wt gain appears to be some beneficial rebound from prev (previous) loss. On dysphagia mech altered diet with po intake ~75% (improved). Also receives 2.0 house suppl TID (three times a day) (increased on 10/4). BMI 21.4, WNL (within normal limits). No changes recommended at this time. Discussed in wt mtg w/IDT. The current weight was documented as 128.5 which was a 5% gain in 30 days, 7.5% gain in 90 days and 10% gain in 180 days.On 12/5 the RD documented a weight change note that read in part, Sig wt loss noted. Res with recent decline and recent oral thrush noted. Nursing reports res (resident) is now total assist for meals and is requiring cueing to swallow. Is on speech therapy caseload. On puree diet with nectar liq (liquids), po intake ~51-75% with 2.0 house suppl TID. Recommend weekly weights x 4 for monitoring. Discussed in wt mtg w/IDT. The current weight was documented as 121 lbs. which was a loss of 5% in 30 days and 10% in 180 days.On 12/26/25 the RD documented a weight change note that read in part, Sig wt loss prev (previously) addressed, but down an additional 2# (pounds). Recent diet upgrade noted, which will likely help, as well as completion of treatment for oral thrush. On dysphagia advanced diet w/ground meat and nectar thick liq. PO intake avg ~51-75%. Receives 2.0 house suppl TID (intake varies from 0-100%). Currently on weekly wts. No changes recommended at this time, just cont (continue) to monitor per protocol. Discussed in wt mtg w/IDT. The current weight was documented at 119 lbs.The weights documented in the clinical record were reviewed. There was no weight recorded for the second week of September, the third week of October, and the second week of December. The comprehensive person-centered care plan included a focus that read, the resident is at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, DM (diabetes), HF (heart failure), dementia, hx (history) protein calorie malnutrition. Texture modified diet w/thickened liq. Sig (significant) wt (weight) fluctuation, most recently loss. This care plan focus was created on 10/31/2022 and revised on 12/28/25. Some of the interventions listed on the care plan were encouragement to eat, record meal % intake, supplements as ordered, and total assist for meals which had a revision date of 12/7/25, and weights as ordered.The documentation survey report which consists of the certified nursing assistant (CNA) documentation of meals and activities of daily living (ADLs) provided to resident #1 was reviewed for December 2025. The level of assistance for meals provided to resident #1 was documented as 05 which means set up assistance, and 06 which means independent for meals every day in December except 12/11/25 for the evening meal the resident was documented as being dependent. Out of 93 total meals served in the month of December resident #1 was documented as eating 76-100% for 48 meals, 51-75% for 31 meals, 26-50% for 9 meals and 0-25% for 5 meals which included 2 refusals, one on 12/25/25 and one on 12/31/25. On 3/11/26 at 11:36 the Physician's Assistant (PA) who cared for resident #1 was interviewed. They stated that on 1/8/25 they, along with the facility IDT met with the family and went through the plan of care due to a decline in condition. The PA stated, Someone from the facility, I'm not sure who, had called them on the 7th and there was some sort of miscommunication about what was going on. They were made to feel like because she was a DNR (do not resuscitate), we weren't treating the decline. The family got here and saw that wasn't at all true, we had IV (intravenous) fluids going, we were doing labs and had started antibiotics for a UTI (urinary tract infection) so they were good with all we were doing. I think they did question if she should be sent to the hospital but in the end, we agreed to keep her here and treat her. On the 9th I called them again because she was profoundly dehydrated and definitely needed to go to the hospital. They questioned if the staff was feeding her and offering fluids and I know that they were. I know she was on the list to be fed by the aides. The PA stated that she was never in the room at mealtime so never saw staff feed resident #1. On 3/11/26 at 1:14 PM Certified Nursing Assistant (CNA) #1 was interviewed. They stated they were very familiar with resident #1. CNA #1 stated that resident #1 was independent with meals at first but then toward the end we had to feed her. CNA #1 did not recall when staff started to feed the resident exactly but stated, I don't remember when she was put on the list, it wasn't too long before she went out to the hospital. When asked if the resident was feeding herself in December, around Christmas they stated, Yes, I think we didn't start feeding her until after that sometime. We would take her tray in and set her up and let her try to feed herself and go back and check on her. If she wasn't eating or needed help, we would help her. When asked if that was how it was done after resident #1 got put on the feed list, CNA #1 stated, Yes, we would set her up first because sometimes she could do it. The last week or two we just fed her though, I think I can't remember for sure, but we always made sure she ate. CNA #1 stated that they have a list on the unit for residents who need to be fed and when they come to work, they are assigned certain people on the list to feed each day. On our unit, we make sure all our residents are fed and eat. On 3/11/26 at 2:22 PM CNA #2 was interviewed. When asked about resident #1 and how she ate they stated, She was supervision at first. We would set her up and let her feed herself and we'd check on her and help her if she needed it. CNA #2 stated resident #1 could drink independently, Probably about a week before she died, I had to hold the cup for her. Her appetite and desire to drink really declined fast. When asked how the staff know who to feed, they stated, We have a list. If the residents name is in bold letters we feed them, but if it isn't in bold letters, we supervise like set them up and go back and check to see if they need help. On 3/11/26 at 2:31 PM the Unit Manager (UM) was interviewed. When asked if they recalled when resident #1 was put on the list to be fed, they stated, She was always on the list but was just supervision at first. She had a rapid decline, a week or so before she went out, she was up in her chair in the day room watching TV. When asked how the staff know to feed residents they stated, We have a list if the name is in bold print, they are supposed to feed that person, if it isn't in bold, they set them up and go back and check to see if they need help or not. UM could not recall the timeframe but thinks resident #1's name was in bold print. On 3/11/26 at 3:16 PM Licensed Practical Nurse (LPN) #1 was interviewed. When asked if resident #1 fed herself they stated, She was on the feed list. She wasn't able to feed herself at the last, for quite a while before she went out. She wasn't able to drink on her own either. I tried to make sure when I worked to keep the family updated because I knew they were concerned. The daughter did ask me during one long conversation if anyone was giving her water or feeding her, she said they had friend or somebody visiting that told them she wasn't getting fed but I told her that absolutely was not true. It could have been when they were her, she had already eaten or they hadn't gotten to her yet, but she was being fed every day.The Director of Nursing (DON) was interviewed on 3/11/26 at 4:00 PM. They stated that resident #1 had a very rapid decline. She had some weight loss we were watching closely and then bam, she needed IV's and just wasn't doing well. When asked about the weekly weights they said that resident sometimes refused care including being weighed due to pain and they would look for documentation of the missing weights or refusals. The DON was able to produce documentation of the resident refusing the December weekly weight but was unable to locate any documentation for the missing weights in September and October. The DON clarified the facility does not generally put in orders for weights but does follow RD recommendations for weights.On 3/11/26 at 4:10 PM LPN #2 was interviewed. When asked about resident #1 and if she was a feed or not, they stated, Yes the staff were feeding her and offering fluids, the last 4 months or so she was just kind of up and down. We had speech therapy in, and they changed her diet a couple times because she was having some swallowing problems but then she got some better. The last two months I would say she was dependent for eating.On 3/11/26 at 4:37 CNA #3 was interviewed. They stated that resident #1 occasionally refused meals and that was the case on 12/25/25 and 12/31/25. Once we started having to feed her all the time there were times when she wouldn't open her mouth or would hold the food in her mouth and not swallow it. CNA #3 stated the resident was not able to hold a drink at the end but would frequently drink better than she would eat. CNA #3 could recall the timeframe of when the resident went from being set up or supervision to being a total feed. The policy entitled, Weight Monitoring and Tracking with an effective date of 1/29/24 was requested and provided. The policy read in part, The center has a system in place to weigh, monitor, and track patient's weights. Weights are tracked, monitored and analyzed by the interdisciplinary team. Item #1 under procedure read, The Director of Nursing is responsible for ensuring patients are weighed in an acceptable time frame, using proper technique. Nursing staff are responsible for recording the weight in the clinical record.The Administrator, DON and Regional Director of Clinical Services were notified of the concern during a pre-exit meeting on 3/11/26 at 4:30 PM. No further information was provided prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 2 of 7 residents, Residents #3 and #4.The findings included:1. The facility staff failed to ensure Resident #3's provider ordered medication Heparin was available for administration.Resident #3's diagnoses included non-traumatic subdural hemorrhage. Resident #3's comprehensive care plan included the focus area anticoagulant, the resident is at risk for bleeding, hemorrhage, excessive bruising and complications related to anticoagulant use secondary to subdural hemorrhage. Interventions included administer medications as ordered. Date created 06/11/24. Resident #3's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/14/24 included a brief interview for mental status (BIMS) score of 15. Indicating Resident #3 was cognitively intact. Resident #3's clinical record included a provider order for Heparin sodium injection solution 5000 UNIT/ML (milliliter) inject 1 ml subcutaneously every 8 hours for anticoagulation. Date of order 06/10/24 start date 06/11/24. A review of Resident #3's medication administration records (MARs) for 07/2024 revealed that for 07/03/24 the facility nursing staff documented a 9 for this medication at 8:00 a.m. and 4:00 p.m. and again on 07/04/24 at midnight and 8:00 a.m. Per the preprinted code on the MARs a 9=other/see progress notes. Resident #3's clinical record included the following progress notes.07/03/2024 9:17 a.m., Heparin sodium injection solution 5000 UNIT/ML inject 1 ml subcutaneously every 8 hours for anticoagulation. On next pharmacy delivery run, out of stock in Omnicell. Resident and Nurse Practitioner (NP) aware. 07/03/2024 12:48 p.m., contacted pharmacy in regard to Heparin. Medication was reorder through computer on 07/02/24 & has not been received. Medication previously pulled out of Omnicell & at this time Omnicell is out of stock. Pharmacy tech states that the refill has been processed & will be sent out on night/next run. NP made aware of missed dosages of Heparin. 07/03/2024 5:03 p.m., Heparin sodium injection on next pharmacy delivery run, out of stock in Omnicell. Resident and NP aware. 07/03/2024 11:43 p.m., Heparin sodium injection Solution 5000 UNIT/ML inject 1 ml subcutaneously every 8 hours for anticoagulation awaiting medication to arrive from pharmacy. Medication not available in Omni-Cell. M.D. aware. 07/04/2024 10:49 a.m., on order waiting on pharmacy. 07/04/2024 10:56 a.m., Contacted pharmacy again to follow up on delivery of Heparin which was supposed to be sent on night delivery on 07/03/24. Overnight nurse also contacted pharmacy & pharmacy tech states that medication was out for delivery. At this time medication was not delivered. This writer called pharmacy & requested that the medication is sent to a local pharmacy due to the delay in delivery. Request has been sent in & awaiting call from local pharmacy for pick up. The facility nursing staff documented this medication had been administered on 07/04/24 at 4:00 p.m. The facility staff provided the surveyor with a copy of their policy titled, Medication Unavailability. This policy read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered.If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures. On 08/20/25 at 10:45 a.m., during a meeting with the Administrator, Director of Nursing (DON), Regional Director of Clinical Services #1 and #2, and Administrator in Training the issue with the Heparin not being available for administration was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility staff failed to ensure the provider ordered medications Oxycodone HCl oral tablet 5 mg and Glargine Insulin were available for administration. Resident #4's diagnoses included diabetes, muscle weakness, and open wound left lower leg. There was no completed minimum data set assessment for this resident. Resident #4 was alert and orientated.Resident #4's care plan included the focus area diabetes mellitus and at risk for pain. Interventions included administer medications as ordered. Resident #4's clinical record included provider orders for Oxycodone HCL oral tablet 5 mg give 1 tablet by mouth every 6 hours for pain. The clinical record also included an order for Insulin Glargine inject 40 units subcutaneously at bedtime for diabetes. The order date and start date were both documented as 08/14/25. A review of Resident #4's medication administration records (MARs) for August 2025 revealed that for 08/14/25 at 9:00 p.m. for Resident #4's Glargine Insulin the facility staff documented a 9. For the medication Oxycodone on 08/14/25 at 6:00 p.m. the facility nursing staff documented a 9. Per the preprinted code on the MAR a 9=other/see progress notes. Resident #4's clinical record included the following progress notes.08/14/25 at 6:00 p.m. patient is a new admission, awaiting delivery from the pharmacy. This progress note did not identify what medication was not available. 08/14/25 at 11:18 p.m., Insulin Glargine unable to administer medication at this time as patient is a new admit and medication hasn't arrived from pharmacy at this time, medication unavailable in Omnicell. Physician Assistant made aware. A review of the facility stat box list revealed this medication would not have been available in the stat box for administration. The facility staff provided the surveyor with copies of two policies. Policy #1 was titled, Medication Unavailability. This policy read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered.If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures. Policy #2 was titled, Admitting a Patient and read in part, PROCEDURE.Provide pharmacy notification, if applicable.Further review of Resident #4's MAR revealed the nursing staff had administered this resident's insulin on 08/15/25 at 9:00 p.m. and Oxycodone at midnight on 08/15/25. On 08/19/25 at 1:15 p.m. the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #1 and #2 were notified that Resident #4's insulin and Oxycodone were not available for administration on 08/14/25. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review the resident's total program of care from a hospital discharge to include blood glucose checks for 1 of 7 residents, Resident #4.The findings include:The facility staff failed to ensure the attending physician and/or provider reviewed the hospital discharge summary for a hospital stay ending on 08/14/25. Resulting in Resident #4 not receiving blood glucose/blood sugar checks. Resident #4's diagnoses included diabetes.There was no completed minimum data set assessment for this resident. Resident #4 was alert and orientated. Resident #4's clinical record included a discharge summary with a date of service of 08/14/25. Under the heading of CONTINUE taking these medications this paperwork included the following information insulin pen needle 1 each every day, blood glucose meter 1 each every day, glucometer 1 each as directed (diabetes) and glucometer test strips. It also included a dexcom receiver and sensor. Resident #4's clinical record did not include any provider orders for blood glucose/blood sugars to be monitored. On 08/19/25 at 5:10 p.m., during an interview with Physician Assistant (PA) #1 this staff was asked if Resident #4 should have been receiving blood glucose/blood sugar checks. The PA stated yes before meals and at bedtime. The PA stated they had been off, just met the resident today and had received their discharge summary. Further review of the clinical record revealed that an order for accuchecks (blood sugars) before meals and at bedtime had been transcribed into the clinical record on 08/19/25 at 5:16 p.m.On 08/19/25 at 5:25 p.m., during an interview with Licensed Practical Nurse (LPN) #1 this staff acknowledged they had been the admitting nurse for Resident #4 and stated they remembered seeing something about a dexcom, but the resident did not have one. LPN #1 stated they remembered speaking with the Unit Manager but did not remember anything more. The facility nursing staff had documented in a progress note on 08/19/25 at 5:55 p.m. that Resident #4's blood glucose was checked. The blood sugar was documented as 148. On 08/19/25 at 5:30 p.m., during a meeting with the Administrator, Director of Nursing (DON), Regional Nurses #1 and #2, and the Administrator in Training the issue with Resident #4's blood glucose/blood sugars not being ordered upon admit was reviewed. On 08/20/25 at 8:50 a.m., during an interview with Resident #4 this Resident stated the facility staff had not been checking their blood sugars they were checking them now and they were running about what they were prior to being admitted to this facility. On 08/20/25 at 8:55 a.m., during an interview with the Unit Manager, this staff was asked the procedure for approval of orders. The Unit Manager stated if the provider was on site they would have them review the discharge summary. When Resident #4 was admitted there was no provider on site, and they could not recall if anyone had reviewed their orders. When asked what the procedure was if a provider was not in the building the Unit Manager stated they would call the provider to check the orders especially if there was anything that needed to be clarified.On 08/20/25 at 10:35 a.m., during an interview with PA #2, this staff stated when Resident #4 had been admitted they were filling in for another provider. PA #2 stated Resident #4 did not have an actual discharge summary from the hospital in the computer, and they had to utilize what they had. PA #2 stated they did not know if they had a full medication list and they were not at the facility when the Resident was admitted and did not know who approved their orders. On 08/20/25 at 11:30 a.m., the DON provided the survey team with a copy of an in-service/education record dated 08/19/25. The subject of this in-service was admissions/new. The facility staff also provide the survey team with a copy of their policy titled, Admitting a Patient with an effective date of 01/29/24. This policy read in part, PROCEDURE.Obtain provider's orders or verify transfer orders with attending physician for the patient's immediate care.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to ensure safe and secure storage of medications and/or blood collection tubes for 3 of 6 medication carts (200 Hall, 400 Hall, and 500 Hall) and 1 of 2 medication storage rooms (Unit 2). The findings included: 1. The 500 Hall medication cart contained three used insulin pens which were not labeled with a resident's name or date of opening. The 400 Hall medication cart contained an insulin pen without a clearly identifiable resident name, an expired box of Levothyroxine 75 mg tablets, and a half full vial of Insulin Glargine with a dispense date of 2/14/24 and a beyond use date of 5/13/24. On 5/23/24 at 9:43 AM, surveyor observed Registered Nurse (RN) #3 drawing insulin out of an insulin pen into an insulin syringe. RN #3 stated they did not have any pen needles in the medication cart. The insulin pen being used by RN #3 was Basaglar Insulin and was not labeled with a resident's name or in a labeled bag. RN #3 discarded the insulin syringe. Surveyor immediately notified the Unit Manager (UM) of the observation. On 5/23/24 at 10:00 AM, surveyor notified the Director of Nursing (DON) of the observations. The DON stated insulin pens are delivered from the pharmacy with multiple pens in a labeled bag and stated when staff remove a pen from the bag the nurse should write the resident's name on the pen. Surveyor returned to the UM at 10:08 AM and the UM stated they removed a total of four unlabeled insulin pens from the 500 Hall medication cart. The unlabeled insulin pens included two used Basaglar Insulin pens, a used Fiasp Insulin Aspart pen and a new unused Fiasp Insulin Aspart pen. The UM stated they were running a report to determine which resident the insulin pens belonged to. When asked how they could determine which residents had used the pens, the UM stated they would throw out the Basaglar pens and obtain new ones but only one resident was prescribed Fiasp Insulin Aspart. On 5/23/24 at 10:24 AM in the presence of the DON, the surveyor observed the 400 Hall medication cart. The cart contained a Levemir Insulin pen without an identifiable resident name, smeared pen ink was visible on the label, an opened box of Levothyroxine 75 mg with an expiration date of 8/2023, and a vial of Insulin Glargine with a dispense date of 2/14/24 and a sticker which read: Beyond Use Date: 5/13/24. Based on several other opened medications, at times staff were writing the open date on the Beyond Use Date sticker, therefore, surveyor was unable to determine when the vial was opened. The survey team met with the Administrator, Assistant Administrator, DON, and Regional Nurse Consultant (RNC) on 5/23/24 at 11:15 AM and discussed the concern of the unlabeled used insulin pens available in the medication carts and the expired medications. The RNC stated they would dispose of the unlabeled insulin pens and obtain new ones. RNC stated insulin pens should be labeled with a resident's name. The RNC returned at 11:45 AM and stated the unlabeled insulin pens were in the possession of management and would be discarded. Surveyor requested and received the facility policy titled, Storage of Medications which read in part III. Expiration Dating (Beyond-Use Dating) .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining . No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24. 47299 2. On 5/22/24 at 8:40 AM during a medication pour and pass observation, this surveyor observed Registered Nurse (RN) # 1 leave 6 (six) medication cards on top of the medication cart unsecured while administering medications to a resident. There were other staff in the hallway where the medication cart was left. The cart was out of RN # 1's line of sight for 4 minutes. No staff or residents approached the cart during that time. The medications left unattended included clopidogrel 75 mg tablets, lisinopril 20 mg tablets, hydralazine 10 mg tablets, Lasix 40 mg tablets, finasteride 5 mg tablets, and Flomax 0.4 mg capsules. When RN # 1 Returned to the medication cart this surveyor asked if they typically leave medications unattended on the cart and they stated, No, I never do that. On 5/23/24 at 10:40 AM this surveyor performed a check of the 500 hall medication cart with RN # 3. In the second drawer of the cart, this surveyor observed an opened box of bisocodyl 10 mg suppositories with two suppositories remaining. The suppositories were house stock and did not have a resident name on the box. The expiration date stamped on the box was 12/2023. RN # 3 would not answer surveyors questions and did not comment, they walked away and stated, Lock the cart when you are done. There were multiple other staff observing this interaction. This surveyor discussed this concern with Licensed Practical Nurse (LPN) # 3. LPN # 3 took the medication and agreed that the expiration date was 12/2023. They stated they would destroy the medication. This surveyor requested and received the policy entitled Administration Procedure for all Medications with an effective date of 09-2018 that read in part, I. Security All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. A second policy entitled, Storage of Medications with an effective date of 09-2018 that read in part, under the heading Policy, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under the heading of General Guidance the policy read in part, 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. This concern was reviewed with the Administrator, Assistant Administrator, Director of Nursing and the Regional Director of Clinical Services on 5/23/24 at 5:03 PM. No further information was provided to the survey team prior to the exit conference. 28169 3. All of the blood collection tubes in the medication room on Unit 2 had expired. On 05/23/24 at 10:17 a.m., the surveyor completed an observation of the medication room on Unit 2 accompanied by the infection preventionist (IP), a licensed practical nurse, LPN #14. There were multiple types of blood collection tubes (i.e. blue tops, red/black tops, green tops, and purple tops). All the blood collection tubes were observed as having expired in various months in 2023. Of the over 100 tubes found, there were no blood collection tubes that were not expired. The IP acknowledged all the blood collection tubes had expired. The IP reported facility staff do not collect laboratory samples, they call a laboratory service for blood collection needs at any time, 24 hours/day. The IP acknowledged the expired blood collection tubes had been available for use and gathered the expired tubes to remove from the medication room. On 05/23/24 at 4:37p.m., the regional nurse was interviewed and reported that although there was no written policy with guidance about keeping the medication rooms with current products, it was the responsibility of central supply and nursing administration. On 05/23/24 at 5:03 p.m., the administrator, regional nurse, and DON were informed of the expired products found in Unit 2's medication room. The regional nurse reported facility staff do not collect their own blood samples and, instead call a laboratory service whenever a blood sample needed to be collected. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to meet the needs of a resident in regard to the timeliness of providing radiology services for 1 of 32 sampled residents, Resident #44. The findings include: For Resident #44 (R44) the facility staff failed to obtain radiology services timely, per the medical providers orders, on 1/19/24 and on 2/13/24. Diagnoses for R44 included but were not limited to, heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity due to excess calories. A review of R44's clinical record revealed physician's orders that included an order dated, 1/19/24, that read in part, .cxr (chest x-ray) d/t (due to) worsening cough. [sic] s/p (status post) treatment for PNA (Pneumonia) 1/19 [sic] .end date 1/22/24 . A physician's order dated, 2/13/24, revealed, .CXR 2/13 [sic] .end date 2/16/24 . A review of R44's Radiology Result Reports revealed the chest x-ray that was ordered on 1/19/24 was not completed until 1/23/24 and a Radiology Result Report could not be located in the clinical record for the x-ray that was ordered on 2/13/24. This concern was discussed with the director of nursing (DON) and regional director of clinical services during an interview on 5/23/24. The DON informed surveyor the x-ray ordered on 1/19/24 for R44, was not obtained until 1/23/24 at 6:00 AM and there was no order for the x-ray. DON also informed surveyor that the x-ray ordered on 2/13/24 was missed and the NP (nurse practitioner) was made aware, and an x-ray was ordered and completed on 2/20/24. This concern was discussed at the pre-exit meeting on 5/23/24 at 5:02 PM, with the administrator, assistant administrator, director of nursing and the regional director of clinical services. Surveyor requested and received a facility policy titled, .Physician's Orders ., that revealed, .Orders .treatment orders must include .Right time .Follow-up Appointments, as necessary .Other orders as indicated by patient's condition with specific directions . No further information was provided to the survey team prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 32 sampled residents, Resident #314. The findings included: For Resident #314, the facility staff failed to obtain a urinalysis as ordered by the medical provider on 2/13/24. Resident #314's diagnosis list indicated diagnoses, which included, but not limited to Pneumonia, Generalized Muscle Weakness, Protein Calorie Malnutrition, Essential Hypertension, and Gastro-Esophageal Reflux Disease. Resident #314's minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #314 was assessed by the facility family nurse practitioner (FNP) on 2/13/24, the progress note read in part .[adult child] reports last night patient showing signs of UTI [urinary tract infection] and was reportedly hallucinating today, patient denies acute issues when asked about dysuria, patient states slight but reports nowhere near discomfort [he/she] has had in the past with recurrent UTIs .Assessment and Plan .UA [urinalysis] with CS [culture and sensitivity] . A provider order for a urinalysis with reflex culture and sensitivity via an in and out catheterization was ordered to be obtained between 2/13/24 and 2/16/24. Surveyor was unable to locate results of the urinalysis or evidence that a urine sample was obtained for testing. On 5/22/24 at 9:30 AM, surveyor spoke with the FNP who stated they saw Resident #314 at the family's request for signs and symptoms of a UTI, but the resident denied having any issues and they ordered a CBC (complete blood count) and a UA. FNP stated the labs were obtained but the urine was not collected. FNP stated there was no documentation from nursing addressing why the urine was not collected. Surveyor requested and received the facility policy titled, Laboratory/Diagnostic Testing which read in part .1. A licensed nurse will obtain laboratory, radiology, or other diagnostic services to meet the needs of its patients as ordered by the provider. 2. A licensed nurse will monitor and track all provider ordered laboratory, radiology, and other diagnostic tests; ensure that tests are completed as ordered and communicate results to the provider . On 5/22/24 at 4:35 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to obtain a urinalysis for Resident #314. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of significant medication errors for 2 of 32 sampled residents, Resident #314 and #62. The findings included: 1. For Resident #314, the facility staff failed to follow medical provider orders for the administration of the medications, Diltiazem, Metoprolol Tartrate, and Midodrine on 2/15/24 and 2/16/24. Diltiazem and Metoprolol Tartrate are antihypertensives and Midodrine is used to treat low blood pressure. Resident #314's diagnosis list indicated diagnoses, which included, but not limited to Pneumonia, Generalized Muscle Weakness, Protein Calorie Malnutrition, Essential Hypertension, and Gastro-Esophageal Reflux Disease. Resident #314's minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. The resident's provider orders included orders dated 2/09/24 for Diltiazem 60 mg by mouth one time a day and hold for systolic blood pressure (SBP) less than 110 and Metoprolol Tartrate 12.5 mg two times a day and hold dose for SBP less than 110. A review of Resident #314's February 2024 Medication Administration Record (MAR) revealed Diltiazem and Metoprolol Tartrate were each administered on 2/15/24 at 9:00 AM with a SBP of 97 and 2/16/24 at 9:00 AM with a SBP of 95. Metoprolol Tartrate was administered again on 2/16/24 at 5:00 PM with a SBP of 95. Resident #314's provider orders included an order dated 2/09/24 to administered Midodrine 10 mg every 8 hours as needed for hypotension if SBP was less than 105. According to the order, Midodrine should have been administered on 2/15/24 at 9:00 AM due to a SBP of 97, 2/16/24 at 9:00 AM due to a SBP of 95, and 2/16/24 at 5:00 PM due to SBP of 95. According to the resident's MAR, Midodrine was not administered as ordered on 2/15/24 and 2/16/24. On 5/23/24 at 8:55 AM, surveyor spoke with registered nurse (RN) #3 who administered the Diltiazem and Metoprolol Tartrate and failed to administer the Midodrine. RN #3 reviewed the resident's MAR and stated, appears I made a med error. Surveyor requested and received the facility policy titled, Administration Procedures for All Medications which read in part .III .1. Prior to removing the medication package/container from the cart/drawer .d. Check for vital signs or other tests to be done during or prior to medication administration . On 5/23/24 at 5:02 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to follow Resident #314's provider orders. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24. 2. For Resident #62, the facility staff failed to follow the physician's order for the administration of Insulin Glargine, a long-acting insulin. Resident #62's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Asthma, Chronic Obstructive Pulmonary Disease, Emphysema, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/04/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #62's current comprehensive person-centered care plan included a focus area stating The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with insulin use with an intervention to administer insulin as ordered. The resident's current provider orders included an order dated 10/03/23 for Insulin Glargine 100 unit/ml inject 40 units subcutaneously every 12 hours and hold if blood glucose below 140. A review of Resident #62's May 2024 Medication Administration Record (MAR) revealed Insulin Glargine 40 units was administered on 5/23/24 at 8:00 AM. In the area on the MAR provided for documentation of the blood sugar, NA was entered by the nurse. Surveyor reviewed the clinical record and was unable to locate documentation of a blood sugar immediately prior to the administration of the insulin. The most recently documented blood sugar of 181 was obtained at 6:24 AM earlier that morning. Surveyor requested and received the facility policy titled, Administration Procedures for All Medications which read in part .III .1. Prior to removing the medication package/container from the cart/drawer .d. Check for vital signs or other tests to be done during or prior to medication administration . On 5/23/24 at 5:02 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to follow Resident #62's provider orders for the administration of insulin. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure provider ordered medications were available for administration for 1 of 27 current sampled residents, Resident #94 and failed to ensure nursing staff correctly implemented the facility scheduled/control monitoring system for 1 of 6 medication carts, the 400-hall medication cart. The findings included: 1. The facility staff failed to ensure Resident #94's provider ordered narcotic pain medication Oxycodone was available for administration. Resident #94's clinical record included the diagnoses, malignant neoplasm of bronchus of lung, chronic obstructive pulmonary disease, muscle weakness, and cirrhosis of liver. Section C (cognitive patterns) of Resident #94's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/12/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #94's comprehensive care plan included the focus area at risk for pain. Interventions included administer medications as ordered. Resident #94's clinical record included a provider order dated 01/11/24 for the pain medication Oxycodone 1 tablet 3 times a day for pain hold for sedation or lethargy. A review of Resident #94's clinical record revealed that the facility nursing staff documented that for the narcotic pain medication Oxycodone on 04/20/24 this medication was unavailable, 04/29/24 on order from pharmacy, and on 05/05/24 awaiting delivery from pharmacy. On 05/21/24 at 5:06 p.m., the surveyor interviewed Resident #94 regarding their Oxycodone medication not being available for administration. Resident #94 stated they had run out of it one time and they had to reorder it from the pharmacy, but it wasn't an issue they just needed it at bedtime. On 05/22/24 at 11:20 a.m., Registered Nurse (RN) #1 was interviewed regarding the procedure for unavailable medications. RN #1 stated they would notify the provider, call the pharmacy, and try to get the medication as soon as possible. When asked about the backup supply at the facility RN #1 stated sometimes the medications were available and sometimes not. On 05/22/24 at 12:05 p.m., the Director of Nursing (DON) and Regional Nurse Consultant were made aware of the issue regarding Resident #94's medication not being available for administration. The surveyor requested a list of medications in the facility stat box (back up box). On 05/23/24 at 8:30 a.m., the Regional Nurse Consultant provided the surveyor with a copy of the stat box list. A review of this list revealed that this medication would not have been available onsite for administration. The facility policy titled, Medication Unavailability with an effective date of 01/29/24 read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered. 1. A licensed nurse will notify the provider of the unavailability of medication and discuss an alternative order, if necessary . On 05/22/24 at 4:35 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Administrator in Training, and Regional Nurse Consultant the issue with the unavailability of the Oxycodone was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 42353 2. The Controlled Drug Administration Record for Resident #313's Gabapentin 600 mg did not reconcile with the actual amount of Gabapentin 600 mg tablets available in the medication cart. Resident #313's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Alzheimer's Disease, Type 2 Diabetes Mellitus, and Bilateral Foot Calcaneal Spurs. Resident #313's current medical provider orders included an order for Gabapentin 600 mg by mouth every 12 hours for neuropathy scheduled to be administered at 8:00 AM and 8:00 PM. On 5/23/24 at 10:42 AM, the surveyor and Director of Nursing (DON) reconciled the resident's documented Gabapentin count with the actual amount available for administration in the medication cart and a discrepancy of one tablet was identified. According to Resident #313's Controlled Drug Administration Record Tablet, the medication cart should contain a bubble pack with 14 tablets and a bubble pack of 28 tablets for a total of 42 Gabapentin 600 mg tablets. The surveyor and the DON observed a bubble pack of 13 tablets and a bubble pack of 28 tablets of Gabapentin 600 mg present in the medication cart. According to Resident #313's Controlled Drug Administration Record Tablet, the last Gabapentin 600 mg tablet was signed out as being administered on 5/22/24 at 9:00 PM. However, Resident #313's May 2024 Medication Administration Record (MAR) indicated Gabapentin 600 mg was administered on 5/23/24 at 8:00 AM. Surveyor requested and received the facility policy titled, Administration Procedures for All Medications which read in part .IV. Administration .7. After administration, return to cart .document administration in the MAR or TAR and the controlled substance sign out record, if necessary . On 5/23/24 at 5:02 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of the discrepancy in Resident #313's Gabapentin count. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24.

Based on observation, resident interview, clinical record review and facility document review, the facility staff failed to administer oxygen according to the attending medical provider's orders for 1 of 32 sampled residents, Resident #44. The findings include: For Resident #44 (R44) the facility staff failed to administer oxygen per the medical provider orders at 4 liters per minute via nasal cannula. Diagnoses for R44 included but were not limited to, heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity due to excess calories. The most recent minimum data set (MDS) assessment with an assessment reference date of 5/7/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15, indicating intact cognition. On 05/21/24 at 4:30 PM, surveyor observed R44 in a wheelchair in the dining room receiving oxygen (02) with a nasal cannula via a portable 02 tank that was observed to be on three (3) liters of oxygen. On 05/22/24 at 1:17 PM, surveyor observed R44 lying in bed and observed resident to be receiving 02 from a nasal cannula via a 02-concentrator set on 3 liters. Surveyor asked R44 how many liters of oxygen she is supposed to be on and R44 stated she is on 3 liters of oxygen. On 5/22/24 at 1:59 PM, surveyor observed R44 up in her wheelchair receiving 02 from a nasal cannula with a portable O2 tank set on 3 liters and resident stated, I am on 3 liters. R44's current physician's orders included an active order dated 1/17/24, that read in part, Oxygen at 4 (four) liters per minute via nasal cannula every day and night shift . A review of the medication administration record (MAR) for May 2024 read that R44's 02 was administered as ordered. A review of R44's comprehensive care plan revealed a focus statement that read in part, RESPIRATORY: the resident is at risk for respiratory complications secondary to Acute & Chronic Respiratory Failure . and an intervention statement that read in part, .administer oxygen as ordered . This concern was discussed at an end of day meeting on 5/22/24 at 4:35 PM with the administrator, assistant administrator, director of nursing and the regional director of clinical services. On 5/23/24 at 10:42 AM, surveyor observed R44 lying in bed with 02 being administered via nasal cannula from a 02-concentrator set on 4 liters. R44 stated they told her this morning that she is supposed to be on 4 liters of oxygen. Surveyor requested and received a facility policy titled, .Physician's Orders ., that revealed, .Orders-medication and treatment orders must include .Right dosage . Surveyor also requested and received a facility policy titled, .Respiratory Care & Oxygen Equipment ., that revealed, .Follow provider's order including; .Flow rate .For continuous oxygen therapy, verify and document in the medical record each shift and PRN . This concern was discussed at the pre-exit meeting on 5/23/24 at 5:02 PM, with the administrator, assistant administrator, director of nursing and the regional director of clinical services. No further information was provided to the survey team prior to exit.

Based on observation, staff interview and clinical record review, the facility staff failed to provide care and services as ordered by the primary care physician for one (1) of 32 residents in the survey sample (Resident # 46). The findings include: For resident # 46, the facility staff failed to ensure water flushes were delivered according to the physician's order through the PEG (percutaneous endoscopic gastrostomy) tube. Resident # 46's diagnoses include but are not limited to dysphagia following a cerebrovascular accident, hemiplegia, hemiparesis, unspecified protein-calorie malnutrition, and unspecified heart failure. Resident # 46's minimum data set (MDS) assessment with an assessment reference date of 3/26/24 indicated that resident was severely cognitively impaired and is rarely or never understood. On 5/21/24 at 4:14 PM this surveyor observed resident lying in bed with tube feeding pump at bedside. Surveyor noted that the pump was running and was set to deliver 250 milliliters (mls) of water every 4 hours. Resident # 46 was not interviewable. The medical record was reviewed, and a physician's order was located that was dated 3/24/24 and read, Free Water: 200 cc via PEG (percutaneous endoscopic gastrostomy) Q 4 hours. The Medication Administration Record (MAR) was reviewed and did include an entry for this order that was signed off as administered each day this month. On 5/21/24 at 5:45 PM this surveyor asked Licensed Practical Nurse (LPN) # 2 if they knew how much water resident # 46 was supposed to be getting through their tube. They stated, I believe it's 200 mls every four (4) hours but let me check to be sure. After checking the orders they stated, Yes, (resident # 46) gets 200 mls every 4 hours. This surveyor asked LPN # 2 to check the pump. LPN # 2 asked LPN # 3 to come as well. Surveyor asked LPN #3 what the pump was set for and they stated 250 mls every 4 hours, what is it supposed to be? LPN # 2 stated, The order is for 200. LPN # 3 changed the setting to 200 mls every 4 hours. Surveyor asked LPN # 3 if they agreed that the pump setting was incorrect and they stated, Yes, it should have been set for 200 mls every 4 hours. On 5/22/24 8:59 AM this surveyor observed resident # 46 lying in bed with tube feeding running and pump was set to deliver water flushes at 200 mls every 4 hours. On 5/23/24 at 5:03 PM the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and Regional Director of Clinical Services. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 32 sampled residents (Resident #37). The findings included: Resident #37's comprehensive person-centered care plan was not revised to address: (a) a change in the resident's code status and (b) the implementation of comfort care measures. Resident #37's most recent Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 3/1/24. Resident #37 was assessed as being able to make self understood and as usually being able to understand others. Resident #37's Brief Interview for Mental Status (BIMS) summary score was documented as a nine (9) out of 15; this indicated moderate cognitive impairment. On 5/23/24 at 9:00 a.m., Resident #37's care plan included the focus of The resident has an advanced directive of Full Code. Resident #37's care plan did not address the resident receiving comfort care measures. Resident #37's medical provider orders included: (a) an order for COMFORT CARE: no hospitalization s, no labs, no weights, no TF (tube feeding), no IVFs (intravenous fluids) with a revised date of 5/13/24 and (b) an order for DNR (Do Not Resuscitate) with a revised date of 5/14/23. On 5/23/24 at 9:06 a.m., the surveyor asked the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) about Resident #37's care plan not addressing the DNR and Comfort Care orders. On 5/23/24 at 9:13 a.m., the RDCS confirmed the care plan did not address the DNR and Comfort Care. The RDCS reported Resident #37's care plan was being updated. Resident #37's updated care plan indicated the focus of The resident has an advanced directive of DNR was revised on 5/23/24. This focus included the following intervention which was documented as being revised on 5/23/24: COMFORT CARE: no hospitalization s, no labs, no weights, no TF, no IVFs. The following information was found in a facility policy titled Care Planning (with an effective date of 11/1/19): - A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. - Care plans will be updated on an ongoing basis as changes in the patient occur, and [sic] reviewed quarterly with the quarterly assessment. The survey team met with the facility's Administrator, Director of Nursing, and Regional Director of Clinical services on 5/23/24 at 5:04 p.m. The surveyor discussed Resident #37's comprehensive care plan not being revised to address the residents code status change and the implementation of comfort care measures.

Based on staff interview, clinical record review, and facility document review, the facility staff failed develop and implement a comprehensive person-centered care plan for 2 of 32 sampled residents, Resident #18 and Resident #35. The findings include: 1. For Resident #18 (R18) the facility staff failed to develop a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs. R18's diagnosis list indicated diagnoses that included, but were not limited to, Major Depressive Disorder, History of Falling, Bipolar Disorder, Schizophrenia, Dementia, Cognitive Communication Deficit, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15, indicating R18 was moderately impaired in cognitive skills for daily decision making. A review of R18's clinical record on 5/21/24 revealed an Activities-Admission Review assessment dated , 9/16/2015 that revealed, .Use this data to design an activities program that meets the residents needs and preferences. Update the care plan on completion . A review of the most recent Activities Reassessment dated [DATE], revealed, .Residents Activity-Related Focus(es) including Needs, Strengths and Preferences: a. Activity-Related focuses remain appropriate/current as per current care plan .Goals were met .Interventions/approaches have been effective in reaching goals . Surveyor reviewed R18's comprehensive care plan and was unable to locate documentation of an activity person-centered focus or goal. One activity intervention with a created date of 02/12/2024 read, Activities of resident choice. On 5/22/24 at 11:25 AM, surveyor interviewed Activity Director (AD). Surveyor informed AD that an activity care plan could not be located in the clinical record for R18. AD stated the corporate consultant does audits and if an activity care plan was missed, she (corporate consultant) would have let her know and she could not believe R18 would not have an activity care plan. AD stated she would look and see if she had one. On 5/22/24 at 2:03 PM, AD brought surveyor a copy of R18's care plan that revealed one activity intervention that was highlighted, with a created date of 02/12/2024 and read, Activities of resident choice. AD agreed R18 should have an activity person-centered care plan in place. This concern was discussed at an end of day meeting on 5/22/24 at 4:35 PM and at the pre-exit meeting on 5/23/24 at 5:02 PM, with the administrator, assistant administrator, director of nursing and the regional director of clinical services. Surveyor requested and received a facility policy titled, Recreation .Care Plan . that revealed, .Recreation staff will actively participate in the development of an individualized care plan for each patient .to support patients in their choice of activities, use the information gathered through the assessment process to develop the activities component of the comprehensive care plan which is individualized to match the skills, abilities, interests and preferences of each patient .Care plan focuses and/or goals .include measurable objectives and time frames, focus on desired outcomes, and describe the services that are to be furnished to attain or maintain the patient's highest practicable physical, mental and psychosocial well-being .View the other disciplines' focuses and goals and add appropriate activity interventions . No further information was provided to the survey team prior to exit. 21227 2. Resident #35's comprehensive person-centered activity care plan did not address the resident's activity preferences and interests. Resident #35's most recent Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 5/2/24. Resident #35 was assessed as being able to make self understood and as being able to understand others. Resident #35's Brief Interview for Mental Status (BIMS) summary score was documented as a 11 out of 15; this indicated moderate cognitive impairment. Resident #35's care plan included a focus area, created on 7/13/23, of Alteration of prior leisure routines to continue life-long interests and preferences as conditions allow. This focus area included the following two (2) interventions dated as being created on 7/13/23: (a) Honor patient's preferences of leisure activities and (b) Offer leisure materials such as . No specific leisure materials were detailed as part of this care plan. Resident #35's ACTIVITIES REassessment dated [DATE] included the following activity information: - The resident reported it was somewhat important to listen to music they like. - The resident reported it was somewhat important to be around animals/pets. - This assessment indicated it was important for the resident to spend time with friends, watch TV, and explore the building. The resident was assessed as having a very social personality. On 5/23/24 at 2:40 p.m., the Activity Director (AD) reviewed Resident #35's care plan. The AD stated the activities care plan was incomplete. Resident #35's activities care plan was revised on 5/23/24 to include the following interventions: (a) Honor patient's preferences of leisure activities such as interest in music, socials, visiting, and sitting outside in the courtyard and occasionally church and (b) Offer leisure materials such as magazines, newspapers and other materials as requested. The following information was found in a facility policy titled Care Planning (with an effective date of 11/1/19): A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. The survey team met with the facility's Administrator, Director of Nursing, and Regional Director of Clinical services on 5/23/24 at 5:04 p.m. The surveyor discussed Resident #35's incomplete activities care plan during this meeting.

Based on staff interviews and clinical record review facility staff failed to accurately complete minimum data set (MDS) assessments for 2 of 32 residents. (Resident #5 and #107) The findings were: 1. The facility staff failed to accurately code Resident #5's physical restraint status. The MDS read Resident #5 used physical restraints (bedrails) daily when the resident did not have physical restraints. Resident #5's diagnoses included but were not limited to, hereditary and idiopathic neuropathy, paranoid schizophrenia, major depressive disorder, recurrent bipolar II disorder, heart failure, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #5's quarterly MDS assessment with an assessment reference date of 05/13/2024 coded a brief interview for mental status score of 14 out of 15. In Section P (restraints and alarms) Resident #5 was coded as using a physical restraint (bedrails) daily. The resident's clinical record contained a document titled, Device Assessment - V 3 dated 05/13/24 which read the device used was assist bars x2 to help with bed mobility and transfers and the device was not considered to be restrictive. On the morning of 05/22/24, this surveyor met Resident #5 in the resident's room. The surveyor observed the resident in bed with assist bars attached to the bed on both sides. No side rails were present. After speaking with the director of nursing (DON) and regional director of clinical services (regional nurse) about Resident #5's MDS assessment showing restraints in the form of bedrails used daily, on 05/23/24 at 9:20 a.m. both the DON and regional nurse reported they had just observed the resident's side rails and determined they were assist bars and not restrictive. The regional nurse acknowledged the MDS was coded incorrectly. On 05/23/24 at 9:32 a.m. the MDS coordinator (RN #5) who coded Resident #5 as using physical restraints daily was interviewed. The coordinator stated he may have coded it incorrectly since the MDS assessment listed bedrails as a physical restraint option but did not list assist bars as an option. RN #5 reported being aware the device assessment read the assist bars were not restrictive. On 05/23/24 in the afternoon, a different MDS coordinator (RN #2) provided a modified MDS which documented in Section P (restraints and alarms) that Resident #5 had no physical restraints. On 05/23/24 at 5:03 p.m., during a meeting with the administrator, DON, and regional nurse, Resident #5's physical restraint versus assist bars and how the MDS was coded and modified was discussed. No further information was provided prior to the exit conference. 28567 2. For Resident #107, the facility staff failed to accurately code a discharge minimum data set (MDS) assessment. The facility staff coded the discharge MDS assessment as if the resident was discharged to a short-term general hospital. Resident #107 was in fact discharged home. Resident #107's diagnoses included, but were not limited to, malignant neoplasm of breast, cognitive communication deficit, and muscle weakness. Resident #107's clinical record included a discharge MDS assessment with an assessment reference date (ARD) of 02/23/24. This MDS assessment was coded as if Resident #107 was discharged to a short-term general hospital. The clinical record included a progress note documented by the Activities Director that read in part, Patient discharged to home 2/23/24 . On 05/22/24 at 4:20 p.m., the surveyor reviewed this MDS assessment with Licensed Practical Nurse (LPN) #5. This staff stated they would review this information. On 05/23/24 at 8:25 a.m., the Regional Nurse Consultant stated the MDS assessment had been corrected to indicate the resident discharged home. On 05/22/24 at 4:35 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Administrator in Training, and Regional Nurse Consultant the issue with the MDS was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to electronically transmit minimum data set (MDS) assessments for 2 of 3 residents reviewed for the Resident Assessment task, Resident's #8 and #92. The findings included: 1. For Resident #8, the facility staff failed to electronically transmit a discharge MDS assessment. Resident #8's diagnoses included, but were not limited to, metabolic encephalopathy, muscle weakness, and diabetes. Resident #8's clinical record included a discharge MDS assessment with an assessment reference date (ARD) of 02/15/24. During the survey process the Resident Assessment task triggered for an MDS over 120 days old for this resident. On 05/23/24 at 11:50 a.m., Licensed Practical Nurse (LPN) #5 and Registered Nurse (RN) #2 was asked to review the MDS submissions for this resident. On 05/23/24 at 12:30 p.m., RN #2 confirmed that Resident #8's discharge MDS assessment with an ARD of 02/15/24 had not been transmitted prior to today and it had now been transmitted. On 05/23/24 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Administrator in Training, and Regional Nurse Consultant, the issue with the MDS not being transmitted was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #92, the facility staff failed to electronically transmit a discharge MDS assessment. Resident #92's diagnoses included, but were not limited to, diabetes, muscle weakness, and chronic obstructive pulmonary disease. Resident #92's clinical record included a discharge MDS assessment with an ARD of 12/27/23. During the survey process the Resident Assessment task triggered for an MDS over 120 days old for this resident. On 05/23/24 at 11:50 a.m., Licensed Practical Nurse (LPN) #5 and Registered Nurse (RN) #2 were asked to review the MDS submissions for this resident. On 05/23/24 at 12:30 p.m., RN #2 confirmed that Resident #92's discharge MDS assessment with an ARD of 12/27/23 had not been transmitted prior to today and it had now been transmitted. On 05/23/24 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Administrator in Training, and Regional Nurse Consultant, the issue with the MDS not being transmitted was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a clean and sanitary homelike environment for 1 of 27 current sampled residents, Resident #1. The findings included: For Resident #1, on three separate days of the survey, a large area of multiple dried, brown, drips were observed on the wall to the left of the resident's bed. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Bipolar II Disorder, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/22/24 assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 indicating the resident was severely cognitively impaired. During initial survey rounding on 5/21/24 at 3:49 PM, surveyor observed a large area of multiple, dried brown drips on the wall to the left of Resident #1's bed. Surveyor made additional observations of Resident #1's room on 5/22/24 at 1:30 PM, 5/23/24 at 8:31 AM, 5/23/24 at 10:22 AM, and 5/23/24 at 3:38 PM with no changes in the appearance of the dried drips on the wall. On 5/23/24 at 3:42 PM, surveyor spoke with the Housekeeping Supervisor (HS) and requested they visualize the wall in Resident #1's room. The drips remained and the HS stated they would get a housekeeping cart and clean the wall. Surveyor requested and received the facility policy titled, Daily Resident/Patient Room Cleaning which read in part .spot clean all necessary areas . On 5/23/24 at 5:02 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of the soiled wall in Resident #1's room. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/23/24.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to support the nutritional well-being for 4 of 27 current samples residents (R 89, R 76, R 411, R 412), of the facility with a nourishing, well-balanced diet. The findings include: The facility staff failed to support the nutritional well-being for residents of the facility with a nourishing well-balanced diet, by not serving an adequate amount of ham salad as indicated on the corporate recipe. On 5/21/24 at 5:43 PM, Resident #89 (R 89), asked surveyor to look at her ham salad sandwich on her dinner tray. R 89 removed the top slice of bread from the sandwich and surveyor observed a minimal amount of ham salad on the bottom slice of bread. The ham salad appeared as a flat smear that was approximately the size of a teaspoon. R 89 stated she didn't think it was even a teaspoon amount. Surveyor asked R89's roommate, Resident #76 (R 76), if she could observe her ham salad sandwich. R 76' s' ham salad sandwich was observed to have a minimal amount of ham salad on the bottom slice of bread. The ham salad appeared as a flat smear that was approximately the size of a teaspoon. On 5/21/24 at 5:45 PM, surveyor asked the administrator (ADM) to accompany her to the room of R89 and R76. R89 and R76 showed ADM their ham salad sandwiches. ADM offered both residents another sandwich. On 5/21/24 at 5:55 PM, surveyor interviewed regional director of operations (RDO) for contracted dietary services. Surveyor asked RDO what the serving size for the ham salad sandwiches should be and RDO stated it just said, 1(one) whole on the diet guide. RDO stated ADM had made him aware of the problem with the ham salad sandwiches for dinner this evening and he currently had two dietary staff out on the floor offering residents a second sandwich. On 5/22/24 at 8:25 AM, surveyor interviewed RDO. RDO stated he was not sure which scoop the cook used for the ham salad sandwiches served at dinner on 5/21/24, but stated the cook should have used a #(number) 24 (twenty-four) scoop. Surveyor requested to see a #24 scoop and RDO could not locate a #24 scoop. RDO located a #30 (thirty) scoop and stated that was the closest to a #24 they had. RDO agreed if the cook used the #30 scoop, there would have been more ham salad on the bread than what was served and he stated he agreed one hundred percent, the sandwiches served on 5/21/24, did not have an adequate amount of ham salad. On 5/22/24 at 9:10 AM, surveyor interviewed Resident #412 (R412) and Resident #411 (R411). Surveyor asked R412 if she had a ham salad sandwich for dinner last evening (5/21/24) and resident stated yes, but there could not have been more than a teaspoon of ham salad as she pointed to a plastic teaspoon on her over-the-bed table. R411 stated there couldn't have been more than a teaspoon of ham salad in the middle of the bread. On 5/22/24 at 11:48 AM, surveyor interviewed dietary cook #1 (DC#1). Surveyor asked DC#1 about the ham salad sandwiches that were served for dinner on 5/21/24. DC#1 stated she looked at the chart and the chart said, red scoop #24. DC#1 stated she couldn't find a red scoop, so she used a blue scoop #16 (sixteen). DC#1 stated she used the blue scoop on all the sandwiches, but she did add a little more (ham salad) on some of the sandwiches. Surveyor asked DC#1 the protocol for not having the red scoop (#24) and she stated she didn't think to ask the RDO for the best option, but she knows now to ask, and she apologized for the error. DC#1 agreed she should have used the #30 scoop when a #24 scoop could not be located. This concern was discussed at an end of day meeting on 5/22/24 at 4:35 PM and at the pre-exit meeting on 5/23/24 at 5:02 PM, with the administrator, assistant administrator, director of nursing and the regional director of clinical services. Surveyor requested and received a facility document titled, Corporate Recipe-Number 21 (twenty-one) Soft Ham Salad Sandwich, which revealed, .Spread One #24 Scoop of Filling Between 2 (two) Slices of Bread . No further information regarding this issue was provided to the survey team prior to the exit.

Based on resident and staff interview, clinical record review and facility document review, the facility staff failed to follow physician orders for 1 of 8 (eight) residents reviewed, Resident #1. The findings were: For Resident #1, facility staff failed to administer Timolol eye drops as directed by provider order. Timolol eye drops treat glaucoma (an eye condition which can damage the optic nerve). Resident #1's facesheet listed diagnoses which included but were not limited to, fracture of left femur, difficulty walking, gout, and glaucoma. A quarterly minimum data set with an assessment reference date of 06/16/23 assigned the resident a brief interview for mental status score of 15 out of 15 in Section C, cognitive patterns. This surveyor interviewed Resident #1 on 02/20/24 at 11:45 a.m. The resident reported it had been 5 days since she received her eye drops and stated, They keep saying they should be here tomorrow. Later the same day, Resident #1 clarified the eye drop she had not been receiving was the one administered in the mornings. Resident #1's clinical record was reviewed on 02/20/24. The February 2024 medication administration record (MAR) and provider orders list included a 10/06/23 order for Timolol Maleate Solution 0.25% Instill 1 drop in both eyes one time a day for Glaucoma; The eye drops were scheduled daily at 9:00 a.m. There was no end date. For the month of February, the Timolol eye drops had a check mark documented each day which indicated the medication was administered. The registered nurse (RN#1) assigned to Resident #1 on 02/20/24 was interviewed in person about the resident's morning eye drops on 02/20/24 at approximately 2:20 p.m. RN#1 reported the morning eye drops were not in the medication cart and acknowledged it had been approximately four (4) days since she had administered Resident #1 the Timolol eye drops. The nurse and surveyor observed the RN's medication cart. No Timolol eye drops were found in the drawer where RN#1 reported they should be stored. RN#1 reported the eye drops had been reordered and showed the surveyor in the software a reorder date of 02/20/24. When asked why the nurse had documented the medication as administered when the medication was not available, RN#1 stated that was her fault. The nurse stated she should have charted a progress note explaining the medication was not administered and had been reordered. On 02/20/24 after the interview with RN#1, the surveyor informed the director of nursing (DON) about the concern that Resident #1's Timolol eye drops had not been administered and the medication was not available. The DON planned to investigate the issue. The surveyor contacted the facility's pharmacy initially on 02/20/24 at 12:41 p.m. At 4:24 p.m. the same day, the pharmacy's quality assurance employee reported Resident #1's Timolol eye drops had last been sent from the pharmacy on 01/21/24 with an expected renewal/resend date of 03/05/24. The Timolol eye drops were supplied in a 5 ml bottle which should allow for 100 doses, or 50 days given Resident #1's order for one drop/day in both eyes. The pharmacy employee acknowledged their software indicated the medication was electronically reordered by facility staff on 02/13/24. The facility staff needed to call the pharmacy for an override for the medication to be sent sooner than expected. The pharmacy policy #6.10 with an effective date of 09-2018, revision date of 08-2020 and titled, Unavailable Medications was reviewed. It read in part that nursing staff shall, 3. Notify the pharmacy of the replacement order. The administrator, regional director of clinical services, DON, and administrator in training were informed of the unavailable medication and documentation concern during an end of day meeting on 02/21/24 at 5:00 p.m. No further information was provided prior to the exit conference.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 8 (eight) residents reviewed, Resident #1. The findings were: For Resident #1, facility staff failed to accurately document Timolol eye drops were unavailable for administration and instead, documented the medication was administered. Timolol eye drops treat glaucoma (an eye condition which can damage the optic nerve). Resident #1's facesheet listed diagnoses which included but were not limited to, fracture of left femur, difficulty walking, gout, and glaucoma. A quarterly minimum data set with an assessment reference date of 06/16/23 assigned the resident a brief interview for mental status score of 15 out of 15 in Section C, cognitive patterns. This surveyor interviewed Resident #1 on 02/20/24 at 11:45 a.m. The resident reported it had been 5 days since she received her eye drops. Later the same day, Resident #1 clarified the eye drop she had not been receiving was the one administered in the mornings. Resident #1's clinical record was reviewed on 02/20/24. The February 2024 medication administration record (MAR) and provider orders list included a 10/06/23 order for Timolol Maleate Solution 0.25% Instill 1 drop in both eyes one time a day for Glaucoma; The eye drops were scheduled daily at 9:00 a.m. There was no end date. For the month of February, the Timolol eye drops had a check mark documented each day which indicated the medication was administered. The registered nurse (RN#1) assigned to Resident #1 on 02/20/24 was interviewed in person about the resident's morning eye drops. RN#1 reported the morning eye drops were not in the medication cart and acknowledged it had been approximately four (4) days since she had administered Resident #1 the Timolol eye drops. The nurse and surveyor observed the RN's medication cart. No Timolol eye drops were found in the drawer where RN#1 reported they should be stored. When asked why the nurse had documented the medication as administered when the medication was not available, RN#1 stated that was her fault. The nurse stated she should have charted a progress note explaining the medication was not administered and had been reordered. On 02/20/24 after the interview with RN#1, the surveyor informed the director of nursing (DON) about the concern regarding Resident #1's Timolol eye drops. The DON was informed RN#1 had not administered Resident #1's morning eye drops. The eye drops were unavailable however, the nurse had documented the medication had been administered. The DON planned to investigate the issue. The surveyor contacted the facility's pharmacy initially on 02/20/24 at 12:41 p.m. At 4:24 p.m. the same day, the pharmacy's quality assurance employee reported Resident #1's Timolol eye drops had last been sent from the pharmacy on 01/21/24 with an expected renewal/resend date of 03/05/24. The pharmacy employee acknowledged their software indicated the medication was electronically reordered by facility staff on 02/13/24. The facility staff needed to call the pharmacy for an override for the medication to be sent sooner than expected. On 02/22/24 at 12:40 p.m., the regional director of clinical services (consultant) reported her expectation of nursing staff was to document that unavailable medications were not administered. The consultant denied having a policy that directed staff how to document unavailable medications. The administrator, regional director of clinical services, DON, and administrator in training were informed of the unavailable medication and documentation concern during an end of day meeting on 02/21/24 at 5:00 p.m. No further information was provided prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and care in accordance with the comprehensive person-centered care plan and physician's orders for 8 of 34 residents in the survey sample, Resident #109, #113, #316, #317, #318, #167, #216, and #41. 1. For Resident #109, the facility staff failed to administer medications as ordered by the medical provider and failed to treat a wound to the chest for five days following admission. Resident #109's diagnosis list indicated diagnoses, which included, but not limited to Neuropathy, Muscle Weakness, Cardiogenic Shock, Laceration to Left Front Wall of Thorax, Pericardial Effusion, Cardiac Tamponade, Hypovolemic Shock, and Low Back Pain. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 5/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #109's comprehensive person-centered care plan included an intervention dated 5/19/23 to administered medications as ordered. On 6/05/23 at 4:39 pm, surveyor spoke with Resident #109 who stated their medications were late most days. Surveyor reviewed Resident #109's June 2023 medication administration record (MAR), however, the MAR did not include documentation of the exact time the medications were administered. Surveyor requested and received the Medication Admin Audit Report for Resident #109 for 6/01/23 through 6/06/23. This report included the scheduled time of administration for each ordered medication, the actual administration time, and the time administration was documented. Resident #109's current physician's orders included an order dated 5/30/23 for Guaifenesin Oral Liquid 10 ml by mouth four times a day for cough and congestion for 14 days. According to the Medication Admin Audit Report, Guaifenesin was administered late on 12 separate occasions ranging from 32 minutes to 2 hours and 25 minutes late from 6/01/23 through 6/06/23. The current physician's orders also included an order dated 5/18/23 for Methocarbamol 500 mg by mouth four times a day for pain. The Medication Admin Audit Report indicated the Methocarbamol was administered late on 12 separate occasions ranging from 32 minutes to 2 hours and 25 minutes late from 6/01/23 through 6/06/23. Resident #109's current physician's orders included an order dated 5/18/23 for Acetaminophen Extra Strength 500 mg two tablets by mouth four times a day for pain. The Medication Admin Audit Report indicated the Acetaminophen was administered late on three separate occasions ranging from 48 minutes to 2 hours and 25 minutes late from 6/01/23 through 6/06/23. On 6/08/23 at 2:34 pm, surveyor spoke with licensed practical nurse (LPN) #2, who administered the resident's medications late on 6/05/23. LPN #2 stated there were two nurses on the unit that shift, and each had 30 residents to give medication to and Resident #109 was at the end of the hall, and they got to them late. Surveyor asked LPN #2 if medications were administered at the time indicated on the report and they stated yes. Surveyor also asked the LPN if they sign the MARs at the time of administration or afterwards and LPN #2 stated they did both. On 6/09/23 at 8:46 am, surveyor spoke with registered nurse (RN) #2, who administered the resident's medications late on 6/03/23. RN #2 stated Resident #109 got up and walked in the facility, went to therapy and nurses were not allowed to give medications unless it was in their room, or a private area and they did not track the resident down. RN #2 stated they try to give medications within the 1 hour before to 1 hour after scheduled timeframe. Surveyor requested and received the facility policy entitled Administration Procedures for All Medications with a revised date of 8/2020 which read in part . IV. Administration .7. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR . On 6/05/23 at 4:42 pm, surveyor spoke with Resident #109 who stated the wound to their chest was not packed for four days following admission because the nurse stated they did not know how to do the treatment. According to Resident #109's clinical record, the resident was admitted to the facility on [DATE]. The hospital discharge summary dated 5/18/23 included instructions stating in part Discharge Wound Care: Daily dressing changes, pack wound with saline moistened 4 x 4 gauze and cover with dry gauze . Surveyor reviewed the resident's physician orders and this order was not transcribed to the resident's admission orders. Resident #109 was seen by the nurse practitioner (NP) on 5/19/23, the progress note included documentation stating the resident required daily dressing changes to the wound with saline moistened 4x4 and a dry cover dressing. Resident #109 was seen by the wound NP on 5/22/23, the progress note described the wound to the resident's left upper quadrant as measuring 3.00 cm x 1.00 cm x 2.5 cm with a moderate amount of serosanguineous exudate. Treatment recommendations were to cleanse the wound daily with wound cleanser, apply normal saline packed gauze to the base of the wound and secure with bordered gauze. A physician's order for treatment to the wound was not transcribed until 5/23/23 at 11:06 am and with the first treatment to the area administered on 5/24/23, six days following admission. On 6/08/23 at 1:14 pm, surveyor spoke with the treatment nurse regarding the reason for Resident #109's treatment not being initiated upon admission. The treatment nurse stated they were not sure why the order was not entered. The treatment nurse further stated they were unaware of the resident when they were admitted and did not know who reviewed the resident. On 6/09/23 at 4:05 pm, the survey team met with the Administrator, Director of Nursing, and the Regional Nurse and discussed the concern of Resident #109 receiving medications late on multiple occasions and not receiving treatment to a wound as indicated. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/09/23. 2. For Resident #113, the facility staff failed to administer the antibiotic, Cefepime as ordered by the provider. This was a closed record review. Resident #113's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Combined Systolic and Diastolic Heart Failure, and Cardiac Arrhythmia. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 5/11/23 assigned the resident a brief interview for mental status (BIMS) summary score of 4 out 15 indicating the resident was severely cognitively impaired. Resident #113's physician's orders included an order dated 5/15/23 for Cefepime 1 gram intramuscularly (IM) one time only for infection and an order dated 5/16/23 for Cefepime 1 gram IM one time a day for three days for infection. According to the resident's May 2023 Medication Administration Record (MAR), the Cefepime was never administered. According to Resident #113's clinical record, the resident was seen by the nurse practitioner (NP) on 5/15/23 with noted lethargy, increased respirations, oxygen saturation level 85-88%, and decrease in oral fluids. An order was given for stat labs including a complete blood count with differential (CBC) and a complete metabolic panel (CMP) due to lethargy and low-grade temperature. Resident #113 received a one-time order for Cefepime 1 gram IM on 5/15/23 at 4:10 pm. According to the resident's MAR and a nursing note dated 5/15/23 at 7:37 pm, the Cefepime was not administered due to awaiting arrival from the pharmacy. The 5/15/23 CBC revealed an elevated white blood cell count of 14.98 (normal range 4.5 - 10.5) indicating the presence of infection. Resident #113 was again seen by the NP the following day, 5/16/23. The progress note stated the antibiotic would be continued due to elevated white blood cells (WBCs). An order was provided on 5/16/23 at 10:19 am for Cefepime 1 gram IM one time a day for three days for infection. According to the resident's May 2023 MAR, the Cefepime was never administered. A nursing progress note dated 5/17/23 at 9:47 pm documented the medication was not administered due to awaiting arrival from the pharmacy. Surveyor was unable to locate additional documentation for the reason the Cefepime was not administered on 5/16/23 or 5/18/23. Another CBC blood test was completed on 5/19/23 and the resident's WBCs remained elevated at 14.7. Surveyor requested and received a listing of the facility in-house medication supply maintained in the Omnicell. The inventory list indicated Cefepime 1 gram was available in the facility Omnicell supply to be used for Resident #113. The director of nursing (DON) provided a pharmacy packing slip which indicated three vials of Cefepime were received by the facility on 5/17/23 at 1:25 am. On 6/09/23 at 1:00 pm, surveyor spoke with the NP who stated they believe Resident #113 received the Cefepime, but the nurses did not sign it off on the MAR. NP stated they were constantly checking on the resident asking the staff if the antibiotics and fluid were given, and they were told they were. NP also stated the resident was improving as much as possible. On 6/09/23 at 1:21 pm, surveyor spoke with the DON and asked if they could provide any evidence of the Cefepime being administered and the DON stated no and stated unless you ask the nurse. Surveyor attempted but was unable to reach the nurse who documented they were awaiting arrival of the Cefepime on 5/15/23 and 5/17/23. Surveyor requested and received the facility policy entitled Medication Management/Medication Unavailability with an effective date of 4/21/22 which read in part .3. If medications are determined to be unavailable for administration, licensed nurse will notify the provider of the unavailability. Licensed nurse will document notification to the provider of the unavailability in the medical record. Licensed nurse will notify provider of the unavailability of medication and request an alternate treatment if possible. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures. Surveyor also requested and received the facility policy entitled Administration Procedures for All Medications with a revised date of 8/2020 which read in part . IV. Administration .7. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR . On 6/09/23 at 4:05 pm, the survey team met with the Administrator, DON, and Regional Nurse and discussed the concern of Resident #113 not receiving the antibiotic Cefepime as ordered by the provider. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/09/23. 3. For Resident #316, the facility staff failed to administer Oxycodone, a narcotic used to treat pain, as ordered by the physician on six (6) separate occasions. Facility staff also failed to administer the resident's medications as ordered on the night of 2/06/22. This was a closed record review. Resident #316's diagnosis list indicated diagnoses, which included, not limited to Nondisplaced Trimalleolar Fracture of Left Lower Leg, Type 2 Diabetes Mellitus, Major Depressive Disorder, Seizures, Anxiety Disorder, Essential Hypertension, and History of Transient Ischemic Attack, and Cerebral Infarction. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/31/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #316's comprehensive person-centered care plan included a focus area addressing pain with an intervention to medicate as ordered. Resident #316's physician's orders included an order dated 2/02/22 at 7:36 am for Oxycodone 5 mg by mouth every 6 hours for 5 days, 2/02/22 through 2/07/22. According to Resident #316's February 2022 Medication Administration Record (MAR), the resident did not receive the scheduled Oxycodone 5 mg as ordered on 2/05/22 at 12:00 pm, 6:00 pm, 2/06/22 at 6:00 am, 12:00 pm, 6:00 pm, 2/07/22 midnight, and 6:00 am. A nursing progress note dated 2/05/22 at 11:53 am stated holding on pharmacy. A nursing progress note dated 2/07/22 at 8:14 am stated medication not administered due to supply and a subsequent note at 8:15 am stated medication not administered, administration aware and preparing to remove from U. Surveyor was unable to determine which medication the nursing notes were referencing. The facility provided a report from the Omnicell in house medication supply indicating Oxycodone 5 mg was removed on 2/07/22 at 7:48 am for Resident #316. This report indicated this was the only Oxycodone 5 mg removed for Resident #316 from 2/01/22 through 2/07/22 at 8:00 am. On 6/07/23 at 3:38 pm, the Regional Nurse stated there were no narcotic count sheets for Resident #316's Oxycodone 5 mg from 2/05/22 through 2/08/22. The facility was unable to provide evidence that Resident #316 received Oxycodone as ordered on 2/05/22 at 12:00 pm, 2/05/22 at 6:00 pm, 2/06/22 at 6:00 am, 2/06/22 at 12:00 pm, 2/06/22 at 6:00 pm, and 2/07/22 at midnight. According to the Omnicell inventory supply list provided by the facility, Oxycodone 5 mg was available in the facility for administration for Resident #316 on the above occasions. On 6/06/23 at 1:44 pm, surveyor spoke with LPN #4 and asked for the acceptable procedure if a resident's pain medication was not available, and LPN #4 stated they would call the pharmacy for a one-time pass code for the Omnicell and if a new script was needed they would call the provider for an e-script. Resident #316's clinical record included a nursing progress note by the director of nursing (DON) dated 2/07/22 at 12:52 pm which stated in part This writer received message that rsd [resident] had concerns and wanted to speak with someone about them, upon enter [sic] rsd room with discharge planner rsd was asked if she had concerns rsd states she had concerns about time that her medication was giving [sic] the night before. Concerns was addressed . Surveyor requested and received the Medication Admin Audit Report for Resident #316 which provided the scheduled time, actual administration time, and documented time for each of the resident's ordered medications. According to Resident #316's Medication Admin Audit Report, the resident's scheduled 2/06/22 9:00 pm medications including Ambien, Aricept, Lipitor, Oxcarbazepine, Plavix, Metformin, Topamax, Wellbutrin, Baclofen, Docusate, and Prozac were not documented as administered until the following morning, 2/07/22, between 8:17 am and 8:23 am. According to Resident #316's MAR for 2/06/22, the 9:00 pm dose of Humulin 70/30 was not administered due to resident concerns of hypoglycemia and the 9:00 pm dose of Novolog sliding scale insulin was refused by the resident due to hypoglycemia. There was no documentation of a 9:00 pm blood glucose check. Resident #316's blood glucose was checked the following morning and documented as 198 on 2/07/22 at 9:00 am. Surveyor was unable to interview the nurse providing care for Resident #316 on the night of 2/06/22 as they were no longer employed by the facility. Surveyor requested and received the facility policy entitled Administration Procedures for All Medications with a revised date of 8/2020 which read in part . IV. Administration .7. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR . On 6/09/23 at 4:05 pm, the survey team met with the Administrator, Director of Nursing, and the Regional Nurse and discussed the concern of Resident #316 not receiving medications as ordered by the physician. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/09/23. 4. For Resident #317, the facility staff failed to administer Lipitor 40 mg, a medication used to treat high cholesterol and triglyceride levels, as ordered by the physician. This was a closed record review. Resident #317's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Emphysema, Chronic Congestive Heart Failure, Atherosclerotic Heart Disease, Anxiety Disorder, Muscle Weakness, and Difficulty in Walking. Resident #317's clinical record included a Speech Language Pathology Worksheet which assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating Resident #317 was moderately cognitively impaired. Resident #317's admission physician's orders included an order dated 7/12/22 for Lipitor 40 mg by mouth at bedtime for lipid regulation. According to the resident's July 2022 Medication Administration Record (MAR) a 9 indicating Other/See Progress Notes was documented for the 7/12/22 9:00 pm administration of Lipitor. A 7/12/22 11:14 pm nursing progress note stated, on order. Surveyor attempted to interview the writer of the nursing note; however, they were no longer employed by the facility. Resident #317's MAR was blank for the 7/13/22 9:00 pm administration of Lipitor. Surveyor was unable to locate documentation indicating the reason the medication was not administered. On 6/06/23 at 1:44 pm, surveyor spoke with licensed practical nurse (LPN) #4 who stated 4:00 pm was the cut off time to order medications to be delivered from the pharmacy with the 9:00 pm night delivery. LPN #4 stated if the medications had not arrived, they obtain them from the Omnicell and if the medication was not in the Omnicell, they contact the provider and family. Surveyor requested and received the facility Omnicell list of medications available in the facility at the time of Resident #317's admission and the list indicated Lipitor 40 mg was available for administration on 7/12/22 and 7/13/22. On 6/08/23 at 10:17 am, surveyor met with the Administrator, Director of Nursing, and the Regional Nurse and discussed the concern of Resident #317 not receiving Lipitor as ordered. The Regional Nurse returned at 3:30 pm and stated they could not find where the Lipitor was administered. Surveyor requested and received the facility policy entitled Medication Management/Medication Unavailability with an effective date of 4/21/22 which read in part . 3. If medications are determined to be unavailable for administration, licensed nurse will notify the provider of the unavailability. Licensed nurse will document notification to the provider of the unavailability in the medical record. Licensed nurse will notify provider of the unavailability of medication and request an alternate treatment if possible. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/09/23. 5. For Resident #318, the facility staff failed to transcribe and initiate physician's orders for treatment to bilateral lower extremity vascular ulcers present on admission. Resident #318's diagnosis list indicated diagnoses, which included, but not limited to Encephalopathy, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3 A, Congestive Heart Failure, and Generalized Muscle Weakness. Resident #318 was admitted to the facility on [DATE], the Admission/Readmission Nursing Collection Tool dated 6/03/23 included documentation stating in part, . Presence of bilateral leg ulcers noted, covered with wrapped gauze dressings . On 6/05/23, the surveyor reviewed Resident #318's clinical record and was unable to locate a physician's order for treatment to the bilateral leg ulcers. Resident #318's hospital Discharge Summary dated 6/03/23 documented in part .Lower extremity lymphedema. Continue wound care recommendations A 5/30/23 Wound Care Consult provided to the facility from the hospital included treatment recommendations to clean bilateral lower extremities with water and apply Xeroform daily and cover with ADB pad and secure with roll gauze. On 6/06/23 at 9:58 am, surveyor spoke with the Director of Nursing (DON) and the Regional Nurse and informed them that the resident did not have treatment orders in place for the lower extremity leg ulcers. An order for treatment was entered and treatment was provided to the areas on 6/06/23, three days following admission to the facility. On 6/09/23 at 8:42 am, surveyor spoke with registered nurse (RN) #1 who stated they help with the resident admission assessments and the primary nurse enters the admission orders. RN #1 stated there should have been treatment orders for Resident #318's bilateral lower extremity ulcers and if there were no orders on the Discharge Summary, the nurse should call the physician for orders. Surveyor requested and received the facility policy entitled Physician's Orders with an effective date of 3/24/20 which read in part . 2. b. Admission orders should include: 9) Other orders as indicated by patient's condition with specific directions . No further information regarding this concern was presented to the survey team prior to the exit conference on 6/09/23. 22218 Based on resident interview, staff interview, clinical records review, and facility documentation facility staff failed to provide treatment and care in accordance with the comprehensive person centered care plan and physician's orders. 6. For Resident #167, facility staff failed to ensure medications were administered within acceptable time frames. Resident #167 was admitted to the facility with diagnoses including hypertension, cardiopulmonary disease, acute respiratory failure, chronic kidney disease, muscle weakness, and repeated falls. The Office of Licensure and Certification received a complaint that residents did not receive medications in a timely manner on 9/23/2022. On the Minimum Data Set assessment with assessment reference date 9/13/22, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. On 6/5/2023, the surveyor interviewed the ombudsman by phone and notified of the complaint investigation. The ombudsman reported visiting the facility on that date. The resident and the resident's room mate reported at 11:20 AM that neither had received morning medications scheduled for 8 and 9 AM. The nurse practitioner was present for the conversation. The ombudsman spoke with the nurse working the medication cart. That nurse stated there were only 2 nurses for 50 residents and they were behind administering medications. The surveyor interviewed the nurse practitioner (NP#1) on 6/8/23. The NP was unable to confirm the specific date, but stated that residents frequently complain to the NP that medications are late. The medication administration record (MAR) documented all medications on all days were administered on time. Surveyors interviewed several medication nurses and learned that the charting software allows nurses to tab through the screens where nurses can document reasons for administering medications outside the expected parameters (within 1 hour of the scheduled time). Nurses typically do not document that medications were administered late. The surveyor obtained the Medication Administration Audit Report for the resident for 9/23/22. Medications scheduled for 9:00 that date were reported as administered between 13:26 and 13:30. The administrator and director of nursing were notified of the concern with late medication administration during a summary meeting on 6/7/2023. 28169 7. For Resident #216, facility staff failed to administer pain medication according to orders or within acceptable time frames. The medication was available in Omnicell. Resident #216's admission record listed diagnoses to include, but not limited to, cerebral infarction, emphysema, fracture of left fibula, fracture of right tibia, type 2 diabetes, atrial fibrillation, morbid obesity, and obstructive sleep apnea. The minimum data set with an assessment reference date of 11/27/21 coded the brief interview for mental status as 13 out of 15. This was a closed record review. Resident #216's medication administration record (MAR) for December 2021 contained a schedule for Roxicodone Tablet 5 MG (oxyCODONE HCl) Give 2 tablets by mouth every 6 hours for pain for 10 days to start on 12/07/21 at 7:29 p.m. On 12/10/21 at the 12:00 noon dose, the LPN (licensed practical nurse) documented 9 which according to the MAR's chart codes stood for Other/See Progress Notes. The LPN's progress note, documented on 12/10/21 at 12:49 p.m., read awaiting pharmacy refill [sic] md aware [sic] called pharmacy. The Omnicell inventory list dated 10/14/21 listed Oxycodone IR 5mg Tablet as available. The director of nursing (DON) acknowledged the Oxycodone IR 5mg tablet was the same medication ordered for Resident #216 and should have been retrieved and administered. The LPN who documented waiting on the pharmacy refill was an agency nurse who no longer worked at the facility so was not interviewed. The regional director of clinical services was interviewed on 06/09/23 at 11:15 a.m. She reported that although two nurses were required to obtain Oxycodone from the Omnicell, there would have been another nurse within the facility. Since the dose for 12/10/21 at noon was on a Friday in the middle of the day, there would have at least been an administrative nurse working that would not have shown up on the schedule. The working schedule for 12/10/21 showed six nurses scheduled for 7 a.m. to 7 p.m. between the two units, 4 agency nurses and two facility employee nurses. One nurse's name said late beside it and one agency nurse was coming in at 8 a.m. The regional director stated there should always be two nurses with access to the Omnicell. All nurses should have access, even agency nurses, but even if an agency nurse was on their first day or for some reason did not have access, there should be someone else there be it an on-call nurse, administrative nurse or a nurse from the other unit. The facility's pharmacy services' policy titled, Electronic Interim Box, Policy #3.6 with an effective date of 09-2018 and revision date of 08-2020 was reviewed. The policy read, in part, IV. Nursing Responsibilities for Emergency or Non-Emergency Dosing 5. Upon withdrawal of a controlled substance medication from an electronic interim box, an authorized nurse will be prompted by the electronic interim box to obtain a mandatory second nurse witness to verify and electronically document the controlled substance withdrawal amount and remaining inventory balance after medication withdrawal. 6. In the event that only one nurse is available in the facility, additional staff may be given access to the electronic interim box provided the following: a. The electronic interim box has the ability to provide witness only access and the additional staff member(s) are only granted this access level. b. The staff member(s) is trained and fully understands the responsibilities and implications of performing witness functions. c. The staff member is part of the resident care team within the facility. Housekeeping, maintenance, kitchen etc. staff should never have access to the electronic interim box. No further information was provided prior to the exit conference. 8. For Resident #41, the facility failed to administered pain medication according to orders or within acceptable time frames. The medication was available in Omnicell. Resident #41's admission record listed diagnoses to include but not limited to, pain in left hip, severe protein-calorie malnutrition, esophagitis, major depressive disorder, diaphragmatic hernia, gastrointestinal hemorrhage, gastrostomy, and dysphagia. Resident #41's minimum data set with an assessment reference date of 4/11/23 coded the resident's brief interview for mental status summary score a 15 out of 15. Upon initially meeting Resident #41 in her room on 6/05/23, the resident reported facility staff did not always administer her pain medications on time. The resident specifically mentioning medications at 9:00 a.m. The resident was lying in bed, smiling and had a pleasant demeanor. Resident #41's clinical record contained a provider order dated 4/06/23 for Oxycodone HCl Oral Tablet 5 mg, give 1 tablet via PEG-Tube every 4 hours for pain. Another order dated 4/05/23 read to administer Acetaminophen Oral Solution 650 MG/20.3 ml by mouth four times a day for pain. A review of Resident #41's Medication Admin Audit Report for June noted both the Oxycodone and Acetaminophen medications were scheduled to be given daily at 8:00 a.m. For the Oxycodone and Acetaminophen 8:00 a.m. doses due: 1. On 6/06/23 the medications were documented as administered at 10:43 a.m. (1 hr 43 minutes late). 2. On 6/05/23 the medications were documented as administered at 10:37 a.m. (1 hr 37 minutes late). 3. On 6/04/23 the medications were documented as administered at 9:36 a.m. (36 minutes late). 4. On 6/03/23 the medications were documented as administered at 9:26 a.m. (26 minutes late). 5. On 6/02/23 the medications were documented as administered at 10:24 a.m. (1 hr 24 minutes late). 6. On 6/01/23 the medications were documented as administered at 11:02 a.m. (2 hrs 2 minutes late). The DON reported the medication nurses have a window of time in which to administer medications. The window was one (1) hour before the medication was due until one (1) hour after the medication was due. (e.g. For a medication scheduled to be administered at 8:00 a.m., the nurses could administer the medications between 7:00 a.m. and 9:00 a.m. and still be considered administered on time.) The DON acknowledged Resident #41 had received medications late. One of the licensed practical nurses (LPN #2) working on Unit 1 with Resident #41 was interviewed in person on 6/08/23 at 2:25 p.m. The nurse reported when there were two (2) nurses on Unit 1 instead of three (3) nurses, that meant there were about 30 residents to receive medications in the mornings and there were a lot of interruptions. Resident #41's room was at the end of the hall and it is late when I get to her sometimes. Two policies were provided, 1. Pain Management Assessments, Policy Number 2201 effective 11/01/19, and 2. Administration Procedures for All Medications (a pharmacy provider's policy), policy #9.1 effective 09-2018 with revision date 08-2020. Neither policy addressed timing of medications and/or late administration of medications. The facility's pharmacy services' policy titled, Electronic Interim Box, Policy #3.6 with an effective date of 09-2018 and revision date of 08-2020 was reviewed. The policy read, in part, IV. Nursing Responsibilities for Emergency or Non-Emergency Dosing 5. Upon withdrawal of a controlled substance medication from an electronic interim box, an authorized nurse will be prompted by the electronic interim box to obtain a mandatory second nurse witness to verify and electronically document the controlled substance withdrawal amount and remaining inventory balance after medication withdrawal. 6. In the event tha [TRUNCATED]

Based on staff interview, clinical record review and in the course of a complaint survey the facility staff failed to ensure an accident free environment ofr 1 of 31 Resident, #111. The findings included: For Resident #111 the facility staff failed to ensure an accident free environment resulting Resident receiving a laceration to leg that required suturing. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/19/17 coded the Resident as having both long and short-term memory loss with severely impaired cognitive skills for daily decision making in section C, cognitive patterns. Section G, functional status, coded the Resident as 4/3 in the areas of bed mobility and transfer, which is the equivalent of total dependence/two person physical assist. This is a quarterly MDS. Resident #111's CCP (comprehensive care plan) was reviewed and contained care plan for the Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia. Interventions for this care plan included BATHING/SHOWERING: The Resident requires full assistance, BED MOBILITY: The Resident requires full assistance, DRESSING: The Resident requires full assistance, TRANSFER: The Resident requires Mechanical Lift Hoyer (2) staff assistance for transfers. The CCP also contained a care plan for The Resident is at risk for skin tears Created on: 10/07/14 Revision on: 09/27/17. Interventions for this care plan included use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Created on: 06/30/2015. Revision on: 08/11/2016. Resident #111's clinical record was reviewed on 01/16/19. It contained a nurse's progress noted dated 12/01/17 which read in part, 12/1/2017 20:45 Change of Condition Note Text: Pt obtained skin tear/laceration to right posterior lower leg when in the shower chair. Pressure was applied, hemostasis achieved, dressing applied. PA (physician's assistant) .(name omitted) and order to send to .(name omitted) ED (emergency department) for evaluation. Pt's daughter .(name omitted) notified by .(name omitted), LPN (licensed practical nurse). Report called to .(name omitted) ED. The Resident's clinical record contained an ER report dated 12/01/17 which read in part, [AGE] year-old-female presents to the emergency department after getting a cognitive nursing facility during a transition for bathing. Patient has a large 'dog-eared' laceration to the right lower extremity Patient is non-verbal severely demented and unable to communicate what occured. Her daughter is at bedside and states the the patient received a cut while transitioning for bathing no falls, no other injuries and Wound Extent: no fascia violation noted, no muscle damage noted, no tendon damage noted and no vascular damage noted .Base of wound likely viable with good vascularization closed with 4 sutures. But the distal part of the wound open but reapproximated and placed occlusive dressing with Xeroform impregnated gauze and a simple [MEDICATION NAME] wrap. The clinical record also contained an After Visit Summary from the ER which read in part, Call (name omitted) in 1 day. Why: should be followed by wound management . Resident's clinical record contained progress notes which read in part, 12/5/2017 Wound care clinic at this time with new orders to keep dressing intact until Resident returns to clinic in 1 week for dressing change with .(name omitted). Resident to have leg elevated at all times when in wheelchair , 12/13/17 Dressing to right leg clean, dry and intact. No swelling or foul odor noted. Sutures removed. New order to cleanse wound with saline, apply hydorfera blue ready to wound, cover with ABD pad, secure with 4 kling, change every other day. If dressing is hard to remove, may use saline to remove [MEDICATION NAME] blue. Apply tubi-grip E from base of toes to below knee, followed by ACE wrap compression. F/U (follow up) in 1 week with .(name omitted), and 12/19/17 Cleanse with saline, pat dry, appy [MEDICATION NAME] blue, secure with kling, change Monday, Wednesday, Friday. Apply [MEDICATION NAME] from base of toes to below knee. Apply ace wrap from base of toes to beljow knee. Follow up in two weeks. Surveyor requested and was provided with the facility's preliminary investigation which included a written statement from RN (registered nurse) #1 dated 12/02/17, which read in part, Patient .(Resident #111) received a skin tear to her right posterior calf on the evening of 12/1/17 caused by a bolt on the foot portion of the reclining showe chair. The skin tear occurred while CNA .(certified nurse's aide) #3 attemped to replace a soiled lift pad under patient after patient's shower. CNA stated she was alone with patient at the time and han not attempted any transfers because the lift pad was not yet under the patient. CNA stated that the skin tear occured after she flipped the foot rest up and began to reposition patient, and that she immediately called for help when the injury occured Patient to receive all shower via shower stretcher instead of shower recliner or shower chair with staff education provided . Surveyor was unable to interview RN #1. The preliminary investigaton also contained a written statement from CNA #3 dated 12/01/17, which read in part, After I had gave .(Resident #111) a bath I took her to her room to get her prepared for bed. I lowered the head of the chair to put her lift pad back under her, then when I folded the bottom of the chair back it scraped the back of her leg. When I seen blood, I yelled for .(RN #1) to come, he came and wrapped her leg up then called the hospital to come get her. Surveyor could not interview CNA #3 due to no longer being employed by facility. Surveyor spoke with unit manager via telephone on 01/17/19 at approximately 0905. Unit manager stated she was not working at the time Resident obtained skin tear. Surveyor attempted to contact wound care physican via telephone, but was unable to speak with him. Surveyor spoke with RNC (regional nurse consultant) #1, who was DON (director of nursing) at the time of Resident #111's injury. RNC #1 stated that the Resident had obtained the skin tear while CNA #3 was attempting to place a clean lift pad under the Resident after her shower. RNC #1 provided the surveyor with a copy of the final investigation conducted while he was DON, in which he stated the Resident's skin tear had occured whild CNA made decision that more room was needed at bottom so she held legs up and when at same time bringing the foot rest up toward chair scraping Resident's lower leg causing an abrasion. RNC #1 also stated the Resident had fragile skin and history of long term anticoagulant use. RNC #1 provided the surveyor with a copy of 5 Step Plan-Mechanical Lifts 12/04/2017 which read as follows: 1. Quality assurance that practices two staff members are present when performing a mechanical lift transfer. 2. Current Residents requiring mechanical lifts were reviewed by nursing leadership. Care plans were reviewed to ensure that use of 2 staff persons was identified and is being implemented. Corrections were made immediately as indicated. 3. Current nursing staff were educated on procedures for using a mechanical lift with return demonstration. Mechanical lift transfers will be reviewed and observed with new nursing staff during orientation period. SDC (staff development coordinator) or designee will randomly review three lift transfer weekly x 4 to ensure standard procedures are being followed. 4. Process will be reviewed in next quarterly QA (quality assurance). 5. 12/31/17 Throughout the course of the survey, no Residents on the 500 hall were observed to have broken bones. No Residents were observed being left in the bathroom/on toilet for extended periods. This allegation was discussed with the administrative team during a meeting on 01/17/19 at approximatley 1300. No further information was provided prior to exit. This is a complanit deficiency.